The incident occurred January 16 at Gladstone Sub-Acute and Rehab Center, where a resident with congestive heart failure and end-stage kidney disease experienced a dangerous drop in blood oxygen levels to 85 percent. Normal oxygen saturation ranges from 95 to 100 percent.
The resident's responsible party was visiting around 5 PM when the oxygen levels plummeted. A doctor immediately ordered a STAT chest X-ray at 7:19 PM due to increased congestion and the patient's breathing difficulties.
But the X-ray never happened.
Registered Nurse 1, who worked the overnight shift from 11 PM to 7 AM, told federal inspectors she called the contracted radiology company three times during her shift. No technician ever arrived.
The facility's own policy requires STAT orders to be followed up on during the same shift. The policy also mandates that diagnostic services be documented and coordinated to ensure results are received in a timely manner.
RN 1 told inspectors that STAT X-rays needed to be obtained within four hours of the order. The resident's X-ray was ordered at 7:19 PM on January 16. By the time RN 1's shift ended at 7 AM on January 17, more than 11 hours had passed.
The patient had been admitted to the facility just nine days earlier on January 7 with complex medical conditions. In addition to congestive heart failure — a condition where the heart cannot pump blood effectively — the resident suffered from end-stage renal disease requiring regular hemodialysis to filter blood when the kidneys fail to function.
Federal inspectors found the resident was moderately impaired in cognitive skills and required extensive daily care. Staff provided total assistance for toileting hygiene and partial help with dressing and personal care.
The resident's medical fragility made the delayed diagnostic imaging particularly concerning. Congestive heart failure patients who experience sudden drops in oxygen saturation often require immediate evaluation to determine if fluid is accumulating in the lungs or if other cardiac complications are developing.
A chest X-ray would have revealed whether the patient's heart condition was worsening or if pneumonia or other lung problems were causing the breathing difficulties. Without the imaging, medical staff had no way to assess the severity of the resident's condition or adjust treatment accordingly.
The facility's SBAR communication form documented the episode of low oxygen saturation and congestion on January 16, confirming that staff recognized the seriousness of the situation. Progress notes from both January 16 and 17 tracked the resident's condition, but the critical diagnostic test remained incomplete.
Federal regulations require nursing homes to ensure residents receive necessary medical services, including diagnostic tests ordered by physicians. When facilities contract with outside companies for services like radiology, they remain responsible for ensuring those services are actually provided.
The inspection occurred following a complaint and found the facility violated federal standards for providing adequate medical services to residents. Inspectors classified the violation as causing minimal harm with the potential for actual harm to residents.
For this resident with multiple life-threatening conditions, the eight-hour delay in emergency diagnostic imaging meant spending the night without crucial information about their deteriorating respiratory status. The repeated unsuccessful calls from the nurse highlighted a system failure that left a vulnerable patient without timely medical care when they needed it most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gladstone Sub-acute and Rehab Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
Additional Resources
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