Failure to Notify Physician of Abnormal X-ray Results After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of abnormal x-ray results for a resident who experienced a fall. The resident, who had multiple diagnoses including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis, attempted to get out of bed and fell, resulting in left arm pain. The nurse practitioner was notified and ordered an x-ray, with instructions to notify the clinician of any change in condition. When the x-ray results became available later that day, the LPN placed the results in the physician binder but did not directly notify the physician, and there was no documentation of how or when the physician was informed. The facility's policy required direct physician notification for abnormal x-ray results, but this was not followed in this instance.