Delayed Physician Notification of Abnormal X-ray Results Following Resident Fractures
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for a resident, resulting in significant delays in medical intervention. On two separate occasions, the resident sustained fractures to the lower extremities after incidents involving transfers from a shower chair to the bed. In both cases, x-rays were ordered and results indicating fractures were received by the facility, but there was a delay in notifying the physician and in sending the resident to the hospital. For the first incident, the x-ray result showing a left tibia fracture was received, but the resident was not sent to the hospital until five days later. For the second incident, the x-ray result showing a right tibia fracture was received, but the resident was not sent to the hospital until the following day. Interviews and record reviews revealed that nursing staff either did not notify the nurse practitioner (NP) immediately or failed to follow up when no response was received. In some cases, staff relied on text messages to communicate critical results and did not escalate the situation when the NP did not respond. Documentation was inconsistent regarding how and when the NP was notified, and there was confusion among staff about the appropriate steps to take when a physician could not be reached. The Director of Nursing (DON) and other staff members confirmed that there was a lack of clarity and follow-through in the notification process, and that the facility's policies for prompt physician notification were not followed. The resident involved had a history of multiple sclerosis, lack of coordination, and was dependent on staff for transfers and personal care. After each incident, the resident experienced pain and reported that the pain was not adequately managed until she was sent to the hospital. The facility's failure to promptly notify the physician and act on abnormal diagnostic results led to delays in appropriate medical treatment for the resident.
Removal Plan
- The DON, ADON D, and ADON E completed a change of condition assessment focusing on pain on each resident to determine if they are not at their baseline. Each resident was documented on the outcome of their assessment in their progress note in Point Click Care. For any residents that were found not to be at their baseline, their physician was notified and documented on. Any conditions noted after this immediate assessment, and it was found that the physician was not notified, a re-education of physician notification was completed.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- In-services were initiated by the Chief Nursing Officer. Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. The ADM and human resources will ensure these team members are removed from the time clock and PCC access removed. This will be monitored until 100% complete or the team members are terminated. Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered. The passing score will be 80% - 100%.
- Licensed nurses were in-serviced on: Notifying physicians during a change of condition in a resident; Physician on-call schedule; Process on what to do if a physician cannot be reached; Comprehensive Pain Management Treatment Plan for each resident.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- The Corporate Nurse immediately audited the 24-hour facility resident summary to determine if there were any changes of conditions focusing on pain that were noted, and the physician was notified. These findings were sent to the DON, ADON D, and ADON E for follow-up.
- The chief nursing officer reviewed the administrative nurse's follow-up to ensure follow-up happened and will do this daily.
- DON, ADON D, and ADON E will monitor daily residents' current electronic records for a change of condition utilizing the Point Click Care Clinical Dashboard, which includes resident's Change of Condition, 24 Hour Resident Report, Progress notes, Incidents & Accidents, Weights & Vitals, and Diagnostic reports on all residents daily.
- To ensure accuracy, DON, ADON D, and ADON E will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- Interviews were conducted with nurses to verify understanding of on-call physician number access, notification process, change in condition identification, and escalation if unable to reach a provider.
- Record review of facility in-services titled Notifying Physicians During a Change of Condition, Physician On Call Schedule, and What to do if a Physician cannot be reached revealed all nursing staff had signed indicating education was completed by all nurses.
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.
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 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.
A resident experienced a witnessed fall from a wheelchair, striking the head and later developing swelling and bruising around one eye. Nursing staff notified the physician, and a PA subsequently evaluated the resident, noting headache and vision changes and ordering an orbital x-ray. The medical record shows no evidence that the ordered x-ray was ever completed or that results were obtained, even though the facility’s assessment states it will provide access to diagnostic x-ray services. The resident later had another fall and was sent to the hospital, where a head CT was performed, and the ADON later confirmed the orbital x-ray had not been done.
A resident’s x-ray results were reported to the facility but were not promptly communicated to the nurse practitioner. An LPN checked the EMR once during the night and saw the results as pending, did not recheck later in the shift, and did not notify the NP. An RN later documented that results were relayed and the NP ordered hospital transfer, but the NP reported they were not notified by staff and only became aware of the results upon independently reviewing the EMR. The DON stated nurses are expected to check for x-ray results at shift start and end and immediately notify the NP when results are available.
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.
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.
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 Complete Ordered Orbital X-Ray After Resident Fall With Head Injury
Penalty
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.
Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
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