Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to ensure the timely provision of radiology services for a resident who was admitted with conditions including unspecified deep vein thrombosis, gout, and anxiety. The resident, who was cognitively intact, experienced a fall and subsequently complained of right shoulder pain. A physician ordered an x-ray of the right shoulder to rule out a fracture. However, the x-ray was not completed in a timely manner, as confirmed by a review of the resident's clinical record during the survey. On the day of the survey, a STAT x-ray was ordered, but the mobile x-ray company had not completed the imaging by 8:30 PM. Consequently, the resident was sent to the emergency room for the x-ray. Upon arrival, the resident refused the right shoulder x-ray and requested imaging of the left shoulder instead. The left shoulder x-ray was completed and showed no acute fracture. The Director of Nursing confirmed that the x-ray was not completed as originally ordered, indicating a failure in the facility's responsibility to provide timely diagnostic services.
Plan Of Correction
Step 1 Resident # 64 x-ray was obtained on 1/29/2025 with no negative findings. Step 2 To identify like residents that have the potential to be affected, an in-house audit of radiology/diagnostics studies was completed for the last 2 weeks to ensure that diagnostics were completed and followed up in a timely manner. Step 3 To prevent this from happening again, the DON/designee will educate the licensed staff on following up with radiology/diagnostics studies with the physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for radiology/diagnostics studies per week for 4 weeks, then monthly for 2 months to ensure diagnostic tests are followed up in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.
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