Failure to Ensure Completion and Follow-Up of Ordered X-Ray
Penalty
Summary
The facility failed to ensure that a resident received radiology services as ordered by the physician. A physician progress note dated 12/07/25 documented that the resident had a Stage 3 sacral pressure injury that appeared necrotic, and the physician ordered an x-ray of the sacrum and pelvis to evaluate for osteomyelitis. A corresponding physician order dated 12/07/25 directed staff to obtain an x-ray of the pelvis and sacrum. Review of the medical record from 12/07/25 through 12/15/25, when the resident was transferred to the hospital for evaluation, showed no documentation that the ordered x-ray had been completed. Nurse #2 reported that the physician saw the resident late in the evening on 12/07/25 and ordered the sacrum and pelvis x-ray, and that she entered the x-ray order into the radiology provider’s computer portal that same day. She stated the x-ray was not completed before the end of her shift and she was unaware it had not been done. The medical record contained no evidence that nursing staff followed up on the x-ray to determine if or when it was conducted or to obtain and report results to the physician. The DON stated that non-STAT x-rays may take a few days to be completed and reported that the radiology provider later indicated they had cancelled the x-ray because they did not have a credentialed radiologist to read the results, and that the provider did not inform facility staff of this cancellation. The DON stated it was her expectation that x-rays be obtained as ordered by the physician.
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