Failure to Ensure Safe X-Ray Positioning Results in Resident Arm Fracture
Summary
A resident with a history of stroke, contracture of the right arm, diabetes, hypertension, neurogenic bladder, arthritis, aphasia, and osteoporosis experienced significant pain and ultimately a fracture following an x-ray procedure performed by a contracted x-ray technician. The resident was cognitively intact but had physical impairments and required complete assistance for activities of daily living. The x-ray was ordered due to redness, swelling, and pain in both elbows, and the resident was being treated for possible cellulitis at the time. During the x-ray procedure, the technician attempted to reposition the resident's contracted right arm without adequate assistance from facility staff, despite the resident's inability to move the arm due to the contracture. The resident cried out in pain during the procedure, which was heard by a registered nurse who intervened and stopped the technician from further manipulating the arm. The technician stated that she could not obtain the necessary images without straightening the arm, but did not request or wait for staff assistance as required by the x-ray company's own procedures. Facility staff were not present in the room during the initial attempt, and the technician did not seek help despite the resident's obvious physical limitations and pain. Following the incident, the resident continued to experience increased pain in the right arm, which was not relieved by Tylenol and later required stronger pain management. Subsequent x-rays revealed fractures in the right arm, and the resident was referred to an orthopedic physician for casting. Interviews with facility staff and review of the x-ray company's procedures confirmed that facility staff assistance was required for repositioning residents with significant physical limitations, but this protocol was not followed during the incident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident experienced a fall, was found on the floor with a left elbow skin tear, and later reported significant left hip pain with inability to tolerate ROM. An NP ordered a STAT hip X-ray and indicated that STAT imaging should occur within four hours, with nursing responsible for contacting radiology. The assigned RN initially entered the order as routine, later changed it to STAT, and called the X-ray company, but the physician orders did not reflect STAT status. The X-ray was not performed until the following day, at which time imaging revealed an acute comminuted left femoral intertrochanteric fracture.
Delayed STAT Chest X-Ray: An LPN notified the on-call NP after a resident with COPD and oxygen use reported chest pain, and a STAT CXR was ordered. The resident was told the x-ray would be done that night, but it was not completed until the next day. Staff gave inconsistent accounts of the expected STAT timeframe, and the physician/NP was not notified when the test was not completed during the overnight shift.
A resident with hemiplegia and hemiparesis following a cerebral infarction had a physician order for a CT scan to rule out an ascending aortic aneurysm, but the exam was never completed. The Unit Manager entered the CT order into the medical record but did not complete the required appointment request form, so case management was not notified to schedule the test with an outside provider. The DON confirmed this missed CT scan was an oversight, contrary to the facility’s diagnostic services policy requiring timely coordination and completion of ordered diagnostic services.
A resident with severe cognitive impairment, multiple comorbidities, and a history of falls was found with a swollen, bruised, and painful right leg and knee during care. A CNA notified an LVN, who assessed the resident and contacted hospice; a hospice RN assessed the resident and obtained a STAT x-ray order, but the x-ray vendor did not arrive as expected. Despite the STAT designation and subsequent instruction to use the facility’s own x-ray provider, the first x-ray was not performed until the next day, revealing a tibia fracture, and a second x-ray later that day showed a right knee fracture. Approximately 33 hours passed from the initial STAT x-ray request to the resident’s transfer to the ER, during which facility staff did not ensure timely completion of the ordered STAT imaging or clearly document follow-up, resulting in delayed diagnosis of the fractures.
Failure to Follow Up on Recommended Thyroid Ultrasound: A resident with a right thyroid nodule had repeated PM&R notes stating that an US was recommended and would be scheduled, but the facility did not follow up to confirm completion of the diagnostic testing. The ADON stated the notes should have been clarified with the MD, and the DON stated that without follow-up the facility could not provide the right treatment and interventions for the resident.
A resident with multiple comorbidities, including venous insufficiency and CHF, had a right lower extremity duplex ordered, but the contracted radiology provider did not perform the exam within the 24-hour timeframe required by contract and did not communicate the delay to the facility. The imaging was completed several days after the order, and the results were not read or transmitted until days after the exam, despite the provider’s usual 6–8 hour turnaround. Facility leadership confirmed they did not receive results until days later and only contacted the radiology company after the family asked about the test, and there was no documentation of communication between the facility and the provider regarding the delays.
