Delay in Provider Notification of Urgent EKG Results
Summary
Facility staff failed to promptly notify the provider of urgent diagnostic results for a resident with a history of complete AV block, cardiac pacemaker, hypertension, and asthma. The resident experienced bradycardia and upper respiratory symptoms, and an EKG was ordered after persistent low heart rates were observed. The EKG report, which indicated severe bradycardia and possible third-degree heart block requiring immediate follow-up, was faxed to the facility at 12:47 AM. However, the provider was not notified of these urgent results until approximately 7:30 AM, resulting in a delay of several hours before action was taken. During this period, the resident continued to feel unwell and expressed significant fatigue. The delay in provider notification was confirmed through clinical record review and staff interviews, with staff stating that the results were not received or acted upon until the morning. Facility policy required prompt notification of abnormal diagnostic results to the ordering provider, but this was not followed in this instance, leading to a delay in the resident's transfer to the emergency room for further evaluation and treatment.
Penalty
Resources
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A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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