Delay in STAT X-ray for Resident with Lower Leg Swelling
Penalty
Summary
The facility failed to obtain a STAT x-ray in a timely manner for a resident who was severely cognitively impaired and had diagnoses including hypertension, non-Alzheimer's dementia, and malnutrition. The resident was observed to have swelling and discoloration in the right lower leg, prompting a nurse practitioner to order a STAT x-ray of the knee, ankle, and extended tibia/fibula. Despite the urgent nature of the order, the x-ray was not performed until the following day, more than 12 hours after the order was placed. Interviews with nursing staff confirmed that a STAT x-ray should be obtained within a few hours, with the Assistant Director of Nursing specifying a four-hour window. The facility's policy requires that diagnostic services, including radiology, be provided promptly to meet residents' needs. The delay in obtaining the x-ray did not align with the facility's policy or staff expectations for timely diagnostic services.