Failure to File Signed and Dated Diagnostic Report in Resident Record
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who experienced increased heart rate and low-grade fever had a stat EKG ordered by a nurse practitioner. Although an LPN reported that the EKG was performed, the signed and dated EKG report was not filed in the resident's medical record, as confirmed by a review of the electronic record and staff interview.
A resident with a history of traumatic subdural hemorrhage and paraplegia reported genital pain, leading to a physician's order for an ultrasound. The ultrasound was performed, but the results were not filed in the clinical record, reviewed by staff, or reported to the attending physician as required by facility policy. Staff were unaware of the missing results until prompted by a surveyor.
A resident receiving antibiotics for pneumonia did not have a signed and dated chest x-ray report filed in their clinical record, despite staff confirming that such a report should have been present to support the diagnosis and treatment.
A resident with a complex medical history experienced knee and hip pain, prompting x-rays to be ordered. While reports for the left knee and hips were documented, the right knee x-ray report was missing from the medical record, despite a critical fracture being reported. The DON acknowledged the oversight, and the missing report was later provided by the Regional Clinical Operations Director.
A facility failed to include a signed and dated ultrasound report in a resident's clinical record. The ultrasound was ordered for screening the resident's bilateral breasts for lumps or masses. Despite the procedure being completed, the report was not documented in the record, as confirmed by the Assistant DON.
A facility failed to include signed and dated EKG reports in a resident's medical records. The resident, with a complex medical history, was ordered a 12 lead EKG for monitoring, but the reports were not filed. The DON confirmed the report was sent to the provider but not to the facility.
Failure to File Signed and Dated EKG Report in Medical Record
Penalty
Summary
The facility failed to file a signed and dated EKG report in the medical record for one resident. The resident had experienced an increased heart rate and low-grade fever, prompting a nurse to consult with a nurse practitioner, who ordered a stat EKG, chest x-ray, and urinalysis. Although the EKG was reportedly performed later that day, a review of the resident's medical record did not contain any evidence of the EKG being completed or filed, as confirmed by both the electronic results tab and the miscellaneous section of the record. During an interview, the LPN explained that the EKG should have been downloaded into the medical record but was not, resulting in the absence of the required documentation.
Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.
Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.
Missing X-ray Report in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, specifically by not filing a signed and dated x-ray report for the resident's right knee. The resident, who had a complex medical history including hemiplegia, atherosclerotic heart disease, and type 2 diabetes, was experiencing bilateral knee and hip pain. An x-ray was ordered for both knees and hips, and while the results for the left knee and hips were documented, the report for the right knee was missing from the medical record. The deficiency was identified during a review of the resident's medical records, which revealed that the x-ray report for the right knee was not present, despite a critical fracture being reported to the facility. The Director of Nursing acknowledged the oversight, stating that the facility had not received a printed report for the right knee, although the Regional Clinical Operations Director later provided a copy of the missing report. This lapse in documentation highlights a failure in the facility's process for ensuring all diagnostic reports are properly filed in the resident's medical record.
Missing Signed and Dated Diagnostic Report in Resident's Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained signed and dated reports of radiologic and other diagnostic services. Specifically, for one resident, there was an absence of a documented ultrasound report that was ordered by a physician on June 20, 2024, for screening of the resident's bilateral breasts for any abnormal lumps or masses. Despite the ultrasound being completed, as confirmed by the Assistant Director of Nursing during an interview, the clinical record did not contain the necessary signed and dated report, which is a requirement under the relevant regulations.
Missing EKG Reports in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for one resident, identified as Resident 14, by not including signed and dated reports of diagnostic services. Resident 14, who had a complex medical history including cerebral infarction, hemiplegia, cognitive communication deficit, and other conditions, was ordered a 12 lead EKG for monitoring over two days. However, the EKG reports were not found in the resident's medical records. During an interview, the Director of Nursing (DON) acknowledged that the EKG report was obtained but was sent to the provider instead of being filed in the facility's records.
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