Failure to Notify Physician and Family of Abnormal X-ray Results
Penalty
Summary
The facility failed to notify a resident, her physician, and her family of abnormal radiology results following an incident that resulted in a left ankle fracture. The resident, who had diagnoses including end stage renal disease, heart failure, and toxic encephalopathy, was assisted by a CNA after experiencing difficulty standing from the toilet. During this assistance, the resident became unstable and was guided to the floor. Although the CNA reported the incident and the resident later complained of foot pain, there was no documented evidence that the nurse took immediate action or notified the physician at that time. Subsequent nursing notes indicated that the resident's physician eventually ordered an x-ray, which revealed an acute, minimally displaced fracture at the distal fibula, and new orders were given for orthopedic follow-up and non-weight bearing status. Interviews with the resident and her spouse revealed that they were not informed of the abnormal x-ray results until an aide inadvertently mentioned it. The administrator confirmed there was no documentation that the resident, her family, or her physician were notified of the fall or the abnormal radiology findings. Review of facility policy indicated that the nurse is required to notify the physician and the resident's representative in the event of an accident, injury, or significant change in condition, but this protocol was not followed in this case.