**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 17 residents reviewed for treatment and services. (Resident #93) The facility failed to follow MD orders to obtain a CT (Computed Tomography) for Resident #93 on 8/11/22 and on 8/17/22. Resident #93 did not have a CT while she was in the facility. She had to have surgery for an abscess on 8/26/22. This failure could place residents at risk of not receiving care as required and could result in further decline of condition and possible death. An IJ was identified on 2/9/23. The IJ template was provided to the facility on 2/9/23 at 12:07 p.m. While the IJ was removed on 2/10/23 at 12:44 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm because (e.g.) all staff had not been trained on Lab and Diagnostic Testing Protocol, and Laboratory Guidelines. Findings included: A record review of the undated face sheet indicated Resident #93 admitted [DATE], was [AGE] years old, and had diagnoses that included: Diverticulitis of large intestine with perforation and abscess without bleeding (severe inflammation of the bowel wall layers with necrosis and loss of intestinal wall integrity), unspecified open wound of abdominal wall (surgical opening in abdomen), pain, colostomy status (a piece of the colon is diverted to the abdominal wall to bypass a damaged part of the colon), and Peritonitis (inflammation of the peritoneum caused either by the blood or after rupture of an abdominal organ). (The peritoneum is the serous membrane lining the cavity of the abdomen and covering the abdominal organs.) A record review of the MDS dated [DATE] indicated Resident #93 admitted [DATE], had clear speech, understood others and was understood by others. The MDS indicated she had was cognitively intact and required the limited assistance of 1 staff for bed mobility and supervision with set up help for transfer. The MDS indicated Resident #93 had occasional pain and received PRN (as needed) medication for pain. The MDS indicated she had surgical wound(s) and received surgical wound care. The MDS indicated she had received an opioid (pain medication) 5 of 7 days of the look back period. The MDS indicated she had an ostomy and had received IV medications. A record review of the care plan dated 7/28/22 indicated Resident #93 would have care assist documented: breakfast, lunch, dinner, and percentages of her evening snack. The care plan indicated she preferred to have her bath/shower at 5:00 a.m. The care plan indicated she would receive nail care, oral care, and a weekly head to toe skin assessment. The care plan did not address her surgical wound, ostomy, pain, IV antibiotics, or physician's orders. A record review of the physician's orders dated 7/1/22 indicated Resident #93 had orders indicating: 8/11/22 CT (Computed Tomography-a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of abdomen and pelvis with IV (intravenous) oral contrast ASAP. STAT - Immediately, ordered by her PCP. 8/17/22 CT of abdomen and pelvis with IV oral contrast ASAP, ordered by her PCP. A record review of the physician's orders on 2/9/23 at 9:16 a.m. indicated LVN G documented on 8/17/22, Resident #93 had an order for: 8/17/22 CT of abdomen and pelvis with IV oral contrast ASAP. A record review of a progress note indicated Resident #93 discharged from the facility 8/25/22 at 10:20 a.m. The note indicated she was ambulatory, left in a personal car with a friend with her medications. The note indicated she had discharged with a surgical wound. During a phone interview on 2/6/23 at 11:39 a.m., Resident #93 said she stayed in the facility for 25 days. She said the MD ordered a stat CT and she never got it because the facility did not make the appointment. She said she had 3 surgeries before admitting to the facility on 7/27/22. She said one of those surgeries was due an abscess in her abdomen. She said she admitted to the hospital on [DATE] a few hours after discharging from the facility and had surgery on 8/26/22 for an abscess. She said when she left the facility she did not tell anyone she had fever and chills because she just wanted to leave. She said she went to the ER the same day she left the facility (8/25/22) because she felt bad. During an interview on 2/7/23 at 9:32 a.m., LVN G said she remembered Resident #93. She said she was on an antibiotic the entire time she was in the facility. She said she went off of her antibiotic and they called the infection control MD and he put her right back on the antibiotic. She said Resident #93 had a wound vac and her abdomen had mesh or Vaseline gauze on it or something along with the wound vac. She said she would have to look in the notes to see when she got the CT of her abdomen. She said she remembered the order for the CT. During an interview on 2/7/23 at 9:52 a.m., LVN G looked at the notes and said Resident #93 was on an antibiotic 7/27/22 to 8/1/22. She said that same day the same antibiotic was restarted on 8/1/22 until 8/6/22. She said she started antibiotics again on 8/11/22 through her day of discharge on [DATE]. She said she never complained of being sick or feeling bad. She said she wanted to leave and did not give them time to set up home health. She said Resident #93 was determined to leave earlier than her planned