Delayed Notification of Diagnostic Results Leads to Resident Harm
Summary
The facility failed to promptly notify the ordering physician or nurse practitioner of diagnostic results that fell outside of clinical reference ranges, as required by their policies and procedures. This deficiency was identified in the case of a resident who complained of pain during peri care at 5:00 am on June 6, 2024, but was not sent to the hospital until over 18 hours later. Upon hospital admission, the resident was diagnosed with an intertrochanteric fracture of the right femoral neck of indeterminate age. The resident, an elderly female with a history of cognitive communication deficit, muscle contracture, aneurysm, constipation, hemiplegia, hemiparesis, and insomnia, was bed-bound and required assistance with activities of daily living (ADLs). On June 6, 2024, the Assistant Director of Nursing (ADON) was informed by a Certified Occupational Therapy Assistant (COTA) that the resident was experiencing pain in her right leg. The ADON conducted a brief assessment and reported the issue to the Director of Nursing (DON), who ordered an X-ray. The X-ray was performed, and the results, which indicated a fracture, were available by 2:25 pm the same day. Despite the availability of the X-ray results, there was a delay in notifying the appropriate medical personnel. The Licensed Vocational Nurse (LVN) misinterpreted the X-ray report and sent it to the nurse practitioner via text message, but the nurse practitioner did not receive it. The DON eventually reviewed the X-ray report at 11:00 pm and instructed another LVN to contact the on-call doctor to arrange for the resident's transfer to the hospital. The resident was finally sent to the hospital at 12:02 am on June 7, 2024, highlighting a significant delay in addressing the resident's medical needs.
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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