Failure to Notify Physician of Abnormal X-ray Results
Summary
The facility failed to promptly notify the attending physician of abnormal x-ray results for a resident, leading to a delay in treatment. The resident, who was admitted with diagnoses including Type 2 diabetes and multiple ulcers, had a wound consult on July 10, 2024, which recommended an x-ray due to the deterioration of a pressure ulcer on the right heel. The x-ray, completed on July 11, 2024, revealed calcaneus erosion consistent with osteomyelitis. However, there was no documentation indicating that the physician was informed of these results on the same day. The deficiency was further highlighted when a change in condition assessment five days later noted increased pain and confirmed osteomyelitis, prompting the physician to be notified and the resident to be sent to the hospital. The Nursing Home Administrator confirmed the failure to notify the physician promptly, which was a breach of the facility's responsibility to ensure timely communication of critical health information.
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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