discharge date (on 8/26/22) and discharged on 8/25/22. She said Resident #93 was determined to discharge even though she did not have home health and could not take the wound vac (facility wound vac.) During an interview on 2/7/23 at 11:18 a.m., the MDS nurse said Resident #93 had a planned discharge for 8/26/22 but she was determined to discharge on [DATE]. She said Resident #93 said she would do her own wound care and her friend that picked her up when she discharged with would help her with it. She said if she correctly remembered the surgical wound on her abdomen was almost healed. During an interview on 2/8/23 at 9:10 a.m., the ADON said she was looking for the CT that was ordered 8/11/22 for Resident #93. She said she would continue to look. During an interview on 2/8/23 at 9:17 a.m., the ADON said she had looked in the records and did not see that Resident #93 had gotten the CT. She said she would continue to check. She said she saw where the information was faxed to the hospital by LVN A to request the appointment. She said LVN A was out of the country and could not be reached. During an interview on 2/8/23 at 9:22 a.m., the RNC said if a CT was ordered for Resident #93 she should have gotten it per the MD orders. She said she would call the hospital to see if they had one. During an interview on 2/8/23 at 9:31 a.m., Resident #93 said she was in the hospital 8/25/22 through 9/6/22. She said she started feeling bad and had chills a couple of hours after she discharged from the facility on 8/25/22. She said she had surgery 8/26/22 to remove an abscess. She provided the names and numbers of her physician's. She said pain was not a problem while she was in the facility. She said she received medication and her pain was controlled. She said the issue was she did not get the CT the MD wanted her to have. She said she thought the infectious disease MD had wanted her to have it. She said she was released from wound care last Friday. A record review on 2/8/23 indicated Resident #93's recorded vital signs on the day of discharge were: Temperature 97.9 and respirations 18. There were no other documented vital signs for 8/25/22. Vital signs for her stay at the facility were reviewed and were within normal limits. A review of the MAR for July and August 2022 indicated she received pain medication and her pain was controlled. A record review on 2/8/23 of the (facility) Wound Care MD's notes for Resident #93 indicated: 7/29/22, post-surgical wound, 33 x 6 x 4 cm, light serous exudate, 5% slough, 90% granulation (healthy pink tissue), and 5% muscle. The treatment plan was negative pressure wound therapy applied twice a week for 30 days. The notes indicated the Wound Care MD had debrided the wound. (Removing the dead or necrotic tissue.) 8/5/22, post-surgical wound, 27 x 6 x 3 cm, light serous exudate, 5% slough, 90% granulation tissue, 5% muscle. The treatment plan was negative pressure wound therapy twice a week with a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved. 8/12/22, post-surgical wound, 24 x 5 x 3 cm, light serous exudate, 5% slough, 90% grandulation tissue, 5% muscle. The treatment plan changed as Resident #93 wanted a break from the wound vac, educated resident it would take longer to heal without it. Resident continued to want a break from the vac. Treatment was alginate calcium with an abdominal pad apply once daily for 30 days and a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved. 8/19/22, post-surgical wound, 20 x 5 x 2.5 cm, light serous exudate, 5% slough, 90% granulation tissue, 5% muscle. The treatment plan was alginate calcium with an abdominal pad apply once daily for 30 days and a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved. During a phone interview on 2/8/23 at 2:19 p.m., the nurse for Resident #93's infectious disease MD said the MD for Resident #93 was no longer in the state. She said she would research and let this surveyor know why a ASAP CT was ordered 8/11/22. A record review of the MD orders dated 7/1/22 for the facility on 2/8/23 at 3:08 p.m., indicated Resident #93's Primary Care Physician ordered a CT of abdomen and pelvis with IV oral contrast ASAP, STAT immediately for Resident #93 on 8/11/22. A record review on 2/8/23 of Infectious Disease Skilled Nursing, Nursing Home Orders indicated on 8/11/22 the infectious disease MD ordered Resident #93 a CT with IV/oral contrast ASAP and restarted her IV antibiotic medication. During a phone interview on 2/8/22 at 3:17 p.m., Resident #93's PCP said he could not find the reason for the order for a CT for Resident #1 on 8/11/22. He said he may had ordered it for the Infectious Disease MD, but he did not remember. He said based on the records he was looking at on 8/11/22 Resident #93's antibiotic was restarted after she saw her infectious control MD. He said an ASAP CT was ordered along with restarting her antibiotic. He said her diagnoses at that time were: Localized peritonitis, long term use of antibiotics, and the last diagnosis was dated 7/18/22 and was Perforated diverticulitis. He said on 8/22/22 Resident #93 saw her surgeon for an office visit and she had an abdominal exam that indicated she was healing slowly with no signs or symptoms of infection or hernia and granulation