Failure to Review and Report Abnormal X-ray Result Led to Delay in Fracture Care
Penalty
Summary
A deficiency occurred when a nurse failed to properly review and interpret an abnormal X-ray result for a resident who had a recent fall and was experiencing pain. The resident, an elderly female with a history of muscle weakness, dementia, and hypertension, was assessed as having low cognitive function and a high risk for falls. After reporting pain following a fall, the resident was evaluated and an X-ray was ordered. The X-ray, which showed a stable acute nondisplaced fracture of the left pubic rami, was misread by the nurse as negative, and this incorrect information was verbally relayed to other staff and the nurse practitioner. The resident continued to experience pain and showed signs of impaired mobility, such as dragging her left leg. Despite ongoing complaints and ineffective pain management, the abnormal X-ray findings were not recognized or acted upon for two days. The nurse who received the X-ray result only reviewed the first page, which did not indicate a fracture, and failed to read the subsequent page that documented the fracture. This led to a delay in appropriate medical evaluation and treatment for the resident, who was eventually sent to the hospital where the fracture was confirmed and pain management was initiated. Interviews with staff revealed that the process for reviewing and reporting diagnostic results was not consistently followed, and that communication breakdowns contributed to the delay in care. The nurse practitioner did not receive the faxed X-ray result and relied on a verbal report from the nurse, which was inaccurate. The deficiency was identified as Immediate Jeopardy due to the risk of harm from delayed treatment, and the facility's investigation confirmed that the failure to review and report the X-ray findings in a timely manner constituted neglect.