Monument Healthcare Millcreek: Notification Failures - UT
Resident 21, admitted with traumatic subdural hemorrhage and complete paralysis, experienced severe intestinal distress on November 2nd. His colostomy bag "exploded twice" during the night, and he complained of abdominal bloating with excessive gas.
The nursing staff contacted the facility's nurse practitioner, who immediately ordered a KUB x-ray — a kidney, ureter, and bladder scan used to diagnose bowel obstructions and other abdominal emergencies.
The x-ray was performed. Results came back the next morning showing "increased fecal material" in the resident's abdomen. The on-call doctor was notified.
Then the results disappeared.
Federal inspectors conducting a complaint investigation discovered the signed and dated x-ray report was nowhere to be found in Resident 21's medical record. The facility's own staff couldn't locate it either.
Licensed Practical Nurse 3 described the facility's standard protocol during interviews with inspectors. When a physician orders an x-ray, the nurse enters the order into the medical record and calls the mobile x-ray company. The company faxes results back to the facility.
"When she gets the results, she will contact the Director of Nursing and the physician," inspectors noted. The nurse then enters results into the resident's medical record and makes copies — one for the Director of Nursing's office, another for the physician's office.
But LPN 3 admitted she was "unaware of what happens with the results after placing them in the offices."
LPN 2 described a similar process with a crucial additional step. After calling the physician about results and receiving any new orders, she makes copies for both the physician and unit manager. "Once the unit manager reviews the results, they will give it to medical records to be scanned and put on the resident's medical record."
The Regional Compliance Nurse told inspectors she "was unable to locate the KUB results for resident 21 on their medical chart." She needed to ask the unit manager to retrieve the results from the facility's computer portal to provide them to state surveyors.
This admission revealed the x-ray results existed somewhere in the facility's electronic systems but had never been properly filed in the resident's official medical record.
The Director of Nursing confirmed the facility's policy: x-ray results are faxed to the facility, nurses contact physicians with findings, and copies go to the unit manager and physician for review. After review, the fax should be "forwarded to medical records to be attached to the resident's medical chart."
Management expects this filing to happen "within a week from the ordered date," according to both the Director of Nursing and Administrator.
For Resident 21, that week had stretched to 18 days when inspectors discovered the missing documentation.
The resident's medical history made proper record-keeping particularly critical. Beyond his quadriplegia from spinal stenosis, he suffered from traumatic subdural hemorrhage with loss of consciousness and post-traumatic stress disorder. His complex medical needs required careful monitoring and complete documentation.
The November 2nd incident that triggered the x-ray order highlighted his vulnerability. Nursing notes described him staying in bed all day with a "blooded" abdomen full of gas. Staff administered medication for gas relief, but his condition worsened overnight when his colostomy malfunctioned twice.
The subsequent x-ray showing increased fecal material suggested possible bowel complications — exactly the kind of finding that requires immediate physician review and ongoing monitoring through proper medical records.
Federal regulations require nursing homes to maintain complete medical records for each resident, including signed and dated reports of all diagnostic services. These records serve as the foundation for ongoing care decisions and legal protection for both residents and facilities.
The inspection found Monument Healthcare Millcreek's system breaking down at the final step. Staff understood their roles in ordering tests and communicating results to physicians. The mobile x-ray company provided proper documentation. But somewhere between the unit manager's desk and the medical records department, critical health information vanished from the official record.
The facility's own protocols, as described by multiple staff members, should have prevented this failure. The redundant system of copies and reviews was designed to ensure nothing fell through the cracks.
Yet for Resident 21, whose colostomy emergency required immediate diagnostic attention, the system failed completely. His urgent abdominal x-ray results — showing concerning fecal buildup that prompted physician notification — existed only in electronic limbo, inaccessible to future caregivers who might need that critical diagnostic information.
The Administrator acknowledged expecting all documentation to be attached to resident medical charts within one week of receipt. Eighteen days later, inspectors had to ask staff to retrieve the missing results from the computer portal just to verify they existed at all.
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.
Resident 21, admitted with traumatic subdural hemorrhage and complete paralysis, experienced severe intestinal distress on November 2nd.
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.