Failure to Obtain Timely STAT X-ray Following Resident Fall
Penalty
Summary
The facility failed to provide or obtain timely radiology services for a resident who sustained an unwitnessed fall and exhibited symptoms suggestive of a hip fracture, including right groin pain and a leg length discrepancy. A STAT right hip X-ray was ordered by the provider, and the resident was placed on bed rest pending results. Despite the STAT order, the X-ray was not performed within the expected timeframe, and the contracted radiology company did not provide a technician promptly. Nursing staff communicated with the resident about the pending X-ray and contacted the radiology company, but the X-ray was still not completed. Over the following day, the resident developed additional symptoms, including malaise, fever, and hypoxia, and experienced significant pain during care. The provider was updated about the resident's deteriorating condition, and the resident was eventually sent to the hospital, where a hip fracture was confirmed. Interviews with staff revealed that a STAT X-ray should be performed within four hours and that the provider should be notified if there are delays. The DON acknowledged that staff did not notify the provider of the delay in obtaining the X-ray, resulting in prolonged pain and hospitalization, and also stated that timeliness of X-ray services had been an ongoing issue with the contracted company.