F0552

D

Failure to Inform Resident and Responsible Party of STAT Hip X-Ray Order

Los Angeles, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to follow its resident rights policy requiring that residents and/or their responsible parties be notified of their medical condition, changes in condition, and treatments. A resident admitted with multiple diagnoses, including displaced intertrochanteric fracture of the right femur, displaced fracture of the epiphysis, anxiety disorder, and major depressive disorder, had documented limited decision-making capacity and moderate cognitive impairment. The resident required assistance with toileting, bathing, and lower body dressing, and the MDS indicated Spanish as the preferred language with a need for an interpreter to communicate with medical staff. A physician’s order was entered for a STAT bilateral hip x-ray due to the resident’s condition.

During interviews and record review, the RN acknowledged that although the resident was alert to name and able to express basic needs, it would be better to inform the responsible party because the resident would not remember, and confirmed there was no documentation that either the resident or responsible party had been informed of the x-ray order. The RN stated the resident later alleged that a man was taking a picture of her and admitted the failure to notify and document notification of the procedure. An LVN reported being present with the x-ray technician and explaining to the resident, in English, that the x-rays were being taken due to leg pain, but the LVN did not speak Spanish and confirmed there was no documentation that the order and procedure were explained to the resident. This sequence of events resulted in the resident and responsible party not being fully informed or able to understand and participate in decisions regarding the x-ray, contrary to the facility’s written resident rights policy.