was present (on the wound). Resident #93's PCP said she had gone to the ER on [DATE] with abdominal pain. He said on 8/30/22 Resident #93 had a drainage catheter placed in the area of fluid in her wound. He said the fluid can be a complication of surgery. He said she had 70 cc of fluid aspirated and he could not tell if the wound was infected. He said he did not think her having a CT on 8/11/22 would have prevented the hospitalization or procedures. During a phone interview on 2/8/22 at 5:05 p.m., Resident 93's PCP said if she had an abscess it could have shown on a CT scan but he was not sure. He said if a CT had been performed on 8/11/22 he did not know if it would have prevented the hospitalization on 8/25/22 because he did not believe abscess was a primary diagnosis and she was admitted to the hospital on [DATE] to remove fluid. During an interview on 2/8/22 at 5:16 p.m., LVN B said she did not remember Resident #93 having nausea and vomiting but that was a long time ago. She said she tried to show her how to do wound care and she was very involved in her care. She said she did not remember anything about a CT being ordered. She said if you get an order for a CT you send the resident information by fax to [Lab/Hospital name]. She said if they did not respond then the nurse would have to call them. She said the nurse that had taken the order for the CT was responsible to make sure it was done. She said the risk of not getting a CT when one is ordered by the MD could be serious illness, infection, and death. She said she remembered Resident #93 always reminded them when it was time for her pain medication. During an interview on 2/8/22 at 5:28 p.m., the ADON said when a nurse took an order for a CT it was up to that nurse to call the hospital to set the CT up. She said the nurse would have to fax information to the hospital. She said the nurse was responsible for the CT, but if she did not do it, it would be up to her (ADON), then the DON. She said the order for the CT for Resident #93 should have been on the 24-hour report and should have been noticed immediately during the morning meeting from the 24-hour report. She said they failed to ensure the nurse had taken care of the CT and made the appointment. She said the risk of Resident #93 not getting the CT done per the MD order was it could be very harmful to her and could have caused serious injury or death. She said they did not have a radiology book. During an interview on 02/08/23 at 5:41 p.m., CNA R said she faintly remembered Resident #93. She said Resident #93 always felt bad and always wanted pain medication. During a telephone interview on 02/8/2023 at 5:43 PM CNA V said that she worked nights, and she remembered taking care of Resident #93. CNA V said she seemed to be sad all the time. She said she always complained of being sick and not wanting to do things. She said she would refuse her wound vac at times and complain of pain, but the nurse was responsible for that. During an interview on 02/08/23 at 5:45 p.m., CMA L said Resident #93 had complained of pain around her abdomen and she gave her pain medication that was ordered. She said the pain medication seemed to help her. She said the nurse would usually be the one that asked her to give Resident #93 something for pain. She said Resident #93 would say her stomach had discomfort. She said she had a wound vac. She said she never gave Resident #93 a shower and did not see the wound. She said Resident #93 transferred herself. She said she did not complain about her colostomy. She said she was cooperative with her care, a sweet lady. During a telephone interview on 02/08/2023 6:00PM LVN C said that Resident #93 had an abdominal wound. She said Resident #93 did not like to have the wound vac in place and would at times refuse it, turn it off, and refuse wound care. LVN C said she did not recall an order for CT scan, but if there ever was an order, she would have called DON or ADON to notify of the order, place on the 24-hour report, and follow through to ensure it was completed. LVN C said an order for a CT scan was important and could result in issues or complications related to the reason for the order. During an interview on 2/8/23 at 6:10 p.m., the ADON said LVN F took the order for the CT on 8/11/22 for Resident #93. She said she was a mobile nurse for their company and she will find her phone number. A record review of the hospital records indicated Resident #93 admitted [DATE] (no time was documented) with chief complaints of nausea and vomiting. The records indicated she had a CT on 8/25/22 indicating she had loculated (localized failure of an area to drain fluid, resulting in an enlarged mass) 9.3 x 5.1 x 3.2 cm fluid collection in her left lateral abdomen at the level of the previous perforation. The CT also indicated she had fluid collection that was probably extraperitoneal (the portion of the abdomen and pelvis which does not lie within the peritoneum) which could represent post operative seroma (a pocket of fluid) fluid collection under the skin near the cut the doctor made during surgery), but suggested aspiration to rule out abscess. The aspiration procedure on 8/26/22 indicated Resident #93 had a peritoneal abscess and 70 ml of fluid was aspirated. The