Monument Healthcare Millcreek: Medication Errors - UT
Monument Healthcare Millcreek failed to file the critical diagnostic report in Resident 21's medical record, despite having clear policies requiring such documentation within one week. The resident suffered from traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder.
The medical crisis began November 2nd when nursing staff documented alarming symptoms. "The patient decided to stay in bed all day today," a progress note stated. "The nurse noted that the patient's abdomen was blooded with a lot of gas and administered a gas pill. The patient stated that he had a watery bowel movement yesterday and last night his colostomy exploded twice."
A nurse practitioner immediately ordered a STAT kidney, ureter, and bladder X-ray.
The imaging revealed serious findings. At 3:46 am on November 3rd, nursing notes documented the results: "Abdomen x-ray. Impression: increased fecal material. The doctor on call was notified. No new orders."
But when federal inspectors arrived November 17th to review medical records, the X-ray report had vanished.
The Regional Compliance Nurse admitted she "was unable to locate the KUB results for resident 21 on their medical chart." She told inspectors she needed to ask the unit manager to retrieve the results from an electronic portal to provide them to surveyors.
Multiple staff members described elaborate filing procedures that apparently failed. Licensed Practical Nurse 3 explained the process: after receiving faxed results from the X-ray company, she contacts the Director of Nursing and physician, enters results in the resident's medical record, then makes copies for both the DON's office and physician's office.
"After that she is unaware of what happens with the results after placing them in the offices," inspectors noted.
Licensed Practical Nurse 2 described a similar routine. She receives physician orders, calls the mobile X-ray company, gets faxed results, calls the physician with findings, then makes copies — one for the physician, another for the unit manager. The unit manager supposedly reviews results before forwarding them to medical records for scanning into the resident's chart.
The Director of Nursing confirmed this system exists. X-ray results get faxed to the facility, nurses contact physicians with findings, copies go to unit managers and physicians for review, then medical records receives the fax to attach to the resident's chart.
Management expects completion "within a week from the ordered date," the DON said.
The Administrator echoed this timeline, stating he expects documentation attached to residents' medical charts "within a week of receipt date."
Yet three weeks after the emergency X-ray, the results remained missing from Resident 21's file.
The inspection found this violated federal regulations requiring nursing homes to keep signed and dated reports of X-rays and other diagnostic services in residents' records. The violation affected few residents — just one out of 37 sampled cases — but demonstrated a breakdown in basic medical record-keeping.
For Resident 21, the missing documentation represented more than paperwork problems. The X-ray revealed "increased fecal material" in someone already struggling with complex medical conditions including traumatic brain injury and complete paralysis. Without proper filing, future medical providers would lack crucial diagnostic information about his gastrointestinal issues.
The case highlighted how nursing home bureaucracy can fail residents at critical moments. Despite multiple staff members knowing the correct procedures, despite management setting clear expectations, despite the resident's urgent medical needs, the system broke down.
Resident 21's colostomy explosion and resulting complications became a medical mystery with missing evidence. The X-ray technician completed the imaging. The radiologist interpreted dangerous fecal buildup. The on-call doctor received notification. But somewhere between fax machines and file cabinets, the documentation disappeared.
The facility's own staff couldn't explain where the results went. The Regional Compliance Nurse had to scramble to locate them in an electronic portal when inspectors arrived. Even then, the official medical record remained incomplete.
Federal inspectors classified this as minimal harm or potential for actual harm. But for a quadriplegic resident dealing with traumatic brain injury and exploding colostomies, missing medical records represent more than administrative oversight.
They represent a system that failed to properly document his suffering.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Healthcare Millcreek from 2025-11-20 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
Monument Healthcare Millcreek in Salt Lake City, UT was cited for violations during a health inspection on November 20, 2025.
The resident suffered from traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder.
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.