Failure to Obtain Timely CT Imaging After Abnormal Chest X-Ray
Penalty
Summary
Facility staff failed to obtain a timely diagnostic CT scan as recommended and ordered for a resident with a history of goiter. The resident was admitted in 2024 with diagnoses including goiter and later had a chest X-ray on 3/3/25 to rule out pneumonia. The X-ray report noted nonspecific superior mediastinal widening with overall findings worse compared to a prior study from 4/22/2024 and specifically recommended a CT scan. Despite this recommendation, a physician order for the CT scan was not placed until 3/28/25. That order was updated on 4/3/25 to include a scheduled CT date of 4/8/25. On 4/7/25, the CT scan order was discontinued because the imaging provider would not take the resident on a stretcher, and no alternative arrangements were documented in the record at that time. The resident was hospitalized from 4/15 to 4/18/25, and the hospital discharge summary again referenced imaging that showed moderate left paratracheal soft tissue density deviating the trachea to the right, compatible with probable substernal thyroid, and recommended correlation with a chest CT as an outpatient. The chest CT was not ordered or obtained until the resident was sent to the hospital on 6/9/25. The Regional Director of Clinical Operations confirmed that facility staff failed to follow up and obtain the CT scan from 3/3/25 until 6/9/25.
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