Failure to Promptly Notify Practitioner of Abnormal X-ray Result
Summary
A deficiency occurred when a nurse failed to properly review and communicate the results of an abnormal X-ray for a resident with muscle weakness, dementia, and hypertension. The resident, who had a low cognitive function as indicated by a BIMS score of 4 out of 15, experienced pain in her left hip and waist. After a stat X-ray was ordered due to ongoing pain, the result, which showed a stable acute nondisplaced fracture of the left pubic rami, was not correctly read by the nurse on duty. The nurse misinterpreted the report, only reviewing the first page and reporting a negative result to the nurse practitioner, which led to a delay in appropriate medical intervention. The resident continued to experience pain and was observed dragging her left leg, with routine pain management proving ineffective. Despite ongoing complaints and visible symptoms, the abnormal X-ray findings were not communicated to the practitioner or acted upon for two days. The error was discovered only after the resident was sent to the hospital, where a hip fracture was confirmed and pain management was initiated. Interviews with staff revealed that the nurse responsible for reviewing the X-ray result failed to read the entire report and provided incorrect information to both the nurse practitioner and the next shift nurse. The facility's policy required immediate notification of abnormal diagnostic results to the practitioner, but this protocol was not followed, resulting in a delay in care for the resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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