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F0777
D

Failure to Complete Ordered Diagnostic Ultrasound

Baltimore, Maryland Survey Completed on 01-13-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility nursing staff failed to follow a physician’s order to obtain a right upper quadrant ultrasound for a resident whose laboratory tests showed elevated liver enzymes. The resident’s medical record showed that in September 2025 labs revealed elevated liver enzymes, and on 9/18/2025 the physician ordered a right upper quadrant ultrasound. Subsequent review of the medical record revealed no evidence that the ultrasound was completed or that results were obtained. During an interview, the Director of Nursing confirmed that nursing staff did not complete the ordered ultrasound, and the surveyor identified this as a concern related to failure to follow a physician’s order. The deficiency was identified during a complaint survey initiated after a complaint alleging the facility failed to monitor the resident’s status and well-being during the stay. Medical record review on 1/12/26 confirmed the absence of ultrasound results despite the prior order, and the DON’s interview on 1/12/25 further verified that the ordered diagnostic test was not carried out by nursing staff.

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