Failure to Communicate X-ray Results to Physician
Summary
The facility failed to ensure that a physician saw and responded to the radiological records for a resident who had X-rays of the shoulder and clavicle after experiencing an unresponsive episode and complaining of pain. The X-rays were completed, and the results for the shoulder showed no acute fracture, which was signed by the physician. However, the clavicle X-ray indicated a fracture, but the results were not signed or acknowledged by the physician, indicating that the physician did not receive or review these results. The resident, who had intact cognition and was their own decision-maker, was admitted for rehabilitation following surgery on the nervous system and had multiple diagnoses, including a right clavicle fracture. Despite the facility receiving the clavicle X-ray results, the registered nurse who documented the shoulder X-ray results did not recall receiving the clavicle X-ray results. Consequently, the physician was not informed of the fracture, and the resident continued to experience pain and instability in the shoulder area. Interviews with the occupational therapist and the director of nursing revealed that the clavicle fracture was only discovered when preparing for an orthopedic appointment. The physician confirmed that they had not seen the clavicle X-ray results and indicated that the treatment would not have changed significantly. However, the lack of communication and oversight resulted in a delay in the appropriate acknowledgment and management of the resident's clavicle fracture.
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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