Failure to Notify Practitioner of X-ray Results
Summary
The facility failed to notify the ordering practitioner of radiology results for a resident who experienced back pain after being repositioned by nursing aides. The resident, who has a history of Type 2 diabetes mellitus with diabetic neuropathy and coronary angioplasty, reported sharp pain in her back and legs following the incident. An x-ray was ordered, and the results indicated moderate disc space narrowing and degenerative changes, but there was no documentation that the ordering practitioner was informed of these findings. Additionally, no follow-up x-ray was ordered. Interviews with facility staff revealed that the nurse on duty did not notify the resident's family or the doctor about the x-ray results, only passing the information to the nurse on the next shift. The facility's policy requires that diagnostic test results be communicated to the ordering physician within 24 hours, but this protocol was not followed. The Director of Nurses acknowledged the oversight and indicated that education would be provided to prevent future occurrences.
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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