Delay in Acting on X-ray Results for Resident with Fracture
Penalty
Summary
Facility staff failed to provide timely care and services for a resident with severe cognitive impairment who developed a bruise on her left leg. The resident, diagnosed with dementia and unable to make daily decisions, was found with a bruise and pain to touch. Staff notified the physician and after-hours provider, and ice was applied for pain as needed. The resident was monitored for pain, and an X-ray was ordered later that evening to assess the injury. The X-ray, performed the following day, revealed a comminuted, angulated, intertrochanteric fracture of the left femur. According to the X-ray company, the facility was notified of the positive finding the same day, but the nurse on duty did not recall receiving the call. The facility did not document receipt of the X-ray results until the next morning, at which point the nurse practitioner was notified and the resident was subsequently sent to the hospital for evaluation and treatment. Interviews with staff confirmed that the facility's protocol required nurses to follow up with the X-ray company if results were not received by the end of the day. Both the LPN and RN interviewed agreed that the nurse should have called the X-ray company for the results and acknowledged that there was a delay in treatment for the resident. The delay in acting on the X-ray results led to a delay in the resident receiving appropriate evaluation and treatment for her fracture.