Failure to Timely Notify Physician of Critical X-ray Results
Penalty
Summary
The facility failed to ensure timely notification of a physician or APRN regarding critical x-ray results for a resident with multiple sclerosis, obstructive and reflux uropathy, and a history of constipation. The resident was identified as cognitively intact and at risk for constipation, with interventions in place to monitor and manage bowel function. On the day in question, the resident underwent a STAT abdominal x-ray due to loose stools, which revealed a severe colonic ileus and a suspicious finding for partial sigmoid volvulus. The radiology report, marked as critical, was available in the facility's EMR and faxed to the facility in the evening. Despite the critical nature of the findings, nursing documentation indicated that staff were unaware of the x-ray results for several hours after they became available. Nursing notes from the evening and overnight shifts repeatedly stated that results were pending, even though the report had been faxed and uploaded to the EMR. The radiology team attempted to notify the facility by phone and fax, eventually reaching a nurse supervisor in the early morning hours, but the physician was not notified until after the night shift ended. Interviews with nursing staff revealed that the process for checking and reviewing faxed results was inconsistent, with one RN supervisor stating she may have missed the report due to the high volume of paperwork. Another RN supervisor indicated she did not notify the physician because she had not received the printed report, despite being verbally informed of the results. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not followed in this instance.