hospital records also indicated she had a chest X-ray on 8/26/22 to evaluate for infection, due to her running a fever. The results of the X-ray indicated no active chest process. During an interview on 2/9/23 at 8:51 a.m., the RNC said the process for radiological orders was that once an order was received, if it was not something that could be done in-house the nurse that took the order would contact the hospital for scheduling. She said their process was not followed regarding Resident #93 and her CT. She said the process was not followed in the morning stand-up meeting because they are supposed to go over all new orders in the meeting and Resident #93's CT was missed. She said she was not sure they were having the morning clinical meeting. She said all orders should be discussed in the morning clinical meeting and the nursing administration, the ADON, and DON were responsible to make sure all new orders were double checked and to make sure orders had been scheduled. She said all new orders should be reviewed by the ADON and DON every day in the morning clinical stand-up meeting. She said on Monday's the meeting goes back for 72 hours to check all new orders during the weekend. She looked at her calendar and said 8/11/22 was a Thursday so it should have been noticed either then or on the following Monday (8/15/22). The RNC said she believed the new order for Resident #93 was missed somehow. She said a STAT or ASAP CT should have been completed in 24 to 48 hours. She said, As soon as possible means as soon as possible. She said she could not answer why Resident #93's CT was not done because there was no documentation as to why it was not done. She said to go over the process for taking orders for radiology it was: 1. Nurse takes the order and follows up that it was done. Discuss the new orders in the morning clinical meeting with the 24-hour report. 2. Follow-up that the order was scheduled or completed, ensuring a date and time for the procedure. 3. Schedule transportation for the resident to go to the appointment. She said no one person was responsible because it was the responsibility of the ADON and DON. 4. The charge nurse was responsible to make sure the resident went to the scheduled appointment. The RNC said the failure was that the new order for Resident #93 was not discussed in the morning clinical stand-up meeting. She said the information about Resident #93's CT ordered 8/11/22 was on the 24-hour report. She said they had checked all their orders for CT's and radiological services and nothing else had been missed from August 2022 to present. During a phone interview on 2/9/23 at 9:20 a.m., Resident #93's PCP said he did not remember reordering the CT on 8/17/22. He said it may have been because the CT was not done when ordered on 8/11/22 but he did not remember. He said the abscess on 8/26/22 on Resident #93's left abdomen had nothing to do with her incision. He said it had to do with her initial perforation prior to going to the facility on 7/27/22. He said the surgeon indicated on 8/26/22 Resident #93 had base grandulation in her wound based on the records he was looking at. He said he did not know if Resident #93 getting a CT on 8/11/22 or 8/17/22 would have prevented her hospitalization on 8/25/22 because he did not know if the abscess was there at that time. He said it could have been fluid left over from her surgery (prior to admitting at the facility). Resident #93's PCP said somewhere between her surgery prior to admitting to the facility and 8/25/22 she developed an infection on her left side which was the original area of perforation that caused the initial problem (prior to admitting to the facility A record review on 2/9/23 of the progress notes indicated: On 8/8/22 LVN G documented Resident #93 complained of heartburn and indigestion and requested medication for acid reflux. LVN G notified the MD and received an order for Protonix 40 mg by mouth daily. On 8/9/22 LVN C documented Resident #93 stated the Protonix was very effective. On 8/11/22 LVN F documented: Face sheet, order, and last doctor's visit with infectious disease faxed to [name and hospital] to schedule CT of abdomen and pelvis per orders. Awaiting approval for testing. On 8/16/22 the ADON documented Resident #93 had vomited sometime after her scheduled Zofran (a medication for nausea and vomiting). The ADON documented Resident #93 wanted Mylanta and the ADON was awaiting a call back from the MD. The ADON documented she asked Resident #93 to please call her if she vomited so she could see it and inform MD of amount, color, smell. The resident voiced understanding. The progress notes indicated Resident #93 saw her surgeon on 8/22/22 with a new order to restart the wound vac. The office visit from the surgeon dated 8/22/22 indicated her abdomen was healing slowly, with no signs or symptoms of infection and no signs or symptoms of a hernia with granulation active on the midline of her surgical wound. On 8/23/22 the MDS nurse documented she spoke with the resident regarding the potential need to stay a little longer due to being on the wound vac and the continuation of her IV medication. The MDS nurse documented on 8/23/22 Resident #93 was adamant she was going home on 8/26/22. The MDS