Delayed Physician Notification of Abnormal X-ray Results Following Resident Fractures
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for a resident, resulting in significant delays in medical intervention. On two separate occasions, the resident sustained fractures to the lower extremities after incidents involving transfers from a shower chair to the bed. In both cases, x-rays were ordered and results indicating fractures were received by the facility, but there was a delay in notifying the physician and in sending the resident to the hospital. For the first incident, the x-ray result showing a left tibia fracture was received, but the resident was not sent to the hospital until five days later. For the second incident, the x-ray result showing a right tibia fracture was received, but the resident was not sent to the hospital until the following day. Interviews and record reviews revealed that nursing staff either did not notify the nurse practitioner (NP) immediately or failed to follow up when no response was received. In some cases, staff relied on text messages to communicate critical results and did not escalate the situation when the NP did not respond. Documentation was inconsistent regarding how and when the NP was notified, and there was confusion among staff about the appropriate steps to take when a physician could not be reached. The Director of Nursing (DON) and other staff members confirmed that there was a lack of clarity and follow-through in the notification process, and that the facility's policies for prompt physician notification were not followed. The resident involved had a history of multiple sclerosis, lack of coordination, and was dependent on staff for transfers and personal care. After each incident, the resident experienced pain and reported that the pain was not adequately managed until she was sent to the hospital. The facility's failure to promptly notify the physician and act on abnormal diagnostic results led to delays in appropriate medical treatment for the resident.
Removal Plan
- The DON, ADON D, and ADON E completed a change of condition assessment focusing on pain on each resident to determine if they are not at their baseline. Each resident was documented on the outcome of their assessment in their progress note in Point Click Care. For any residents that were found not to be at their baseline, their physician was notified and documented on. Any conditions noted after this immediate assessment, and it was found that the physician was not notified, a re-education of physician notification was completed.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- In-services were initiated by the Chief Nursing Officer. Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. The ADM and human resources will ensure these team members are removed from the time clock and PCC access removed. This will be monitored until 100% complete or the team members are terminated. Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered. The passing score will be 80% - 100%.
- Licensed nurses were in-serviced on: Notifying physicians during a change of condition in a resident; Physician on-call schedule; Process on what to do if a physician cannot be reached; Comprehensive Pain Management Treatment Plan for each resident.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- The Corporate Nurse immediately audited the 24-hour facility resident summary to determine if there were any changes of conditions focusing on pain that were noted, and the physician was notified. These findings were sent to the DON, ADON D, and ADON E for follow-up.
- The chief nursing officer reviewed the administrative nurse's follow-up to ensure follow-up happened and will do this daily.
- DON, ADON D, and ADON E will monitor daily residents' current electronic records for a change of condition utilizing the Point Click Care Clinical Dashboard, which includes resident's Change of Condition, 24 Hour Resident Report, Progress notes, Incidents & Accidents, Weights & Vitals, and Diagnostic reports on all residents daily.
- To ensure accuracy, DON, ADON D, and ADON E will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- Interviews were conducted with nurses to verify understanding of on-call physician number access, notification process, change in condition identification, and escalation if unable to reach a provider.
- Record review of facility in-services titled Notifying Physicians During a Change of Condition, Physician On Call Schedule, and What to do if a Physician cannot be reached revealed all nursing staff had signed indicating education was completed by all nurses.