Delayed X-ray Results Lead to Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure timely care and treatment for a resident who required an x-ray to rule out a fracture in the left forearm. The x-ray was ordered by a medical doctor on the night of 12/05/2024, but it was not performed until 12/07/2024. The results, which indicated fractures of the midshaft radius and ulna with mild displacement, were finalized on 12/08/2024 but were not communicated to the facility until 12/09/2024. This delay in obtaining and acting upon the x-ray results led to the resident being transferred to the hospital for further evaluation. The facility's policy required that final written reports be submitted within 48 hours, but this was not adhered to. Interviews revealed that the medical doctor did not order a STAT x-ray initially due to the resident not complaining of pain and the swelling being attributed to a possible medical condition. The Director of Nursing and the Medical Director noted that the facility did not receive timely communication from the radiology department, which stated that it was the facility's responsibility to follow up on outpatient results. This lack of timely follow-up and communication contributed to the deficiency in care provided to the resident.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 F 684 483.25 Quality of Care § 483.25 Quality of care I. The Following actions were accomplished for the resident identified in the sample: Immediate action to correct the alleged deficient practice included MD, and family notification of resident #1 x-ray results. On 12/10/24 resident returned to facility with hard cast to the left arm in place. Full body assessment of the resident complete, no additional area of concern noted. Pain assessment completed, pain management implemented, continued monitoring for skin integrity and circulation. The resident was immediately placed on another unit in another pavilion of the facility. Resident #1 was also placed on 1:1 monitoring for safety and observation. Resident was seen by psychiatrist on 12/11/24, physician determined there was “no psychological impact.” Rehabilitation consultation was ordered. Physical and Occupational Therapy consultation was completed on 12/12/24. Resident #1 was seen by orthopedics in the ER with follow-up on 12/14/24. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents requiring x-rays have the potential to be affected by the alleged deficient practice. An audit was conducted to ensure all residents with pending x-ray results were obtained and reviewed timely by the physician and timely notification made to resident/family member. A full body assessment was completed on all residents on all floors on 12/12/24 to ensure no other residents have injury, which the facility was not aware of. No other residents were affected by the deficient practice in the facility. Social Services conducted an audit by interviewing alert residents to ascertain whether anyone had witnessed the abuse of other residents or if they have been victims of abuse themselves. No residents have verbalized that they have been abused or observed any abuse of other residents. Risk for Abuse is in place for all residents. The re-education of all staff commenced on 12/10/24 and is ongoing: The following training was provided: 1. Resident Rights 2. Abuse, Neglect & Mistreatment 3. Siderails Monitoring, Bed Entrapment & Restraint 4. Reportable Concerns 5. Pain Management 6. Managing Difficult Residents 7. Resident Safety Quality of Care education commenced on 1/10/25. The following system changes will be implemented to ensure continuing compliance with regulations: On 12/17/24 a medical staff meeting was held, and education was provided to physicians, that effective immediately any suspicion of a fracture or trauma related occurrence, even if low suspicion, order should be made to stat on priority. Physicians are to follow-up on image results in EPIC, if ordered with suspicion of fracture is made. Medical staff meeting was conducted on 1/15/25, physicians were provided with education on residents’ right to be free from physical restraints, reporting of alleged violations and review of the regulations regarding Quality of Care. Education was provided by the medical director and the director of nursing. QAPI Committee meeting was held on 1/10/2025 to review the findings of the compliant survey. Staff Education started on 1/10/25 and is ongoing. Education will be provided during education, annual during mandatory in-service education and as needed. Education will be provided by the staff educator/designee. Nurses were provided with education starting on 12/17/24 that any X-ray orders are to be communicated on the 24-hour report by unit nurse, nurse managers/supervisors. Once the radiology images have been completed, the staff nurse will call the radiology department to obtain results. If the result is not available at the end of the nurses tour it is endorsed to the oncoming shift until results are finalized. Nurses will also check the shared medical records system (EPIC) to obtain posted results. On 1/15/2024, Diagnostic Test Policy and Procedure were reviewed with no changes. The Provision of Radiology Services Policy was reviewed and revised to indicate physicians will check order status in EPIC. IV. The facility’s compliance will be monitored utilizing the following quality assurance system. The facility Director of Nursing and Medical Director Designee will conduct random audit to ensure compliance with the review of x-ray orders and imaging results weekly for 4 weeks then monthly for 3 months and quarterly thereafter. The action plan will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee for further review and recommendations for three months. QAPI committee will make recommendations for ongoing monitoring. The Medical Director and Director of Nursing/Designee will be responsible for the implementation of this plan of correction.