Delay in Urgent X-ray Services Resulting in Delayed Diagnosis of Fracture
Penalty
Summary
The facility failed to ensure that contracted radiological (x-ray) services were available and provided in a timely manner for a resident who required an urgent x-ray. The resident, who had a history of cerebral infarction, reported significant pain in the left thigh, which was documented as a change in condition. A stat x-ray was ordered by the primary care provider to assess the cause of the pain, but the x-ray was not performed as required. Progress notes indicated that the x-ray technician from the contracted service did not arrive to perform the x-ray, and the order remained unfulfilled in the resident's medical record. Despite the stat order, there was no documentation of follow-up with the x-ray provider or escalation to the physician regarding the delay. The resident continued to experience pain, and the x-ray was not completed at the facility. Subsequently, the resident was transferred to an acute care hospital, where an x-ray revealed an oblique fracture of the proximal left femoral shaft. The resident was admitted to the hospital with a diagnosis of femur fracture. Facility staff, including a licensed nurse and the assistant director of nursing, confirmed that the delay in obtaining the x-ray resulted in a delay in care and that facility policy was not followed.