Delay in Physician Notification of Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly notify the physician of x-ray results for one of two sampled residents. The resident was admitted with a midcervical fracture of the right femur and aftercare following joint replacement surgery. On 5/19/2025, a radiology report indicated a superior dislocation of the femoral component of the hip implant. The nurse supervisor received the radiology results around 7 p.m. and communicated the findings to the physician via text message at 10:44 p.m. However, the physician did not respond or contact the facility until the following afternoon. The delay in communication resulted in a delay in treatment for the resident's dislocated hip. The facility's policy required that abnormal test results be promptly reported to the ordering provider, and if there was no response after three call attempts, the staff should escalate the report to the medical director. The director of nursing confirmed that staff should have continued attempts to contact the physician and escalated the issue to avoid delays in care.