Delayed Access to Critical X-ray Results for Resident with Bowel Complications
Penalty
Summary
Facility staff failed to access and act upon critical x-ray results in a timely manner for a resident with a history of multiple sclerosis, obstructive and reflux uropathy, and constipation. The resident was identified as cognitively intact and at risk for constipation, with care plan interventions to monitor for signs of constipation and administer medications as ordered. On one occasion, the resident received a bowel regimen and was ordered a KUB x-ray to rule out constipation and small bowel obstruction. The initial x-ray showed severe colonic ileus with moderate stool, but no obstruction. A follow-up KUB was ordered and performed, with results indicating a coffee bean shaped gas shadow suspicious for partial sigmoid volvulus, a critical finding. The results were available in the facility's EMR and faxed to the facility, but staff did not access or review the results for over 12 hours. Nursing notes repeatedly indicated that the results were still pending, despite the results being available in both the EMR and via fax. The resident was ultimately transferred to the hospital after the results were finally reviewed. Interviews with staff revealed that there was no consistent process for checking the fax machine or EMR for new results, and that the facility's systems did not provide alerts or confirmations for new critical findings. Staff reported high volumes of paperwork and lack of clear protocols for timely review of incoming results. The delay in accessing and acting upon the critical x-ray findings led to a significant delay in notifying the provider and transferring the resident for further care.