Interlochen Health: Delayed X-Ray Risked Fracture - TX
The incident began Monday when a certified nursing assistant noticed swelling in Resident 1's wrist and reported it to Licensed Vocational Nurse H. The nurse practitioner assessed the resident and ordered a stat x-ray along with ice packs for the injury.
But the x-ray never happened.
LVN H knew the protocol. Stat orders must be completed within four hours, and if the x-ray company doesn't arrive within that timeframe, staff should call for an estimated arrival time. If they can't reach anyone and it's an emergency, the resident should be sent to the hospital.
None of that happened.
The Director of Nursing discovered the failure the next day when she arrived Tuesday morning. The x-ray order was sitting incomplete in the computer system. Staff had finally arranged for the x-ray to be done, but they x-rayed the forearm instead of the wrist.
The DON explained the technical failure to inspectors. The stat order "did not go through all the way because you have to click send image." The system had a built-in safeguard that staff missed.
When the x-ray was finally completed, it came back negative. But the nurse practitioner told inspectors that wasn't the end of the story. The doctor reviewed the results and determined the fracture was "on the side" of the bone. Without a lateral view or two-view x-ray, the fracture wouldn't show up.
The single-view x-ray they ordered was inadequate for diagnosis.
The nurse practitioner managed Resident 1's pain with Tylenol and ice while the diagnostic process dragged on. By the time inspectors arrived, she had changed the pain medication to Tramadol twice daily and increased the Tylenol dosage.
LVN H acknowledged his failures when inspectors interviewed him. He confirmed he knew how to enter stat orders correctly in the computer system. He understood that stat meant within four hours. He knew that if the x-ray company didn't arrive on time, he should call them, and if he couldn't reach anyone, he should report to management.
He did none of these things.
"The risk was they would not know what the injury was and could delay care," LVN H told inspectors.
The Director of Nursing was more blunt about the consequences. She told inspectors the risk was neglect. "Resident 1's arm could have broken further," she said. "A lot of things could have happened to that arm."
The facility's own leadership recognized how the delay endangered their resident. A suspected fracture left untreated could worsen. Without proper imaging, staff couldn't determine the extent of the injury or provide appropriate care.
The DON's timeline revealed the scope of the breakdown. Monday: resident reports injury, gets assessed, receives stat x-ray order. Tuesday: DON discovers the order was never completed. The resident spent an entire night with a potential fracture and no definitive diagnosis.
When the x-ray finally happened, staff made another error. They x-rayed the forearm instead of the wrist where the injury occurred. The wrong body part, the wrong imaging technique, and a day-long delay in emergency care.
The nurse practitioner's explanation highlighted why proper imaging matters. Fractures "on the side" of bones require lateral views to detect. A single anterior view can miss significant injuries entirely. The facility's delayed, inadequate x-ray could have left a fracture completely undiagnosed.
LVN H's interview revealed he understood every step of the protocol he failed to follow. He knew stat orders carried a four-hour deadline. He knew to call the x-ray company if they didn't arrive. He knew to escalate to management if he couldn't reach the company.
The knowledge was there. The execution wasn't.
Federal inspectors found the facility couldn't even produce a written policy on x-ray services by the time they completed their investigation. The absence of clear written protocols may have contributed to the breakdown in care.
The violation carries minimal harm designation, but the Director of Nursing's assessment suggests the potential for much worse. Delayed diagnosis of fractures can lead to improper healing, chronic pain, loss of function, and the need for more invasive treatments later.
Resident 1's case illustrates how multiple system failures can compound a single injury. The initial stat order failure. The computer system error that went unnoticed. The wrong body part x-rayed when imaging finally occurred. The inadequate single-view technique that could miss fractures.
Each breakdown extended the resident's time without proper diagnosis and treatment.
The nurse practitioner's medication adjustments suggest Resident 1 continued experiencing significant pain throughout the delayed diagnostic process. From basic Tylenol and ice to Tramadol and increased acetaminophen, the escalating pain management indicates ongoing discomfort that might have been addressed sooner with timely imaging.
LVN H's admission that delayed care was a risk acknowledges what his actions cost the resident. Every hour without proper diagnosis was an hour the injury could worsen, an hour of uncertainty about the extent of damage, an hour of potentially inadequate treatment.
The facility's inability to produce x-ray service policies suggests systemic gaps in emergency care protocols. Without clear written procedures, staff may not understand their responsibilities when stat orders aren't completed on time.
Resident 1 eventually received appropriate pain management and presumably proper imaging, but only after a day-long delay that the facility's own Director of Nursing characterized as neglect. The resident's wrist swelling on Monday should have led to definitive diagnosis within hours, not uncertainty stretching into Tuesday morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Interlochen Health and Rehabilitation Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Interlochen Health and Rehabilitation Center in Arlington, TX was cited for violations during a health inspection on September 4, 2025.
The incident began Monday when a certified nursing assistant noticed swelling in Resident 1's wrist and reported it to Licensed Vocational Nurse H.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.