The resident at WellBridge of Novi had been readmitted with acute congestive heart failure, blood clots in both legs, and swelling throughout her body. Her mental status assessment showed intact cognition with a score of 13 out of 15.
On April 28, 2025, at 1:57 PM, the physician assistant documented a detailed examination after the patient complained of increased weakness, fatigue, joint pain, and difficulty breathing. The resident said she felt weaker than when first admitted. She also reported painful urination and frequent trips to the bathroom.
The clinical findings were concerning. The physician assistant noted the patient appeared chronically ill and weak, with diminished breath sounds and crackling noises at the base of her lungs. Both legs showed trace swelling.
The assessment was clear: shortness of breath likely caused by decompensated congestive heart failure, along with a probable urinary tract infection and persistent irregular heartbeat with rapid pulse.
The treatment plan included multiple immediate interventions. The physician assistant ordered urine tests, an extra 20 milligrams of the diuretic Lasix daily for three days starting that day, and nebulizer treatments four times daily.
Most critically, the plan specifically stated: "Check CXR PA/lat STAT."
STAT means immediate. The chest x-ray was supposed to happen right away for a patient with heart failure who was having trouble breathing.
It didn't happen for over a week.
Federal inspectors found no chest x-ray order was actually implemented until May 6, 2025. The physician assistant had examined the patient and documented the STAT chest x-ray order on April 28. More than a week passed before anyone at the facility actually placed the order in the system.
When inspectors interviewed the Unit Nurse Manager on October 7, she explained the facility's usual process. After a provider examines a resident and orders new medications or tests, the provider either tells the floor nurse to enter the orders or tells the unit manager, who then enters them.
The nurse manager couldn't explain what went wrong with this patient's emergency chest x-ray.
Asked specifically why the STAT order took more than a week to implement, she said "the ordered probably did not hit the board" - referring to the electronic medical system that notifies staff of new orders. She promised to look into the concern and follow up.
An hour later, at 2:41 PM, the same nurse manager reported back. She had reviewed the medical record but was "unable to provide further information or documentation on why the STAT chest x-ray order was not implemented and completed timely."
No further explanation or documentation was provided by the end of the federal inspection.
The patient had multiple serious conditions requiring close monitoring. Her primary diagnosis was acute on chronic diastolic heart failure, meaning her heart's pumping function was severely compromised and getting worse. The blood clots in both legs created additional risks for potentially fatal complications if pieces broke off and traveled to her lungs or heart.
Chest x-rays are standard diagnostic tools for patients with congestive heart failure and breathing problems. They can reveal fluid buildup in the lungs, heart enlargement, or other complications that require immediate treatment adjustments.
The physician assistant had already started aggressive treatment with extra diuretic medication and breathing treatments based on the clinical examination. But the chest x-ray would have provided crucial information about the severity of fluid buildup in the patient's lungs and whether the treatment plan needed modification.
Federal regulations require nursing homes to provide or obtain diagnostic tests when ordered by physicians and promptly inform the ordering practitioner of results. The regulation exists specifically to prevent delays that could harm residents with serious medical conditions.
This resident's case illustrates how communication breakdowns in nursing homes can affect patients with multiple life-threatening conditions. The physician assistant had examined the patient, identified serious symptoms, and ordered immediate diagnostic testing as part of a comprehensive treatment plan.
The facility's electronic notification system apparently failed. Staff didn't catch the missing order for over a week. When federal inspectors asked for an explanation, facility managers had no documentation showing what went wrong or why.
The resident remained at the facility with untreated shortness of breath and no chest x-ray results to guide her heart failure treatment for more than a week after her doctor determined the test was urgently needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellbridge of Novi from 2025-10-07 including all violations, facility responses, and corrective action plans.