The incident at Southern California Hospital at Culver City involved a resident admitted on May 29, 2025, with acute respiratory failure. On November 18 at 1:49 p.m., Medical Doctor 2 placed a stat order for an electroencephalogram while covering for the patient's primary physician.
The EEG technician arrived the next day to perform the brain scan. But the facility's house neurologist, Medical Doctor 3, instructed the technician to postpone the test.
No written order existed to delay the procedure.
Facility Manager 1 told inspectors on November 20 that the EEG was contracted to an outside company, with the technician finally scheduled to return at 5:30 p.m. that day. The house neurologist typically interpreted the results.
Director of Respiratory Department revealed the breakdown during interviews. The EEG technician came on November 19 but "was instructed by MD 3 to hold off from doing the EEG test," the director said. "There was no written order to hold the EEG test."
The test remained on hold until November 20.
The respiratory director noted a critical flaw in the process: "It was a verbal order to hold the EEG test, but MD 3 was not the ordering provider." The technician should have contacted Medical Doctor 2, who placed the original stat order, or informed the assigned nurse about the delay.
The facility's own policy prohibits exactly what happened. The hospital's Telephone and Verbal Orders procedure, reviewed in July 2025, states that "Non-emergent Verbal Orders shall not be accepted."
Emergent verbal orders are permitted only during surgical procedures, resuscitative events, or life-threatening situations. Even then, licensed staff must read back the orders for clarification, and physicians must sign emergent verbal orders before leaving the nursing unit.
Medical Doctor 3's verbal instruction to postpone the EEG met none of these criteria.
EEGs record the brain's electrical activity to diagnose conditions including epilepsy, head injuries, and other neurological disorders. When physicians order stat tests, they expect immediate completion because delays can worsen patient conditions.
Federal inspectors noted that the delay "can potentially cause the patient's condition to worsen or resulted in injury or harm such as prolonged seizures, permanent cognitive impairment, or the need for more invasive treatments, all of which can be prevented with timely action."
The patient had been at the skilled nursing facility for nearly six months when the stat EEG was ordered. The facility provides 24-hour medical support and rehabilitation services for residents requiring intensive care but not acute hospitalization.
The inspection occurred on November 20, 2025, as a complaint investigation. Inspectors found the facility failed to ensure the resident's medical order was completed as directed by the physician.
The case illustrates how communication breakdowns between medical providers can compromise patient care. The ordering physician expected immediate testing. The house neurologist countermanded that order without proper authorization. The technician followed the wrong instruction.
Meanwhile, the patient waited two additional days for a brain scan their doctor deemed urgent enough to order stat.
The facility's policy existed specifically to prevent such confusion, requiring written documentation for all non-emergency order changes. But when the moment came to follow protocol, verbal instructions from the wrong doctor took precedence over written procedures.
Federal regulations require facilities to provide appropriate treatment according to physician orders and resident preferences. The delayed EEG represented a failure to meet that standard, with inspectors citing minimal harm or potential for actual harm.
The resident affected by the delayed brain scan had already spent months recovering from acute respiratory failure. Now they faced additional uncertainty about their neurological status while waiting for a test their doctor had ordered immediately.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southern California Hosp At Culver City D/p Snf from 2025-11-20 including all violations, facility responses, and corrective action plans.
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