Failure to Timely Follow Up on STAT X-ray Results
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring timely follow-up on STAT x-ray results for a resident with a history of Alzheimer's Disease, dementia, left hip pain, and previous fractures. After an unwitnessed fall, the resident complained of left hip pain, prompting a nurse practitioner to order a STAT x-ray. The x-ray was performed, and the results, which showed a nondisplaced intertrochanteric fracture, were electronically signed and available the same evening. However, the results were not reviewed or acted upon until the following morning. Nursing staff on the evening and overnight shifts were aware that the x-ray results were pending but did not follow up with the imaging center or check for the results within the expected timeframe. The LPN on the night shift acknowledged that she did not call to check on the results, despite knowing that STAT results are typically received within a few hours. The Director of Nursing Services confirmed that the nurse assigned to the resident should have followed up on the x-ray results that night. As a result, there was a delay in identifying and responding to the resident's fracture.