Failure to Complete STAT Imaging and Notify Provider After Resident Fall
Penalty
Summary
A resident with a history of osteoarthritis, previous traumatic fracture, and dementia experienced a fall resulting in complaints of pain to the right wrist and right hip. A physician assistant present at the time assessed the resident and ordered STAT x-rays of the right wrist, pelvis, and hip. Despite these orders, the x-rays were not completed as directed. The facility's process involved contacting a mobile imaging service, but the imaging was not performed the same day, and there was no documentation of follow-up with the provider regarding the delay. Throughout the evening and night following the fall, the resident exhibited signs of significant pain, including shaking and a refusal to ambulate or get out of the wheelchair, which was a change from her baseline. These symptoms were reported to nursing staff, but the provider was not notified of the resident's ongoing pain or the failure to complete the STAT imaging. The facility's policy required immediate notification of the provider and the resident's representative in the event of a significant change in condition or if treatment could not be provided as ordered, but this did not occur. The next morning, the resident was found to be in severe pain and was subsequently sent to the emergency room, where she was diagnosed with fractures to the right hip, pelvis, and wrist. Interviews with facility staff confirmed that the provider was not informed of the delay in imaging or the resident's change in condition until after the resident was sent to the hospital. The failure to complete the STAT x-rays as ordered and to communicate this to the provider resulted in a delay in treatment for the resident.