Delayed X-ray for Resident with Acute Injury
Summary
The facility failed to ensure that an x-ray was obtained in a timely manner for a resident, identified as R128, who sustained an acute injury. On October 31, 2024, R128 experienced a fall, resulting in a complaint of pain in her right wrist. A head-to-toe assessment was conducted, and the resident was found to have no other injuries or distress. The local on-call doctor was contacted, and an x-ray of the right wrist was ordered at 6:29 PM. However, the x-ray was not performed until November 1, 2024, at 8:42 PM, which was 26 hours and 13 minutes after the order was placed. The results of the x-ray were not received by the facility until November 2, 2024, at 11:34 AM, approximately 14 hours after the x-ray was conducted. The Director of Nursing (V2) was unaware of the reason for the delay in obtaining the x-ray, noting that x-rays are typically completed within 24 hours if not ordered STAT. The facility's policy, dated September 2020, states that radiology services are available 24/7, including holidays. Despite this policy, the delay in obtaining and receiving the x-ray results indicates a failure to adhere to the established procedures, resulting in a deficiency in the timely provision of necessary diagnostic services for the resident.
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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