Failure to Complete Ordered Orbital X-Ray After Resident Fall With Head Injury
Summary
The deficiency involves the facility’s failure to ensure that an ordered orbital x-ray was completed for a resident following a fall with head impact. The facility’s Facility Assessment dated 11/1/25 states that the facility will employ or contract staff to provide clinical laboratory and diagnostic x-ray services. Nursing progress notes document that the resident had a witnessed fall in the hallway, during which the resident, who was wheeling himself in a wheelchair, scooted out of the chair and hit his head. The following day, nursing notes recorded slight swelling and a bruised right eye, and the night shift nurse notified the facility Medical Director. On 12/31/25, a physician’s assistant evaluated the resident for a fall follow-up and documented a positive review of systems for headache and vision changes, with a plan for an orbital x-ray. Despite this order, the resident’s electronic medical record contains no documentation that the orbital x-ray was ever completed or that any results were obtained. Subsequent nursing notes show that the resident later experienced another fall and was sent to a local emergency room, where a head CT was performed. On 2/10/26, the ADON confirmed that the resident did not receive the ordered orbital x-ray during the time the resident remained in the facility and stated that the x-ray should have been completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cervical stenosis and severe neck and knee pain had an MRI of the cervical spine ordered by a pain specialist, but the facility failed to ensure the test was completed. Facility policy assigns licensed nurses responsibility for arranging ordered diagnostic tests and monitoring results, yet the MRI was not performed as scheduled on two separate occasions, and there was no documentation explaining the missed appointment. The scheduler reported not being informed that the initial MRI was not completed or that it had been rescheduled, resulting in the resident not receiving the ordered imaging.
A resident with dementia and impaired cognition complained of left wrist pain and swelling after a reported fall, leading an LVN to obtain an x-ray order and document the pending result on the 24-hour report. The x-ray, completed later that day, showed acute distal radial and ulnar fractures with displacement and was available in the lab portal late that night, but the night-shift LVN did not check or pull the results or notify the practitioner, despite facility policy requiring prompt review and communication of diagnostic findings and immediate reporting of critical values. The abnormal results were only discovered by another LVN the following morning when the lab portal was checked, confirming the fracture and revealing a delay in communicating significant diagnostic findings.
A resident with a history of chronic compression fracture and fall risk had an unwitnessed fall and was found on the floor. An x-ray ordered by the on-call MD showed a right femoral neck fracture, but nursing did not promptly notify the physician of the positive result until the resident was later transferred to the hospital.
Failure to Obtain and Communicate Diagnostic Test Results: A resident with respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, spinal cord infarction, HTN, and GI hemorrhage had a bone biopsy rescheduled and then went out of the facility, but the chart contained no biopsy results. The resident’s representative said January test results were never communicated, and the DON confirmed the facility had not obtained or shared the bone biopsy results with the MD or representative; the Administrator stated there was no policy for obtaining or notifying about diagnostic test results.
A resident with CHF, COPD, AFib, and respiratory failure had a chest x-ray ordered for cough. The x-ray showed findings concerning for bronchitis and pneumonia, but the medical record had no documented evidence that the physician was notified of the results, and the DON verified the lack of documentation.
A resident with dementia, acute respiratory failure with hypoxia, and right-side heart failure had a chest x-ray ordered for a strong non-productive cough. The x-ray showed cardiomegaly, mild CHF changes, and left lower lung opacification, but the record lacked documentation that the ordering practitioner was promptly notified of the results. An LPN said results were placed in a binder for review, yet the resident’s results were not on the log and no notification documentation was found.
Failure to Ensure Completion of Ordered MRI for Resident With Severe Cervical Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered MRI of the cervical spine was obtained for a resident experiencing severe pain. The facility’s policy titled “Physician Notification of Laboratory/Radiology/Diagnostic Results” dated 12/2025 states that licensed nurses are responsible for notifying the laboratory of physician orders for testing and for monitoring receipt of test results so that prompt, appropriate action may be taken. A pain clinic progress note dated 3/19/26, signed by a pain specialist, documents that the resident, an older adult with cervical stenosis and right knee pain, reported severe cervical pain rated 10/10, with a range of 4–10, described as tender, exhausting, penetrating, miserable, and tiring, interfering with general activity, mood, walking, sleep, enjoyment of life, and relationships. The treatment plan included an MRI of the cervical spine without contrast. A subsequent pain clinic progress note dated 4/16/26 documents that the resident did not receive the MRI ordered on 3/19/26. On interview, the pain specialist’s medical assistant confirmed that at the 4/16/26 follow-up visit, the MRI had not been completed. A hospital X-ray technician reported that the resident was scheduled for MRI appointments on 4/9/26 and again the day before the 4/24/26 interview, but the resident did not show up for either appointment and therefore had not had the MRI. The social service director, identified as the scheduler, stated that they were not made aware that the resident did not receive the MRI on 4/9/26 and that there was no documentation explaining why the MRI was not done on that date. The social service director also stated they were not aware that the MRI had been rescheduled, resulting in the resident still not having received the ordered MRI.
