F0684

D

Incorrect Diagnostic Order Entry and Lack of Follow-Up for Painful Left Knee

Vallejo, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of care and carry out a physician’s diagnostic order correctly for a cognitively intact resident with type 2 diabetes mellitus with diabetic polyneuropathy and weakness. The resident reported bumping the left knee at church and complained of significant left knee pain, with nursing documentation noting the left knee was more prominent than the right, with faint yellowish discoloration on the left lateral thigh. A physician was notified and ordered an x-ray of the left knee related to pain, and a subsequent order directed staff to monitor the left thigh skin discoloration every shift. However, due to a data entry error on the diagnostic requisition, the x-ray was ordered and performed on the right knee instead of the left knee, and no fracture was identified on that incorrect study.

From the time of the initial complaint and order, there was no documented follow-up monitoring of the resident’s left knee from several days following the incident, despite ongoing pain requiring PRN Norco once or twice daily. The resident later stated having fallen at church but was unable to describe the circumstances. The error in body part selection for the x-ray was confirmed by the IDT note, which stated that the x-ray was performed on the right knee instead of the left knee, and that the corrected left knee x-ray subsequently revealed an acute mildly displaced supracondylar fracture of the distal femur. The DON and the nurse who wrote the initial note acknowledged that the x-ray order was for the left knee, that another nurse entered the request incorrectly for the right knee, that there were no follow-up notes on the left knee, and that the resident could have been sent to the hospital earlier if the x-ray had been done on the correct body part.