Failure to Timely Obtain and Report Diagnostic X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a diagnostic x-ray order was carried out and the results were reported in a timely manner for a resident who had sustained an acute fracture. The resident, an older male with multiple complex medical conditions including ataxia, epilepsy, schizoaffective disorder, diabetes with neuropathy, and heart failure, experienced a fall and was found unable to move his left leg, in significant pain, and unable to recall the incident. The nurse on duty assessed the resident, notified the physician, and received an order for an x-ray, which was communicated to the external diagnostic company. However, there was no confirmation of when the x-ray would be performed, and the nurse did not follow up with the company or reassess the resident's pain before the end of the shift. The following day, another nurse discovered that the x-ray had not been completed and, upon contacting the diagnostic company, learned that no order had been received. A STAT x-ray was then ordered, and the resident was found to be immobile and in pain, with a visible bruise on the left hip. The x-ray was performed later that day, and the results, indicating an impacted transcervical fracture of the left femoral neck, were posted in the electronic medical record in the evening. However, the results were not promptly identified or reported by the nursing staff, and the Director of Nursing was not made aware of the findings until the next morning. During this period, the resident remained in bed, continued to experience pain, and was not returned to his baseline level of mobility. The delay in both obtaining the diagnostic test and reporting the results led to a delay in the resident being sent to the hospital for further evaluation and treatment. The deficiency was identified through interviews and record reviews, which confirmed lapses in communication, follow-up, and timely reporting of critical diagnostic information.