Failure to Notify Physician of Abnormal X-ray Results
Summary
The facility failed to notify the physician or nurse practitioner of an abnormal chest X-ray for a resident who was admitted with multiple serious health conditions, including metastatic squamous cell carcinoma of the larynx, primary lung cancer, pneumonia, and chronic obstructive pulmonary disease (COPD). The resident had a history of acute hypoxic respiratory failure and pleural effusion requiring drain placements. A stat chest X-ray was ordered on March 9, 2024, due to the resident's respiratory distress, but the results indicating significant abnormalities were not communicated to the medical team. The facility's policy required that nursing staff promptly notify the attending physician of any abnormal test results, especially when the resident's clinical status is unstable. However, the documentation review revealed that the X-ray results, which showed near-complete opacification of the left lung and other concerning findings, were not communicated to the physician or nurse practitioner. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record indicating that the medical team was informed of the X-ray results. Interviews with nursing staff and the DON indicated a breakdown in communication and documentation processes. The nurse who ordered the X-ray left the responsibility of following up on the results to the next shift, but the results were not communicated. The DON and nurse practitioner confirmed that there was no record of the X-ray results being shared with the medical team, and the secure electronic system used for communication automatically deleted older messages, further complicating the situation.
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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