Failure to Promptly Notify Physician of Abnormal X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a resident's physician by phone, as required by facility protocol, after receiving x-ray results that indicated a right femur fracture. The resident, an elderly female with multiple diagnoses including schizoaffective disorder, dementia, osteoporosis, and a history of falls, was found on the floor with hip bruising. Initial assessments were performed, and the on-call physician, DON, and family were notified of the fall. However, after a portable x-ray was ordered and completed due to post-fall pain, the results showing a mildly displaced fracture of the right femoral neck were received and only faxed to the physician, not communicated by phone as required. The x-ray results were received during the night, but there was no immediate phone notification to the physician. The abnormal findings were instead faxed, and it was not until later the following morning that the ADON called the physician's office to report the fracture and increased pain. The physician then ordered the resident to be sent to the ER, where she was admitted and underwent a right hip arthroplasty. Interviews with staff confirmed that the facility's expectation and protocol were to immediately call the physician with abnormal x-ray or lab results, especially those indicating a fracture, and not to rely on fax communication for critical findings. Facility policy required prompt diagnostic action and direct communication with the physician in the event of a fall with suspected injury, particularly for residents with dementia. The failure to follow this protocol resulted in a delay in notifying the physician about the resident's fracture, as the abnormal x-ray was not reported by phone as required. This delay was confirmed through interviews and record review, and staff acknowledged that the expected process was not followed in this instance.