Missed Chest X-Ray Order for Febrile Resident
Summary
The facility failed to ensure that a chest x-ray ordered for a resident with fever was obtained in a timely manner. The resident had diagnoses including cancer, hip fracture, and anxiety disorder, and the admission MDS documented a BIMS score of 11, indicating moderate cognitive impairment. On 03/09/2026, the resident was observed flushed, shivering, febrile at 101.9 degrees Fahrenheit, with elevated blood pressure and an oxygen saturation of 92% on room air. The physician was notified and ordered blood work, urinalysis, urine culture and sensitivity, and a chest x-ray. A physician order documented a chest x-ray to be obtained that night, and nursing notes later documented that laboratory results were pending, with abnormal urinalysis and blood test results reviewed with the physician. A physician assistant later documented that the resident was awake, alert, and oriented to person and place with periods of forgetfulness, denied respiratory and urinary symptoms, and had stable respiratory status, while noting that chest x-ray and urine culture and sensitivity results would be followed up for further intervention. However, the medical record contained no evidence that the chest x-ray was completed as ordered. The resident later developed shaking uncontrollably and confusion, and the family requested transfer to the hospital, where the resident was admitted with pneumonia. Interviews with nursing leadership and the x-ray vendor indicated the requisition had been sent, but the vendor could not locate it and there was no documentation of follow-up in the medical record regarding the missed x-ray. The Director of Nursing stated the x-ray was not done and that the order should have been completed within 24 hours, but no progress notes documented the communication with the physician or the vendor regarding the missed test.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident injured a finger when a wheelchair rolled downhill and the finger became caught, leaving it swollen, bruised, and very painful with limited ROM. Although an X-ray was verbally ordered, the imaging was not completed until 15 days later, and the resident stated the finger still did not bend fully and remained sore; the resident was not aware of the X-ray results.
Failure to timely arrange ordered diagnostic imaging for two residents. One resident with cardiac disease had a PET scan ordered by cardiology, but the scan was repeatedly cancelled or delayed due to billing issues and was still not completed as documented. Another resident with a history of colon cancer and severe cognitive impairment had a CT abdomen/pelvis ordered for abdominal pain, but the record showed no documentation that the test was scheduled after the order was written. Staff and the ADM acknowledged the facility was responsible for arranging outside procedures and that scheduling should begin promptly after orders are received.
A resident with a recent wrist fracture, pain, and swelling was seen by the NP, who ordered a left wrist x-ray. The record showed the order was marked complete, but there was no documentation that the x-ray was actually done, no results were found, and staff interviews showed the order was not completed in the expected timeframe. The resident later reported worsening wrist pain, swelling, redness, and bruising, and the DON confirmed the x-ray company had not completed the earlier order.
A resident admitted with a pelvic fx had an unwitnessed fall and low O2 sat, prompting the MD to order a stat chest x-ray. The record did not show the x-ray was obtained, and staff interviews indicated stat imaging should have been completed the same day or within 4 to 6 hours, with the MD notified if it could not be done.
A resident with a history of intracerebral hemorrhage, stroke, hemiplegia, falls, and other significant diagnoses slid out of bed during care and was found on the floor. The resident had physician orders for X-rays of the face and C-spine, including a STAT order, but the radiology studies were not completed before transfer to the hospital. The DON said there were record-tracking problems during an ownership/EMR transition and that radiology canceled the X-ray, but no documentation was provided showing when or why the orders were discontinued.
A resident with hemiplegia/hemiparesis, cerebral infarction, morbid obesity, DM2, a right toe fracture, and a non-pressure injury of the left foot had physician-ordered x-rays of both knees, but the facility did not obtain or document the right knee x-ray results. The DON later received the left knee x-ray, but the right knee results were still unavailable.
Delayed X-ray for Injured Finger
Penalty
Summary
The facility failed to obtain diagnostic services promptly for a resident who injured the left middle finger when the resident’s wheelchair rolled downhill and the finger became caught while the resident tried to stop it. Nursing documentation on the day of the injury described the finger as swollen, purple, and bruised, and the resident reported severe pain rated 9 out of 10 with limited range of motion. The resident’s provider was notified and an X-ray was verbally ordered, but the record shows the imaging was not completed until 15 days after the injury was first identified. The clinical record also showed delays and inconsistency in the documentation of the X-ray order and scheduling. Notes indicated the X-ray would be ordered if not already done, later that it was to be scheduled, and then that it was ordered through an outside service. The completed X-ray showed degenerative changes with no fracture or dislocation. During interview, the resident stated the finger still could not bend fully and remained sore from the top knuckle to the tip, and the resident was not aware of the X-ray results.
