F0658

G

Failure to Implement Physician-Ordered X-Ray After Resident Fall

Oxnard, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that services met professional standards of quality when nursing staff did not transcribe and implement a physician’s x‑ray order following a resident’s fall. The resident, who had anemia, dementia, depression, and anxiety and a BIMS score indicating severe cognitive impairment, experienced a fall onto her bottom while attempting an unassisted transfer from bed to wheelchair. A licensed nurse notified the physician and received verbal orders for a hip and sacrum x‑ray and PRN Tylenol for pain, and documented leaving a message for the resident’s daughter about the fall and the new x‑ray order. However, the x‑ray order was never entered into the electronic health record, no paper requisition was completed, and the diagnostic company was not contacted, contrary to facility policy requiring that personnel receiving verbal or telephone orders transcribe them into the system.

Record review confirmed there were no x‑ray orders or results in the resident’s chart following the fall. The licensed nurse later acknowledged she did not transcribe the order or call the diagnostic company and that the x‑ray was never done. The RN supervisor confirmed the absence of x‑ray results in the medical record, and the DON stated that the facility discovered the missed x‑ray only after the resident complained of hip pain during a transfer several days later. The resident was subsequently evaluated in the emergency department, where an intertrochanteric fracture of the right hip was identified. Facility policies on physician orders and fall response, as well as a nursing textbook excerpt on the obligation to follow physician orders, were cited in relation to the failure to carry out the ordered diagnostic testing.