Failure to Ensure Ordered Post‑Fall X‑Ray Was Completed and Tracked
Penalty
Summary
Staff failed to follow physician orders and facility policy for diagnostic testing after a resident’s fall, resulting in ordered bilateral hip x‑rays not being completed or tracked. The resident, who had multiple diagnoses including type 2 diabetes with hyperglycemia, chronic right heart failure, chronic respiratory failure with hypoxia, muscle wasting, right knee pain, and lymphedema, was care planned as at risk for falls and required moderate assistance with transfers. The care plan noted prior witnessed and unwitnessed falls and interventions such as education on using the call light and ensuring the wheelchair was locked. On the evening of 02/16/26, RN A documented that the resident was found on the floor on the left hip beside the bed after an unwitnessed fall while attempting to transfer from bed to wheelchair. A head‑to‑toe and skin assessment were completed, and the resident complained of bilateral hip pain. The resident’s family, physician, and management were notified, and a new order was received for bilateral hip x‑rays. The physician order sheet reflected an order dated 02/17/26 for bilateral hip x‑rays due to the fall and increased hip pain. Subsequent progress notes on 02/17/26, 02/18/26, and 02/19/26 documented ongoing fall follow‑up, normal vital signs and neuro checks, and no complications or signs of pain, but did not document that the x‑ray was obtained or that results were received. Record review showed no x‑ray results in the resident’s chart, and the resident later reported having had a fall about a week earlier with leg pain and stated that no x‑ray had been done since. RN A reported placing the x‑ray orders in the computer, calling the radiology company, being told they would come the next day, preparing a packet for radiology, and then calling again when they did not arrive, but acknowledged not documenting these contacts and not knowing why the x‑ray was never done; the prepared packet remained at the facility. The radiology company reported having no record of any calls from the facility regarding this x‑ray order and stated they document every call received. The DON confirmed that the radiology company reported never receiving an order, that staff must call the company for x‑rays to be done, and that the physician’s orders for the x‑ray were not followed.
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