Delay in Provider Notification of Positive Hip Fracture X-ray Results
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the provider of x-ray results for a resident who had fallen and complained of hip pain. After the fall, the DON assessed the resident and contacted the PA, who ordered a right hip x-ray and pain medication. The x-ray was not ordered as stat, and the mobile x-ray company performed the x-ray the following day. The x-ray report, which showed an acute right femoral intertrochanteric fracture, was faxed to the facility and uploaded to the resident's EMR, but there was no documentation in the progress notes regarding the x-ray or the resident's right hip on the day the results were available. The mobile x-ray company attempted to call the facility five times to report the positive fracture results but was unable to reach anyone. The results were not communicated to the provider until the following day, when a nurse received a call from the x-ray company, checked the EMR, and found the report indicating a fracture. Only then was the provider notified, and the resident was transferred to the hospital for evaluation and treatment. Interviews with staff revealed that nurses are able to access x-ray results in the EMR and that the fax machine is accessible to all nurses, though agency nurses may not be aware of incoming faxes. The delay in provider notification resulted from a combination of the x-ray not being ordered stat, lack of documentation and follow-up in the EMR, unanswered phone calls from the x-ray company, and a lack of awareness among staff regarding the availability of the x-ray report. The administrator was unaware of the multiple failed attempts by the x-ray company to reach the facility, and the PA stated that ideally, the results should have been reported to a provider as soon as they were available.