Delayed Notification of Abnormal X-Ray Results Leading to Prolonged Undiagnosed Fracture
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for Resident #1, leading to a significant delay in diagnosing and treating a left intertrochanteric femoral fracture. Despite Resident #1's complaints of excruciating pain and an additional fall, the facility did not inform the physician or family about the positive x-ray results on 01/18/24, which showed the fracture. This lack of timely communication resulted in Resident #1 remaining undiagnosed and untreated for 29 days, ultimately leading to delayed medical treatment, ongoing pain, and increased risk of complications such as bleeding and death. The failure to have a system in place to ensure prompt receipt of verbal notification from the contracted Radiology company further exacerbated the situation. The facility's records indicated that the x-ray results were received on 01/18/24, but there were unsuccessful attempts to notify the facility of the positive findings. This breakdown in communication highlights a critical gap in the facility's processes for ensuring timely and accurate reporting of diagnostic test results to the ordering practitioner, ultimately compromising Resident #1's care and safety. Multiple interviews with facility staff, including the Assistant Director of Nursing (ADON A), nursing staff, therapists, and the Nurse Practitioner (NP), revealed a lack of awareness and follow-up regarding Resident #1's condition and the x-ray results. ADON A admitted to not recalling the events surrounding the x-ray request and failing to ensure proper documentation and notification procedures were followed. The NP vaguely remembered Resident #1 and did not recall ordering the x-rays, indicating a breakdown in communication and oversight among the facility's clinical staff. These interviews shed light on the various points of failure within the facility's communication and notification processes, ultimately resulting in the deficiency identified during the survey.
Penalty
Resources
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A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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