Delay in Obtaining and Reporting STAT X-ray Results
Penalty
Summary
The facility failed to provide or obtain radiology and other diagnostic services to meet the needs of a resident who required a STAT x-ray. The resident, an elderly female with multiple diagnoses including dementia, multiple sclerosis, and osteopenia, complained of right knee pain and swelling. A STAT x-ray was ordered by the nurse practitioner and performed the same day, with results indicating a nondisplaced lateral plateau fracture and a distal fibular fracture. However, the facility did not review or act upon the x-ray results until four days after the imaging was completed. During this period, the x-ray results were available in the facility's electronic portal, but staff did not access or communicate the findings to the physician in a timely manner. Interviews revealed that staff were unclear about the timeframes for STAT orders and did not consistently follow up on pending results. The Director of Nursing was out of town and assumed the radiology company had resolved a missing diagnosis code, but no further follow-up occurred until she personally checked the portal days later. The 24-hour report sheets and progress notes did not reflect ongoing monitoring or follow-up regarding the x-ray results or the resident's knee condition during this interval. The delay in reviewing and reporting the STAT x-ray results led to a delay in treatment for the resident's fractures. Staff interviews indicated a lack of clear communication and handoff regarding the pending diagnostic results, and the facility's policy required timely notification of results to the physician. The resident continued to experience pain, though it was managed with medication, and there was no documentation of complications during the delay.