Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of Type 2 Diabetes Mellitus experienced a choking incident during a meal. The resident was found in distress, coughing up phlegm, and required suctioning by the RN supervisor. Following this event, a physician issued a STAT order for a portable chest x-ray to be performed immediately. The order was entered into the computer system, and the nurse observed that a technician had been assigned in the system, but did not call the x-ray company to confirm the estimated time of arrival. The x-ray was not completed during the nurse's shift, and there was no follow-up communication with the x-ray company or the physician regarding the delay. Interviews with facility staff, including the LNHA, DON, and nurses, revealed that the facility's expectation was for the nurse to call the x-ray company for STAT orders and to notify the physician if there was any delay. The facility's policy also required follow-through with orders by making appropriate contact or notification. Despite these expectations and policies, the nurse relied solely on the system's indication that a technician was assigned and did not take further action to ensure the STAT x-ray was performed promptly, nor was the physician notified of the delay.