Failure to Provide Timely STAT X-Ray Services for Resident with Hand Injury
Penalty
Summary
The facility failed to provide timely radiology services for a resident who was identified with swelling in the left hand. The resident, who had diagnoses including dementia, major depressive disorder, and severe cognitive impairment, was observed by an LPN to have +3 pitting edema and swelling in the left hand. A STAT x-ray and doppler were ordered by the nurse practitioner, and the orders were placed as required. However, the radiology company was unable to perform the STAT x-ray within the expected timeframe due to high volume, and the x-ray was not completed until the following day. During this period, staff communicated with the radiology company multiple times to follow up on the status of the STAT x-ray, but no estimated time of arrival could be provided. The facility's policy and agreement with the radiology provider specified that STAT x-rays should be performed within 4 hours. Despite this, the x-ray was delayed, and the resident was eventually transferred to the hospital for further evaluation, where a small fracture of the left little finger was diagnosed. Interviews with facility staff, including the administrator, ADON, DON, and nurses, confirmed that STAT x-rays are expected to be completed within 4 to 6 hours, and that delays with the radiology company had been an ongoing issue. Documentation also revealed that the physician was not notified that the STAT x-ray was not completed within the required timeframe, contrary to facility policy, and the delay in obtaining the x-ray was not properly documented in the progress notes.