Failure to Obtain Provider Order and Notify Practitioner of X-ray Results
Penalty
Summary
The facility failed to obtain a provider's order prior to requesting radiology testing for a resident and did not notify the Nurse Practitioner (NP) when x-ray results revealing multiple rib fractures became available. A resident with a history of stroke, muscle weakness, and dementia experienced a fall and subsequently underwent x-rays. The initial x-ray did not show acute fractures, and the NP reviewed these results during a post-fall evaluation. Later, another x-ray was performed without a documented provider order, and this x-ray revealed multiple right-sided rib fractures. The nurse who requested the second x-ray did so based on her own assessment of the resident's symptoms, believing the resident might have similar symptoms to her own, but did not document a provider order. The nurse also could not confirm if she communicated the pending x-ray results to the oncoming nurse. The NP was only made aware of the x-ray results after the resident was sent to the hospital for a change in condition, at which point he discovered the rib fractures in the resident's electronic medical record. Interviews with facility staff confirmed that there was no system in place to ensure provider notification of radiology results when they became available, and the process relied on verbal handoff between nursing shifts. The Director of Nursing stated that all lab or radiology results should be communicated to the provider, but this was not consistently done in this case.