This week’s “Ftag of the Week” on the CMSCG Blog is F776 Radiology/ Other Diagnostic Services. F776, like the name of the tag implies, sets out the requirements for radiology and other diagnostic services for nursing home residents. Facilities that provide their own services are required to meet additional requirements under the CoPs for Hospitals – Radiologic Services, which will not be reviewed for in this SNF-based post. Any provider who does not provide in-house radiologic services or diagnostic services is required to have a written agreement for these services from an approved provider. Issues identified with the actual agreement would be cited under F840 versus F776. So, what’s required?
F776 – What’s Required
Nursing homes must either provide in-house or have an agreement with a provider to obtain radiology and other diagnostic services for their residents. Regardless of whether the services are obtained from an outside provider or are provided by the facility, it is the nursing home’s responsibility to ensure the services are completed timely and for the quality of the services. This is where facilities can find themselves in trouble. Delays in this type of service can result in a delay in appropriate and timely care for a resident, so it’s important to have a reliable service provider or otherwise transfer the resident to the hospital for services that can be provided there.
While this isn’t one of the most frequently cited deficiencies, it shows up on 2567s in different ways. Surveyors will look to see if services were provided as needed, and that the services meet the needs of residents regarding timeliness and/or quality. As noted above, a written agreement to provide services is necessary if these services are not provided in-house. The following examples are different situations identified on survey that included a citation at F776.
Immediate Jeopardy – Standard/Complaint Survey – F776 S/S: J, F684 Quality of Care S/S: J
A facility was put into Immediate Jeopardy for failure to ensure residents received treatment and care in accordance with professional standards of practice, per the CCP as well as failing to provide on-going clinical assessment and identify a change in condition for one resident reviewed for treatment and services (F684). The facility’s failure to follow physician orders after the resident experienced a significant change in condition was what led to multiple deficiencies including F776. The resident’s physician ordered a CT scan which was not completed (F776), and the resident’s condition declined, and staff did not complete a comprehensive assessment. The resident was hospitalized with a subdural hematoma and later expired in the hospital. The Statement of Deficiencies noted that failure could result in a resident not receiving urgent medical care and could resident in death – both of which happened during this event.
Specific to the IJ at F776, the SOD stated that the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner. The facility did not obtain the ordered CT scan per physician’s order, and the resident was sent to the ER and died in the hospital. The resident, who was at high risk for falls due to dementia and use of psychotropic meds, fell and got a hematoma on the left side of her face. The physician ordered a CT scan, which was scheduled for fifteen days after it was ordered. One has to wonder why this diagnostic test was not ordered “stat.” In the meantime, the resident notified staff for approximately a week that she was experiencing headaches on the left side of her head anytime she sat up. She stopped eating, drinking and became unresponsive. Her physician ordered a transfer to the emergency room and the resident was admitted to the ICU with altered mental status and had a subdural hematoma. The hematoma was noted to be approximately three weeks old. The resident required brain surgery while at the hospital and ultimately expired. Staff were interviewed and the LPN stated he thought the headaches were positional and the DON stated she thought the CT scan was not urgent and did not know the resident had experienced a change in condition until she was transferred to the hospital.
While that citation is a worst-case scenario, other facilities have been cited at a lower scope and severity for failure to ensure services are provided for residents.
Standard Survey Citation – F776 S/S: D
A facility was cited at F776 after a STAT x-ray was ordered for a resident who was observed seated on her wheelchair leg rests in her room and was vocalizing pain and discomfort to her arm. Her arm was observed to be bruised and discolored. The contracted x-ray company did not perform the x-ray because the resident was not cooperative and became combative with facility staff and the x-ray technician. The x-ray was rescheduled for the following day and the x-ray company did not keep the scheduled appointment. The resident had her x-ray two days after the fall and the x-ray confirmed the resident had sustained a right humerus fracture.
Complaint Survey Citation – F776 S/S: D
A facility was cited at F776 for failure to ensure a diagnostic x-ray was completed timely for a resident, creating a potential for a delay in reporting any abnormal results to the physician who had ordered the x-ray. A resident was observed on the floor and her physician ordered an x-ray of her skull and c-spine. Five days later, the x-ray had still not been completed. When interviewed, the DON stated that if an x-ray was ordered STAT, it could have occurred on the day it was ordered, but other orders could take a few days. This resulted in a delay in services for the resident. Once again, you have to wonder why these x-rays were not ordered “stat” when you want to rule out a head or spine injury.
Citations at F776 are not common, but you can see that when a surveyor does cite this tag, no matter at what S/S, it is because something has occurred that resulted in a negative outcome for a resident.
If you do not periodically audit ordered x-rays or other diagnostic tests, you should consider it. The results of such an audit that is looking at order date, completion of the x-ray/test, provision of the test results to the facility as well as medical staff review of the results in a timely manner may point to a significant issue that would benefit from a discussion at your next QAPI meeting.