Failure to Obtain Ordered STAT Chest X-Ray for Resident with Respiratory Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to obtain a chest x-ray as ordered for a resident with multiple serious pulmonary and cardiac diagnoses, including COPD, heart failure, bronchitis, emphysema, and a solitary pulmonary nodule. The resident was admitted with these conditions and later experienced a change in condition characterized by shortness of breath. On the morning of 1/24/26, a physician (MD 3) gave a verbal order to a licensed nurse (LN 2) for a chest x-ray. However, this order was not entered into the medical record on that date, and the mobile radiology service was not notified that day. As a result, there was no chest x-ray order documented on 1/24/26 in the facility’s order summary report. On 1/25/26, the chest x-ray order was finally entered into the system as a STAT order, which the Assistant Director of Nursing (ADON) stated should have been completed within six hours. Despite this, the mobile radiology service was not contacted until the morning of 1/25/26, and the chest x-ray was still not completed by the time the resident was transferred to an acute care hospital at 10:20 p.m. that evening for multiple episodes of vomiting with shortness of breath. The ADON confirmed that the chest x-ray should have been completed the same day it was originally ordered and that the facility’s policy requires obtaining radiology services when ordered. The failure to timely enter the order and notify the radiology provider resulted in the ordered chest x-ray not being performed prior to the resident’s transfer.
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