Failure to Obtain Timely Stat X-Ray Following Resident Fall
Penalty
Summary
Facility staff failed to obtain a stat x-ray in a timely manner for a resident who experienced a fall and complained of pain in the left lower extremity and hip. After the fall, the resident was assessed and a stat x-ray was ordered for the left hip, with additional orders for x-rays of the ankle and knee due to pain and visible bruising and swelling. Despite these orders, the x-rays were not obtained promptly, and there was no documented follow-up by staff with the mobile x-ray provider prior to the resident being sent to the emergency department. Interviews with staff revealed an expectation that stat x-rays should be completed within eight hours, and if not, the resident should be sent out for further evaluation. The resident's daughter expressed concern about the delay and the resident's ongoing pain during her visit. Clinical record review confirmed that the x-ray orders were placed, but there was no evidence of timely follow-up or escalation when the x-rays were not performed as expected. The facility's fall prevention policy required assessment, documentation, and physician notification after a fall, but did not ensure that the ordered diagnostic tests were completed in a timely manner. The resident was ultimately sent to the emergency department at the family's insistence, and did not return to the facility. No additional information or documentation was provided by the facility to demonstrate appropriate follow-up or resolution prior to the resident's transfer.