Delay in Notification of Chest X-ray Results Leading to Treatment Delay
Penalty
No penalty information released
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Summary
Facility staff failed to promptly notify the resident's healthcare practitioner of chest x-ray results that indicated new left midlung and right lower lobe opacities, which may represent pneumonia. The resident, who was rarely able to make themselves understood and required total assistance with all activities of daily living, exhibited symptoms including audible moist wheezes, green nasal drainage, and glassy eyes. A STAT portable chest x-ray was ordered and obtained, but the results were not communicated to the healthcare practitioner until two days later, resulting in a delay in ordering antibiotics for pneumonia. The Director of Nursing confirmed the delay in notification and subsequent treatment.