Delayed Follow-Up on X-Ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services as ordered by the physician and as indicated in facility policy for a resident who experienced a fall and subsequently reported pain. The resident, who had a history of dementia and osteoarthritis and required assistance with daily activities, fell and later complained of ankle pain. An x-ray was ordered by the physician, and the imaging was performed the following day. However, the facility did not follow up with the radiology company to obtain the x-ray results in a timely manner. The x-ray, which revealed a nondisplaced complete transverse fracture of the medial malleolus and distal fibula, was not received by the facility until two days after it was performed. Multiple nursing staff members failed to follow up on the pending x-ray report, and there was a lack of communication and endorsement between shifts regarding the need to obtain the results. One nurse contacted the radiology company and learned of technical issues delaying report delivery but did not escalate the issue to the DON or ensure the physician was notified within the facility's required timeframe. As a result, the physician was not notified of the abnormal x-ray findings until several days after the imaging was performed, delaying the resident's transfer to the hospital for further care. The facility's policy required that changes in a resident's condition and test results be reported to the physician within 24 hours, but this standard was not met in this case.