Delayed Notification of X-Ray Results
Summary
The facility failed to promptly notify the ordering physician of x-ray results for a resident, which revealed a left shoulder dislocation. The resident, an elderly female with dementia, malnutrition, and lack of coordination, was found on the floor in her bedroom and complained of pain on the left side of her body. Although pain medication was administered, the x-ray results indicating a dislocated shoulder were not communicated to the physician until two days later. The x-ray was ordered on the day of the fall, and the results were available in the computer system and faxed to the facility the same day. However, the results were not viewed by the facility until two days later, and the physician was not notified until the morning of the second day. During this time, the resident continued to receive pain medication as needed. Interviews with facility staff revealed a lack of clear procedures for checking and communicating diagnostic test results. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not recall seeing the faxed results and only checked the computer system intermittently. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were not aware of specific requirements for checking results, and the Administrator (ADM) expected results to be checked every shift but was unsure of the facility's process.
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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