Delay in X-ray Acquisition for Resident with Acute Injury
Summary
The facility failed to ensure timely acquisition of x-rays for a resident with an acute injury. On November 27, 2024, a resident complained of pain during care, prompting a CNA to alert the nurse on duty. Despite the administration of pain medication and an assessment by the nurse, no immediate findings were noted. Later, the resident again complained of pain, leading the CNA to inform the nurse, who then involved the DON. Suspecting a deep vein thrombosis, the DON contacted the NP, who ordered a venous doppler and a STAT x-ray. However, the x-ray was not performed until the following morning, over 24 hours later, revealing a fracture in the resident's right tibia/fibula. The delay in obtaining the x-ray was noted by the LPN who was on duty during the day shift on November 27, 2024. She expected the x-ray to be completed that evening, but it was not done until the next day. The NP, who assessed the resident later that day, instructed the nursing staff to follow up with the x-ray company and indicated that the resident should have been sent to the emergency department if the x-ray could not be performed promptly. The facility's administrator acknowledged the delay and was investigating the cause. The facility's policy requires laboratory and diagnostic testing to be performed according to the order, with oversight by the DON or a designee, but this protocol was not followed in this instance.
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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