Delay in Emergency Transfer Following Missed STAT X-ray Result
Penalty
Summary
A deficiency occurred when facility staff failed to act in a timely manner to transfer a resident to the hospital after a radiologist confirmed a spiral femur fracture. The resident, an elderly female with advanced dementia, PEG tube dependence, and a history of recent right distal femur fracture, was identified as having swelling, redness, and pain in her right knee during evening care. A STAT x-ray was ordered, and the radiologist signed off on the diagnosis of a spiral femur fracture late that night. However, the resident was not transferred to the hospital until the following morning, resulting in a delay of approximately seven hours from the time the critical finding was available. The delay was due to a lack of follow-up by the night shift nurse, who did not check the x-ray provider portal for results during his shift, despite being aware that STAT x-rays had been ordered and that the resident had a significant change in condition. The nurse stated he was the only nurse for 30 patients and was busy, but acknowledged that it was good clinical practice to follow up on pending x-ray results. The morning shift nurse discovered the x-ray results, contacted the provider, and arranged for the resident's transfer to the hospital. Interviews with other staff confirmed that all nurses had access to the x-ray provider portal and were trained to check for STAT results, and that a fracture was considered a critical finding requiring immediate action. Facility policies required staff to provide timely care and follow up on significant changes in condition, including obtaining and acting on diagnostic results. The failure to review and act on the STAT x-ray results in a timely manner resulted in a delay in emergency care for the resident, who remained in the facility with a confirmed femur fracture for several hours before being transferred for appropriate medical treatment. This delay was acknowledged by facility leadership and staff as not meeting the standard for rapid response to critical findings.