Failure to Timely Notify Physician of Positive X-ray Results
Penalty
Summary
Facility staff failed to notify the physician in a timely manner regarding the X-ray results of a resident who was admitted with multiple diagnoses, including dementia and severe cognitive impairment. The resident was found with a bruise on the left leg and reported pain to touch. Initial actions included notifying the medical doctor and the after-hours provider, as well as the resident's power of attorney. Orders were given for an X-ray of the left hip and lower leg, which was performed the following day. The X-ray results revealed a comminuted, angulated, intertrochanteric fracture of the left femur. According to the X-ray company, the facility was notified of the positive finding on the same day the X-ray was performed, and a registered nurse was reportedly informed. However, a review of the clinical record showed no documentation that the physician was notified of the X-ray results on that day. Nursing staff interviews confirmed that there was no evidence of physician notification on the day the results were received. The delay in notifying the physician resulted in a lack of timely medical intervention for the resident's fracture. The deficiency was identified through clinical record review and staff interviews, which highlighted the absence of required documentation and communication regarding the significant change in the resident's condition.