Failure to Timely Enter Stat X-Ray Order Resulting in Incomplete Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurately documented, and systematically organized medical records for a resident, specifically related to physician orders for a diagnostic X-ray. The resident was an elderly female with dementia, repeated falls, and depression, who used a walker and was independent with eating and toileting but had severe cognitive impairment as indicated by a BIMS score of 3. Her care plan noted dementia-related hoarding behaviors. On a Friday, an NP received a call from an LVN reporting the resident’s rib pain and gave verbal orders for a stat chest/rib X-ray and a 4% lidocaine patch. The LVN documented the NP’s orders as a late entry in the progress notes, indicating orders for a lidocaine patch and an X-ray of the left rib area, but failed to enter the X-ray order into the electronic portal as required. Record review showed that the X-ray order did not appear in the order summary until two days later, when it was entered into the system. The LVN acknowledged in interview that it was her responsibility to enter the X-ray order into the portal immediately and admitted she forgot to do so, which resulted in the resident not receiving the stat X-ray as ordered. The ADON, who worked the following Sunday and reviewed the 24-hour report, saw documentation of the incident and the X-ray order but found no corresponding order in the portal for the resident. This discrepancy between the clinical documentation and the absence of a timely portal entry demonstrated that the resident’s medical record was not complete or accurately maintained in accordance with facility policy and accepted professional standards. Further interviews clarified expectations and timelines for stat X-rays and documentation. The ADON stated she subsequently ordered the X-ray stat via the portal, and the mobile X-ray service arrived but initially could not complete the study due to equipment malfunction, with the X-ray ultimately performed the next day and the report later showing a hairline fracture of the left 5th rib. The infection control RN stated that stat X-rays were expected to be completed within four hours and that if a stat X-ray could not be done, staff were to assess pain and consider contacting the physician about hospital transfer. The NP stated that she expected a stat X-ray to be completed within 6–12 hours and that she was not notified that the X-ray was not done as ordered. The DON confirmed that staff were expected to submit X-ray orders into the portal immediately and that facility policy required a current, chronological list of orders in each resident’s clinical record, underscoring that the missing and delayed X-ray order entry constituted a failure to maintain the resident’s medical record in accordance with policy.
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