Delayed X-ray Results Lead to Hospitalization
Summary
The facility failed to provide timely radiology services for a resident, leading to a delay in diagnosis and treatment. The resident, who had Alzheimer's Disease and severe cognitive impairment, complained of right knee pain, which was assessed as swollen and tender. An x-ray was ordered, but the results indicating a fracture were not promptly communicated to the facility, resulting in a delay in sending the resident to the hospital for further evaluation and treatment. The deficiency was identified when the Director of Nursing (DON) reviewed the nursing documentation and discovered the delay in receiving and acting upon the x-ray results. The x-ray company did not follow their protocol of faxing or calling the facility with critical results, and the facility staff did not access the results through the available portal. This communication breakdown led to an 8-hour delay in addressing the resident's fracture. Interviews with facility staff revealed a lack of a written policy on x-ray services and inconsistent follow-up on ordered x-rays. Staff were in-serviced on the importance of timely follow-up on stat x-rays and the need to notify the physician if results were delayed. The facility's failure to ensure timely communication and follow-up on diagnostic services resulted in delayed medical treatment and hospitalization for the resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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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