Failure to Promptly Review and Report Abnormal X-Ray Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly review and communicate diagnostic test results to the ordering practitioner in accordance with its own policy. A female resident with non-Alzheimer’s dementia, depression, and severely impaired cognition (BIMS score of 6) was admitted with partial to supervised assistance needs for ADLs but was independent with ambulation. On the date of the incident, the resident complained of left wrist pain, and staff observed swelling and pain on palpation. An LVN documented the complaint, administered Tylenol, and obtained an order for an x-ray after the resident reported she had fallen and gotten herself up from the floor. The x-ray was completed that day, and the 24-hour report documented that the left wrist x-ray was pending. The facility’s policy required licensed nurses to review lab/diagnostic results and notify the physician, and specified that critical values must be communicated to the provider within one hour. The x-ray results, available in the lab portal at 11:06 PM, showed acute-subacute distal radial and ulnar fractures with displacement. However, the night-shift LVN responsible for two halls did not check or pull the x-ray results from the lab portal during the 10:00 PM to 6:00 AM shift and did not notify the practitioner of the abnormal findings. The results were not discovered until the following morning when another LVN arrived, checked the lab portal, and saw the fracture report. Multiple therapy staff who worked with the resident on the day of the incident reported that the resident guarded her left hand, did not want to use it, and had slight swelling, but she did not consistently complain of pain. The ADON confirmed that the x-ray results came in during the night shift but were not pulled until the next morning, and stated that charge nurses were responsible for checking the lab portal each shift and that pending x-rays should have been noted on the 24-hour report. This sequence of events led to a delay in recognizing and communicating the abnormal x-ray findings of a fractured wrist to the ordering practitioner. This failure could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition.
Delayed Physician Notification of Fracture Result
Penalty
Summary
The facility failed to promptly notify the physician of a change in a resident's condition when a radiology report confirmed a fracture for Resident R6. Resident R6 was alert and oriented, admitted with a history of chronic compression fracture and recent hospitalization for weakness, and was care planned for bowel and bladder incontinence, one-person assistance with toileting, and fall risk precautions including keeping the bed in the lowest position and using proper footwear. After an unwitnessed fall, the resident was found lying on the floor in the room, and an on-call doctor ordered a 2-view x-ray of the right femur. The x-ray results showed a right femoral neck fracture, but nursing did not inform the physician of the fracture until the resident was transferred to the hospital three days later. The DON stated that nursing failed to inform the physician of the resident's fracture until the transfer.
Failure to Obtain and Communicate Bone Biopsy Results
Penalty
Summary
The facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner for one resident (#44) reviewed for diagnostic testing. Resident #44 was admitted with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. The annual MDS assessment showed the resident was cognitively impaired, had functional range of motion limitations in both upper and lower extremities, and was dependent for all care and transfers. The medical record showed a progress note dated 01/20/26 indicating a bone biopsy had been rescheduled for 02/03/26, and a note dated 02/03/26 indicated the resident was out of the facility. The record contained no results from the bone biopsy scheduled on 02/03/26. The resident representative stated on 03/16/26 that diagnostic testing results completed in January 2026 had not been communicated. The DON confirmed on 03/18/26 that the bone biopsy results had not been obtained by the facility or communicated to the physician and resident representative. The Administrator stated on 03/19/26 that the facility did not have a policy for obtaining diagnostic testing results or notifying the physician and family representative of those results.
Failure to Notify Physician of Chest X-Ray Results
Penalty
Summary
The facility failed to notify the physician of diagnostic radiology results for one resident reviewed for diagnostic laboratory tests and x-rays. The resident had diagnoses including acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, anxiety disorder, nicotine dependence, hyperlipidemia, and benign prostatic hyperplasia, and the care plan identified the resident as at risk for rehospitalization and requiring individualized interventions to detect early changes in condition and avoid unnecessary transfers. A CNP evaluated the resident for cough and ordered a two-view chest x-ray; the resident’s lungs were documented as clear on auscultation, and the x-ray was obtained with results pending later that day. The chest x-ray report showed post-sternotomy status, bilateral hilar prominence, generalized prominence of bronchovascular markings concerning for bronchitis, and ill-defined patchy radiopacities in the right middle and lower zones concerning for pneumonia, with follow-up imaging recommended. The medical record contained no documented evidence that the physician was notified of these diagnostic radiology results. The DON verified on interview that there was no documented evidence the physician had been notified, and the facility policy stated that nursing staff will review resident results and notify the physician via preferred method.
Delayed Notification of Chest X-Ray Results
Penalty
Summary
The facility failed to ensure chest x-ray results were reported to the ordering practitioner in a timely manner for one resident. The resident had diagnoses including dementia, acute respiratory failure with hypoxia, and right-side heart failure. On 12/30/25, a nurse practitioner evaluated the resident for a strong non-productive cough and ordered Robitussin every 4 hours as needed, Prednisone 20 mg daily for 5 days, and a chest x-ray. The chest x-ray completed later that day showed cardiomegaly, mild changes in congestive heart failure, and opacification of the left lower lung field, with findings more pronounced than on the prior chest x-ray and a request for further evaluation with different views. The clinical record did not contain documentation that the physician was notified of the chest x-ray results on 12/31/25. During interview, an LPN stated the results were placed in a binder at the nurse's station for the nurse practitioner or physician to review, but the resident's results were not on the log for 12/31/25 and no documentation of physician notification could be found. The nurse consultant stated the chest x-ray results were reviewed by the nurse practitioner on 1/1/26, and the facility policy required prompt notification and documentation of attempts to notify the practitioner and the response.
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