nurse documented she asked Resident #93 for the safety of a good discharge to see about setting up wound care visits locally where she lived and asked her if she had anyone that could get her there. The MDS nurse noted the resident said she could do her own IV antibiotic and wound care. The MDS nurse explained the difficulty of that and Resident #93 said she was okay and was still going home on 8/26/22. On 8/24/22 the progress notes indicated the DON called Resident #93's surgeon about her planned discharge on [DATE], explained she had no Home Health that would accept her insurance and no would vac. Requested to change her orders to something she and her family could manage at home. On 8/25/22 LVN A documented Resident #93 had no signs or symptoms of infection at 8:27 a.m. The progress notes dated 8/25/22 documented by the MDS nurse indicated Resident #93 was going to discharge today even though she had no Home Health and no wound care set up yet. Resident did not want to wait and had a friend that was picking her up. The MDS nurse indicated she signed her paperwork and left hurriedly. The progress notes indicated LVN A documented on 8/25/22 Resident #93 refused to have the wound vac put back on and LVN A applied a wet to dry dressing to her incision. The progress notes indicated she left the facility ambulatory in a personal car with her friend at 10:42 a.m. A record review on 2/9/23 of the progress notes 8/16/22 through 8/25/22 indicated there were no further notes regarding Resident #93 having nausea, vomiting or requesting Mylanta. There was no documentation of an order for Mylanta. A review of the MAR dated August 2022 did not indicate she had ever been given Mylanta. A record review of the Facility activity report dated 08/11/22-02/02/23 on 02/09/23 at 08:45 a.m. which included all orders of any type of radiology for 54 residents in the facility during the time indicated Resident #93 was resident in the facility from 07/27/22-08/25/22 had CT of abdomen ordered on 8/11/22 as well as 08/17/22 and was never completed. Every order for radiology ordered during the time period had an image that was viewed to correspond to the order. During an interview on 2/9/22 at 9:45 a.m., the ADON said Resident #93 did not get the CT ordered on 8/11/22 or the CT ordered on 8/17/22. She said she thought the infectious disease MD had ordered them. She said the process for taking radiological orders was the same process she explained yesterday, but they should not have been missed in the morning stand-up clinical meeting. She said it was her responsibility to check new orders and make sure everything was completed that was ordered. The ADON said she did not know how she missed the CT's twice for Resident #93. She said she tried to look at all new orders daily but if she did not, it was also up to the DON to check new orders daily. She said she must have been focused somewhere else in the facility and that was why she missed the orders for Resident #93. During an interview on 2/9/22 at 9:55 a.m., the RNC said the CT ordered for Resident #93 on 8/11/22 and the CT ordered on 8/17/22 was not done. She said they were missed because they were not followed up on. She said staff should have followed up. She said Resident #93's nurse's, the ADON, and the DON should have followed up on them to make sure they were done. She said it should have been noticed on the 24- hour report that they went over in the standup clinical meeting in the mornings. She said possible outcomes of missing the CT twice could be serious injury or death because she already had an infection and had been on IV antibiotics while in the facility. During an interview on 02/09/23 at 10:01 a.m., LVN A said she worked 6:00 a.m. to 6:00 p.m. She said if she had an order for a CT she would give the information to the transportation person (CMA L) because she usually made all transportation appointments. She said if she was not available, the facility would make arrangements for transportation. She said if the order read ASAP she would get the CT done as soon as possible. She said they would notify the family and MD, then document the appointment was made. She said Resident #93 had pain when she came to facility but that was nothing unusual as she had major surgery. She said they gave her pain medication prior to wound care. She said Resident #93 did not like the wound vac and had refused it at times. She said the facility Wound Care MD saw her and changed her order because she did not want the wound vac, then Resident #93 saw her surgeon and he put her back on the wound vac. She said the doctor told her it was better for her to use the wound vac. She said there was a calendar in the system where they would document appointments that have been made, then the information was put on the 24-hour report. She said you would not normally tell the ADON or DON because they could see the order for the CT in the computer system. During a phone interview on 2/9/22 at 10:10 a.m., the DON said the process for ordering a CT or radiological order was the MD would usually set it up with the hospital. She said if not, the facility nurse for the resident would call the hospital and fax the necessary information regarding the resident. She said the hospital