Failure to Act on Recommended Follow-Up HRCT After Abnormal Chest X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a recommended radiologic follow-up study was scheduled and addressed in a timely manner for one resident who experienced a change in condition. The resident, admitted with multiple significant diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, complained of increased fatigue while resting in bed. The family requested hospital transfer, but nursing staff explained that the resident could be worked up at the facility, and the family agreed. The physician was notified and ordered a CBC, CMP, urinalysis, urine culture, and a chest x-ray for complaints of shortness of breath. The chest x-ray was completed and the results, dated 09/15/25, showed suboptimal evaluation due to rotation, linear opacities in the left lower zone possibly representing fibro-atelectatic changes, prominence of both pulmonary hila with attenuation of broncho-vascular markings representing congestion, and elevation of the left dome of the diaphragm. The radiology report recommended a follow-up high-resolution CT (HRCT) lung scan. A progress note the following day documented the chest x-ray findings and indicated that the resident’s family and physician were aware of the results. However, during interview, the DON stated she did not recall speaking with the physician about the HRCT recommendation and verified there was no evidence in the record that the HRCT lung scan had been ordered or scheduled. The physician, when interviewed, did not remember what had occurred with this resident, stated that upon re-review of the chest x-ray he did not see anything acute that needed to be addressed, and acknowledged that the HRCT was a recommendation but did not believe it was necessary at that time. The resident’s family member reported not being aware of the recommendation for a CT scan of the lungs. The surveyors determined that the facility failed to ensure that the recommended radiologic follow-up study was acted upon in a timely manner for this resident, resulting in the cited deficiency under the complaint investigation.
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