Failure to Timely Arrange Ordered Diagnostic Imaging
Penalty
Summary
The facility failed to provide timely diagnostic imaging services for two residents. One resident was admitted with atherosclerotic heart disease, a cardiac pacemaker, and a coronary angioplasty implant and graft, and had intact cognitive skills and capacity to understand and make decisions. A cardiology consultant ordered a PET scan and ECHO, and the record showed the resident left for an outside appointment for those tests. However, the PET scan was not completed as ordered, and the record documented that it was delayed because of billing issues and later cancelled, with no rescheduled date documented at one point in the record. The resident stated that the PET scan had been ordered but had not been accomplished in a timely manner, and that scheduled appointments were cancelled. The resident said the delays could delay diagnosis and treatment and caused upset and frustration. Staff interviews confirmed that the PET scan ordered by cardiology had not been completed and that scheduled appointments had been cancelled. The administrator stated that the facility was responsible for getting residents' procedures done even when they had to be completed outside the facility. A second resident, admitted with a history of malignant neoplasm of the large intestine, anxiety disorder, and hypertension, had severely impaired cognitive skills and did not have capacity to understand and make medical decisions. The physician ordered a CT scan of the abdomen and pelvis without contrast for abdominal pain, and the care plan and change in condition evaluation reflected the abdominal pain and need for the CT. The progress notes documented the abdominal pain and the CT order, but there was no documentation that the CT had been scheduled after the order was written. The resident stated that diagnostic procedures had not been scheduled for several days after they were ordered, and staff interviews confirmed that scheduling should begin as soon as orders are received.
Delayed X-ray for Resident With Wrist Pain
Penalty
Summary
The facility failed to obtain a radiology service in a timely manner for a resident who complained of left wrist pain and swelling. The resident had a history of guillain-barre syndrome, pain, panic disorder, and a recent left wrist fracture. On the NP visit, the resident had active left wrist pain and edema after the stabilizing brace had been removed, and an x-ray of the left wrist was ordered. The resident’s record showed the x-ray order was entered as a one-time order for three days, and the MAR indicated it was signed off as completed the same day. However, the record did not contain documentation showing the x-ray was actually completed, the results were obtained, or that the physician was notified about the delay. During interviews, staff described that x-rays are typically called in to the x-ray company and are usually completed the same day or the next day, but multiple staff and leaders were unaware of the earlier order or could not confirm that it had been completed. The resident later reported that the wrist pain had worsened over the prior two weeks, with swelling, redness, bruising, and pain rated 9 out of 10. The resident stated the x-ray ordered at the NP visit had not been completed by the time of the later physician visit. The DON confirmed the x-ray company did not complete the order from the earlier date, and the Administrator said the issue was believed to have been overlooked.
Failure to Obtain Ordered Stat Chest X-Ray
Penalty
Summary
The facility failed to ensure an ordered stat chest x-ray was obtained for a resident admitted with a diagnosis of pelvic fracture after an unwitnessed fall. Progress notes show the resident’s physician was notified on 3/1/26 that the resident had an unwitnessed fall and an oxygen saturation of 85 percent on room air; oxygen was applied and the saturation increased to 93 percent. The physician then ordered a stat chest x-ray, but the resident’s clinical record did not show that the x-ray was obtained on 3/1/26. During interviews, an RN stated that a stat x-ray was to be completed the day it was ordered and that if the x-ray technician could not come to the facility, the physician was to be notified. The DNS stated stat orders were to be obtained within four to six hours and that if they could not be obtained within that time, the physician was to be notified; the DNS also stated there was no x-ray obtained and no indication staff called the physician.
Failure to Complete Ordered X-Rays After Resident Fall
Penalty
Summary
The facility failed to ensure that ordered X-ray services were completed in a timely manner for one resident after a fall from bed during care. A CNA reported that while changing the resident’s brief and turning the resident to the other side of the bed, the resident slid out of bed and was found sitting on the floor between the bed and wall. The resident had been admitted with multiple diagnoses including intracerebral hemorrhage, muscle weakness, falls, cerebral infarction, hemiplegia and hemiparesis affecting the left dominant side, progressive vascular leukoencephalopathy, morbid obesity, glaucoma, an implantable loop recorder, and neuropathy, and had a BIMS score of 15/15 indicating cognitive intactness. The resident’s record showed physician orders for X-rays of the right side of the face and C-spine, including a STAT order, but the radiology tests were not completed before the resident was transferred to the hospital. During interview, the DON stated that during the facility’s transition in ownership and new EMR there were problems with records and tracking orders, and that the X-ray was canceled by radiology. The DON stated the nurse manager should keep up with resident orders, but did not provide documentation of when or why the X-rays were discontinued. The facility policy stated that resident medications, treatments, and plan of care must be in accordance with licensed physician orders and that the facility shall ensure physician orders are followed as entered into the medical chart.
Missing Ordered Knee X-Ray Results
Penalty
Summary
The facility did not ensure that radiology and diagnostic services were obtained to meet resident needs because it failed to obtain the ordered x-ray results for Resident 9's right knee. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of the right toe, and a non-pressure injury of the left foot. On 2/6/26, the physician ordered x-rays of both the left and right knee, but no documentation of the right knee x-ray results was found in the medical record. On 6/2/26 at 2:44 PM, the DON emailed copies of the left knee x-ray, and was informed that the right knee x-ray results were still not available; no results for the right knee x-ray were provided.
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