Delay in STAT Hip X-Ray After Resident Fall With Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely STAT hip X-ray for a resident following a fall. According to progress notes, the resident was found on the floor in front of his wheelchair in an upright sitting position with a skin tear to the left elbow in the early morning, and the NP and the resident’s wife were notified. Later that day, the NP documented that the resident reported left hip pain and was unable to participate in range of motion, and ordered a STAT hip X-ray. The NP stated that a STAT X-ray should be completed within four hours and that nursing staff are responsible for contacting the X-ray company. The DON and ADON confirmed that the X-ray was not performed until the following morning, and the ADON recalled the resident’s daughter questioning why it took until the next morning for the X-ray to be done. The RN assigned to the resident that day reported that the resident complained of pain rated 7/10 and that she initially entered the X-ray as a regular order, then changed it to STAT after being instructed by the NP and called the X-ray company to communicate the STAT status. Progress notes from the next morning show the nurse contacting the X-ray company for an estimated time of arrival, and the radiology report indicates that the hip X-ray results, showing an acute comminuted left femoral intertrochanteric fracture, were not reported until the next day. The physician orders show two one-time hip X-ray orders entered on the day of the fall, neither marked as STAT, despite the facility policy requiring the nurse who takes the order to execute it, including contacting radiology services as required.
Delayed STAT Chest X-Ray
Penalty
Summary
The facility failed to ensure radiology services were obtained and reported in a timely manner for one resident with COPD who used oxygen and had moderately impaired cognition. The resident developed increasing aching chest pain upon exhalation and was assessed by an LVN, who documented vital signs within normal limits, oxygen saturation of 97% on 2 liters nasal cannula, and pain rated 6 out of 10. Nitroglycerin and PRN pain medication were given, the on-call nurse practitioner was notified, and a STAT chest x-ray was ordered. The resident was told the chest x-ray would be completed the same night, but it was not performed during that shift. The next morning, the resident asked for an update because the x-ray had not yet been done. The resident stated she had chest pain the prior day, that the night nurse had called the NP and said the x-ray would be completed that night, and that she had not received it. The resident was not in pain at the time of the later interview and declined transfer to the hospital when offered. Staff interviews showed inconsistent understanding of the expected timeframe for STAT testing, with responses ranging from 2-4 hours, 3-5 hours, and 4-6 hours. The LVN who received the order stated the lab company had not arrived by the end of the shift and said the information was passed to the next shift because the technician was still within the stated window. Other staff stated that if the x-ray could not be completed within the expected window, the physician or NP should have been notified, but that did not occur during the night shift. The chest x-ray was ultimately completed the next day and showed no abnormal results.
Failure to Complete Ordered CT Scan Due to Missed Scheduling Process
Penalty
Summary
The facility failed to carry out a physician order for a CT scan for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. A physician order dated 12/10/2026 directed that the resident receive a CT scan to exclude an ascending aortic aneurysm. Review of the medical record showed no documented evidence that the CT scan was ever completed for this resident. The Unit Manager stated that certain diagnostic procedures, such as X-rays, KUB, and EKG, could be done in the facility, while CT scans, MRI, and barium swallow tests had to be scheduled with an outside provider. The Unit Manager explained that after a physician order for a CT scan is obtained, a nurse is supposed to complete an appointment request form and give it to case management to schedule the procedure. The Unit Manager acknowledged personally entering the CT scan order into the medical record but forgetting to complete the appointment request form, so the order was never communicated to case management. The DON confirmed that the missed CT scan was an oversight. The facility’s Diagnostic Services policy stated the facility would ensure diagnostic services meet residents’ needs and that the facility would be responsible for the quality and timeliness of services, whether provided on-site or by an outside resource, with results reported timely to the ordering physician.
