Monument Healthcare Millcreek: Care Order Failures - UT
Federal inspectors found the facility failed to maintain required medical records for Resident 21, who suffered traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder. The missing documentation involved a Kidney, Ureter, and Bladder X-ray ordered immediately on November 2nd after the resident experienced severe abdominal distress.
The medical emergency began when the resident decided to remain in bed all day. A nursing note at 12:48 pm documented his abdomen was "blooded with a lot of gas," prompting staff to administer medication. The resident reported watery bowel movements and said "his colostomy exploded twice" the previous night. The nurse contacted the Nurse Practitioner, who ordered the emergency X-ray.
Results came back within hours. At 3:46 am on November 3rd, a nursing note revealed the X-ray showed "increased fecal material." Staff notified the doctor on call, who issued no new orders.
But when inspectors searched Resident 21's medical record two weeks later, the actual X-ray report had disappeared.
Licensed Practical Nurse 3 described a complex chain of custody for diagnostic results. She said nurses enter physician orders into medical records, fill out lab slips, and call X-ray companies to dispatch technicians. The company receives faxed orders for their records, then faxes results back to the facility.
"When she gets the results, she will contact the Director of Nursing and the physician," inspectors wrote. The nurse said she enters results into the resident's medical record and any additional physician orders, then makes copies for the nursing director's office and physician's office. After that, she said, "she is unaware of what happens with the results."
Licensed Practical Nurse 2 provided a slightly different account. She said after receiving faxed results and calling the physician, she makes copies - one for the physician, another for the unit manager. The unit manager reviews results before giving them to medical records for scanning into the resident's chart.
The Regional Compliance Nurse couldn't locate the KUB results anywhere in Resident 21's medical chart during the inspection. She told inspectors "she needed to ask the unit manager to retrieve it from the portal to be able to provide it to the State Surveyor."
Nobody could explain where the X-ray report went.
The Director of Nursing outlined the facility's intended process: 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. She said management expects this process completed within one week of the order date.
The Administrator echoed that timeline, stating he expects "any documentation attached to a resident's medical chart within a week of receipt date."
But three weeks after the emergency X-ray order, inspectors found no trace of the diagnostic report that revealed increased fecal material in a quadriplegic resident's abdomen.
Federal regulations require nursing homes to maintain signed and dated reports of all diagnostic services in residents' medical records. The missing X-ray results represented a breakdown in a fundamental record-keeping requirement designed to ensure continuity of medical care.
The facility's own staff described a confusing handoff process where diagnostic results pass through multiple people and locations before reaching permanent medical files. Licensed Practical Nurse 3 admitted ignorance about what happens to results after she places them in various offices. The Regional Compliance Nurse had to ask the unit manager to "retrieve it from the portal" when inspectors requested the missing report.
For Resident 21, the consequences extended beyond paperwork. His complex medical conditions - traumatic brain injury, complete paralysis, spinal problems, and post-traumatic stress disorder - require careful monitoring and complete medical documentation. The emergency X-ray was ordered because of severe abdominal symptoms including explosive colostomy incidents that left him in distress.
The diagnostic results showing "increased fecal material" could inform future medical decisions about his bowel management, pain control, or need for additional interventions. Without proper filing in his medical record, that critical information becomes inaccessible to other physicians, specialists, or emergency personnel who might treat him.
Monument Healthcare Millcreek's violation affected few residents during the November inspection, but revealed systemic problems with medical record management that could impact any resident requiring diagnostic services.
The facility operates in Salt Lake City under federal Medicare and Medicaid certification, serving residents who depend on accurate medical documentation for proper care coordination. When emergency diagnostic results disappear between the fax machine and medical charts, residents lose vital pieces of their healthcare puzzle.
Resident 21 remains at the facility with his complex medical needs and incomplete medical records, his emergency X-ray findings lost somewhere in the administrative maze that was supposed to preserve them.
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 medical emergency began when the resident decided to remain in bed all day.
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.