Failure to Promptly Notify Practitioner of Abnormal X-ray Result
Penalty
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.