Delayed X-ray Result Follow-up and Incomplete Wound Monitoring
Penalty
Summary
The facility failed to ensure timely receipt and follow-up of stat X-ray results, resulting in a delay in treatment for a resident who suffered a right hip fracture. After a fall, the resident initially complained of knee pain, prompting a stat X-ray order for the knee. The following morning, the resident reported severe hip pain, and a stat X-ray of the hip was ordered and completed. The radiology vendor faxed the results, which confirmed a right femoral neck fracture, to the facility within the hour. However, the facility did not receive or act upon these results until approximately 24 hours later, despite the expectation that staff should follow up with the vendor if results were not received within four to six hours. During this period, the resident experienced severe pain and was not transferred to the hospital for evaluation and treatment until the results were finally reviewed the next day. Additionally, the facility failed to ensure weekly wound monitoring and assessments for another resident with a venous ulcer. Although there was an order for regular wound care and the facility policy required weekly documentation of wound assessments, there was no evidence in the medical record that such assessments or monitoring were completed for over a month. The responsible LPN stated that wound measurements were not uploaded into the electronic medical record and that, during her absence, no documentation was available to confirm ongoing monitoring or assessment of the wound, including from outside wound care providers. These deficiencies were identified through medical record review, staff and vendor interviews, and policy review. The failures resulted in actual harm to one resident due to delayed treatment of a hip fracture and placed another resident at risk for more than minimal harm due to lack of wound monitoring.