would then determine insurance and any other requirements, then usually within a few days they would hear back from the hospital with the appointment. The DON said usually a STAT or ASAP order is set up by the MD that ordered it, then the hospital calls them with the appointment. She said she did not know what went wrong with Resident #93 missing two CT's. She said two different nurses put in for a CT for Resident #93 and neither ever followed up on them. She said LVN A took the order on 8/17/22. She said she was out of the country and could not be reached. She said LVN F took the order on 8/11/22. She said usually the new orders stay on the 24-hour report and she and the ADON review the 24-hour report daily. She said on Monday's they look at the weekend 24-hour reports. She said the failure was the new orders were not monitored by herself and the ADON. She said they (ADON and herself) did not see them and did not know what happened to cause them to miss the orders. She said the ASAP or STAT CT ordered for Resident #93 on 8/11/22 should have been done by 8/13/22 or 8/14/22 at the latest. She said the ASAP or STAT CT for Resident #93 should have been done by 8/19/22 or 8/20/22 at the latest. She said if the MD had not set up either of the CT's the nurse, ADON or she should have called the MD for assistance to set up the CT's. She said as the DON she was one hundred precent responsible for making sure the CTs were done. She said the process they were using slipped through this time and it one hundred percent failed with these CTs. She said the CTs being missed should not have happened. She said it was a follow up oversite. She said the CT's ordered were just follow-up's because Resident #93 was not having symptoms of an infection. She said the potential harm for missing the CTs was a chance of a complication. She said she did not know if the potential for complication could be serious. During an interview and record review on 02/09/23 at 10:19 a.m., CMA P /transportation said she tried to make all appointments for CT and radiology as much as possible. She said she made CT and radiology appointments if she was given the information to make it. She said once the appointment was made, she would get with the nurse, who would then input the appointment into the computer. She said she looked daily at the calendar for appointments. This surveyor reviewed August 2022 for any appointments for Resident #93 and did not see any appointments for her. She said she did not remember anyone asking her to make an appointment for Resident #93. She said if she had been told about it she would have made the appointment. CMA P said she would call and call and if needed would go by the place to see if they could get the resident in. But, she said she did not remember doing that for Resident #93. She said during the time they had an active Covid outbreak they had shut down all appointments to keep from spreading Covid but she did not remember if that was during that time or not. During an interview on 02/09/23 at 10:30 a.m., the ADON said they had a Covid outbreak and indicated it was in July. She stated during the outbreak, they did cancel all appointments for a week to prevent the spread of COVID. During an interview on 2/9/23 at 10:31 a.m., the ADON said she could not find the 24-hour reports for 8/17/22 and 8/18/22. She provided the 24-hour report for 8/11/22 - 8/12/22. A record review on 2/9/23 of the 24-hour report dated 8/11/22 - 8/12/22 indicated Resident #93 was ordered: 8/11/22, CT of abdomen and pelvis with IV oral contrast ASAP, STAT, immediately. The order was created by LVN F and signed by Resident #93's PCP. During an interview on 2/9/23 at 10:32 a.m., LVN F said she was a mobile nurse for the company. She said on 8/11/22 she and the DON, or the ADON (she could not remember which one) faxed information to the hospital regarding the order for the CT for Resident #93. She said she did not work the next day (8/12/22) but if she had she would have made sure the CT was scheduled. She said she thought there was a person that followed up on the CT but she did not know who. She said she thought it might have had something to do with Resident #93's insurance, maybe needing a prior authorization but she was not sure. She said she thought the ADON or DON would follow up on the order for the CT. She said she passed the information on in the 24- hour report. During an interview on 2/9/23 at 10:32 a.m., the RNC provided a Lab and Diagnostic Test Results Policy. She said this covered both the Radiological Policy and the Monitor Diagnostic Tests Policy. During an interview on 02/09/23 at 10:34 a.m., RN D said he had worked at the facility since September of 2022, only PRN and only as a medication aide. He said he did not work as a charge nurse. He said as soon as possible meant as soon as possible, as soon as you could get it done. He said if you had an order for a CT, but it would take a while to get the appointment made he would call the MD to see what he wanted to do because of the lengthy time frame. He said if he was able to make the appointment he would put on 24-hour report so the next nurse would see it and follow up on it. He said the information on the 24-hour report usually rol[TRUNCATED]