Failure to Notify Physician of Critical X-ray Results Following Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of critical x-ray results for a resident who experienced acute pain following a fall. The resident reported falling in the bathroom, landing on her right knee, and experiencing immediate and ongoing severe pain. The day after the fall, the nursing supervisor contacted the on-call provider, who ordered a right leg x-ray. The x-ray was performed and results indicating acute, nondisplaced fractures of the proximal tibia and fibula were received by the facility later that day. Despite the x-ray results being available and acknowledged by multiple staff members, including the nursing supervisor and the DON, the results were not communicated to a medical provider until the following day. The nursing supervisor relayed the results to other nurses but did not instruct them to notify the physician, nor did she do so herself. The DON also reviewed the results and confirmed with the nursing supervisor that she had received them, but did not provide explicit instructions to notify the physician. The night shift nurse was informed of the fracture but was not asked to take further action. As a result, the physician and nurse practitioner were not made aware of the resident's acute fractures until the next day. This delay in communication led to a delay in medical intervention and evaluation in the emergency department. The resident ultimately required a two-day hospitalization, with orthopedics recommending a hinged knee brace and non-weight bearing status. Interviews with the nurse practitioner, medical director, and on-call physician confirmed that no notification of the x-ray results was received over the weekend, and that appropriate action would have been taken had they been informed in a timely manner.