The next CMSCG “Ftag of the Week” is our last post before our annual “summer break” for this blog series. This week, we’re looking at F777, which is part of the Laboratory, Radiology, and Other Diagnostic Services regulatory group. Like several of the tags we’ve covered recently on the CMSCG Blog, this regulation is not that long, but has the capacity to result in a high-level citation.
F777 – Regulatory Requirements
Per Appendix PP of the State Operations Manual (SOM), F777 has two requirements to comply with. The first is that a facility must provide or obtain radiology and other diagnostic services only when they are ordered by an approved practitioner in accordance with State law, such as a physician, PA, NP or clinical nurse specialist. That part is not particularly complex, but it’s an important reminder to ensure that you’re aware of the scope of practice laws within your state. On survey, during record review, it could be identified by a surveyor that these services were not provided in accordance with these requirements.
The second requirement is where there’s more potential for trouble. F777 states that the ordering practitioner must be promptly notified of results which fall outside of clinical reference ranges, as determined by the facility’s policies and procedures for notification of a practitioner or in accordance with the ordering practitioner’s medical orders. The Interpretive Guidance (IG) notes that “promptly” means that the results are provided to the ordering practitioner “with little or no delay.” The IG further indicates that policies and procedures should be developed in consultation with the Medical Director and follow current standards of practice. P&P could include:
- Identifying when follow-up is required
- Which concerns/results need to be reported urgently
- Delegation by the ordering practitioner to an on-call individual, if this is appropriate
- How communication effectiveness is monitored to ensure the results were provided to the practitioner
How It’s Cited
As indicated above, there’s opportunities for things to go awry both with the provision of services and with communication. A surveyor could cite F777 if a facility failed to provide/ obtain radiology/ other diagnostic services within the timeframes specified in the orders. Those delays can result in any number of negative outcomes. Let’s look at some examples.
F777 S/S: J (Immediate Jeopardy) – Complaint Survey
A facility was put into Immediate Jeopardy after failing to obtain radiology diagnostic services for a resident who experienced an increased cough, 3 days post-surgery for a fractured hip. A verbal order for a chest x-ray was given by a practitioner to a nurse who did not enter it into the EMR to be completed. The resident experienced acute respiratory distress and was transferred to the hospital and admitted to the ICU, where he died two days later from pneumonia. During the surveyor’s investigation, it was identified that there was no documentation related to the order for the x-ray.
That’s pretty cut and dry, right? Well, there are some additional things contributing factors to what occurred. First, in an interview, the practitioner stated that she both entered her own orders and sometimes gave verbal orders. Then, the unit manager was interviewed and stated that the practitioner entered her own orders when she was at the facility, but when she was offsite, the nurses would input them into the EMR. The unit manager, of course, recalled hearing the practitioner state that she would put the order in, and then the UM was out of work the next day and did not follow-up to ensure the order had been entered. Regardless, the practitioner who verbally ordered the x-ray later assessed the resident but did not check the x-ray results. Topping it off – the resident should have had his vital signs checked routinely due to his recent operation, which also was not being documented as completed.
Although the above citation is about facility staff communication confusion, providers have also been cited under F777 due to delays in getting results back from diagnostic service providers so prompt treatment could be provided to the resident. Here’s an issue identified on a complaint survey.
F777 S/S: G (Actual Harm) – Complaint Survey
A facility was cited for failure to promptly notify a physician of x-ray results which indicated a fracture and resulted in a delay in treatment/harm to a resident. Facility staff did not notify a physician for three days of a resident’s x-ray which showed a hip fracture with complete displacement. The medical record did not show any nursing assessment, interventions or response to the known fracture.
The facility found out about the x-ray results after staff noticed the resident exhibiting pain during care, and when she called to order an x-ray, the provider told her one had already been completed. The x-ray service employee was interviewed and told the surveyor that there was a backup in reading the results and they tried to call the facility to notify them, but no one answered so they uploaded the results to the EMR the following day. This was outside the facility’s expectations of a 24-hour timeframe for results. Upon being notified of the fracture, three days after the x-ray, the resident was sent to the hospital for surgical repair.
As you can see, it’s important to have sound procedures in place for both ordering and communication of diagnostic services. Any missed part of a process can potentially result in a delay in treatment or another negative outcome for a resident.
In case you missed it above, the CMSCG “Ftag of the Week” is on pause for the summer after this post. We’ll still post important information as it happens, and send out timely updates as needed to our subscribers. Not subscribed to receive our newsletters? Click here to sign up.