Delay in STAT X-ray Completion and Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide timely radiology and diagnostic services to meet a resident’s needs after new swelling, bruising, and pain were identified in the resident’s right leg and knee. The resident was an elderly female with traumatic cerebral hemorrhage, a prior left femur fracture, anxiety disorder, hypothyroidism, dementia, and epilepsy, who was severely cognitively impaired and unable to verbally respond, requiring at least supervision or partial assistance for bed mobility and transfers. Her care plan included fall-related interventions such as keeping the bed in the lowest position, use of a fall mat, frequent checks, increased supervision, and evaluation of the environment after falls, as well as monitoring for altered neurological status. On the morning in question, a CNA observed that the resident’s right leg appeared larger than the left and that the resident screamed when her leg was touched during incontinence care. The CNA reported this to an LVN, who assessed the resident and noted swelling, bruising, and a twisted appearance of the right knee and leg. The LVN notified hospice, and the hospice RN came to the facility, assessed the resident, and obtained a STAT x-ray order. The hospice RN then left the facility after calling in the STAT x-ray order. Later that evening, while charting, the hospice RN called the facility and learned that the x-ray technician had not arrived and that the x-ray had not been completed. The hospice RN then instructed facility staff to request x-rays from the facility’s own x-ray provider and sent the STAT x-ray order to the facility. Despite the STAT designation, the first x-ray was not performed until the following morning, approximately 24 hours after the initial STAT x-ray request. That x-ray showed a fractured tibia, and the physician then ordered an additional x-ray of the right knee, which was performed later that afternoon. The repeat x-ray results, received that evening, showed a fractured right knee, and the physician then ordered the resident sent to the ER. In total, about 33 hours elapsed between the original STAT x-ray request and the resident’s transfer to the hospital. Interviews with the DON and LVN indicated that the facility deferred to hospice for treatment decisions for hospice residents, that the facility was responsible for carrying out hospice orders, and that there was no clear documentation of which staff followed up on the delayed x-ray or when. The facility’s own policy required staff to process test requisitions and arrange for tests, and to immediately communicate critical values to the provider, but the STAT x-ray was not obtained or resulted in a timely manner, leading to a delay in diagnosis of the resident’s right femur and right knee fractures.
Failure to Follow Up on Recommended Thyroid Ultrasound
Penalty
Summary
The facility failed to follow up on a recommendation for an ultrasound of Resident 101’s right thyroid nodule for diagnostic testing. Resident 101 was admitted with diagnoses including spondylosis with myelopathy in the cervical region, disorder of bone density and structure, and osteoarthritis in both hands. The resident’s H&P stated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living. Pacific Rehab Consultants PM&R follow-up notes repeatedly documented that an ultrasound was recommended due to the right thyroid nodule and that the recommendation was discussed with nursing and would be scheduled. These notes were dated 11/26/2025, 12/4/2025, 12/19/2025, 1/27/2026, and 3/10/2026. During interview, the ADON stated nurses read the PM&R follow-up notes and that any orders would be placed by the PA, and acknowledged that the recommendation should have been clarified with the doctor and followed up to determine whether the diagnostic testing had been completed. The DON stated that if a recommendation was not followed up, the facility would not be able to provide the right treatment and interventions for Resident 101.
Failure to Ensure Timely Diagnostic Imaging and Results
Penalty
Summary
The deficiency involves the facility’s failure to obtain and/or ensure timely diagnostic imaging and results for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. An order was placed on February 6, 2026, for a right duplex venous scan related to venous insufficiency, and the order indicated the imaging was sent that same day. The radiology company reported that the exam was not actually performed until February 9, 2026, three days after the order, despite a contract requirement that services be provided within 24 business hours or a time be scheduled with notification to the facility if that timeframe could not be met. The radiology company further stated that results are usually available within six to eight hours after imaging, but in this case the exam was not read by a radiologist and the results were not sent to the facility until February 13, 2026. The DON confirmed the facility did not receive the diagnostic imaging results until February 13, 2026, and that she only contacted the radiology company after the resident’s family inquired about the results during a care plan meeting that same day. The radiology company liaison and territory manager acknowledged the delays in both performing the duplex and in resulting the exam, and indicated there was no communication with the facility about these delays, contrary to the contractual obligation to promptly notify the facility if the 24-hour service time could not be met. The facility did not have documentation showing any communication with the radiology company regarding the delayed exam or delayed receipt of results.
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