Delay in Reporting Doppler Results Leads to Delayed Treatment
Penalty
Summary
A resident with a history of stroke, aphasia, hemiparesis, dysphagia, and weakness experienced new onset edema and pain in the right lower extremity. In response, a physician ordered a Doppler ultrasound to assess for possible vascular issues. The Doppler was completed and interpreted, revealing partial clotting in the superficial femoral vein. However, there was no documentation that the abnormal results were communicated to the physician or nurse practitioner upon receipt. From the time the Doppler results were available, there was no follow-up or notification to the ordering practitioner for several days. The lack of timely communication resulted in a delay in treatment, as the resident did not receive an order for anticoagulant therapy until several days after the results were available. The Director of Nursing confirmed that the results were reported by the interpreting company but could not determine when or if the results were relayed to the physician, acknowledging the delay in treatment.