Failure to Ensure Safe X-Ray Positioning Results in Resident Arm Fracture
Penalty
Summary
A resident with a history of stroke, contracture of the right arm, diabetes, hypertension, neurogenic bladder, arthritis, aphasia, and osteoporosis experienced significant pain and ultimately a fracture following an x-ray procedure performed by a contracted x-ray technician. The resident was cognitively intact but had physical impairments and required complete assistance for activities of daily living. The x-ray was ordered due to redness, swelling, and pain in both elbows, and the resident was being treated for possible cellulitis at the time. During the x-ray procedure, the technician attempted to reposition the resident's contracted right arm without adequate assistance from facility staff, despite the resident's inability to move the arm due to the contracture. The resident cried out in pain during the procedure, which was heard by a registered nurse who intervened and stopped the technician from further manipulating the arm. The technician stated that she could not obtain the necessary images without straightening the arm, but did not request or wait for staff assistance as required by the x-ray company's own procedures. Facility staff were not present in the room during the initial attempt, and the technician did not seek help despite the resident's obvious physical limitations and pain. Following the incident, the resident continued to experience increased pain in the right arm, which was not relieved by Tylenol and later required stronger pain management. Subsequent x-rays revealed fractures in the right arm, and the resident was referred to an orthopedic physician for casting. Interviews with facility staff and review of the x-ray company's procedures confirmed that facility staff assistance was required for repositioning residents with significant physical limitations, but this protocol was not followed during the incident.