Delay in Obtaining and Communicating X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to obtain and promptly communicate x-ray results for a resident who experienced a fall with major injury. The resident, who had diagnoses including bilateral osteoarthritis of the knees, muscle wasting, and muscle weakness, was found on the floor with a head injury and later exhibited pain and tenderness in the right femur and ankle. Despite orders for bilateral lower extremity x-rays following the onset of pain, the facility did not receive or follow up on the hip and pelvis x-ray results in a timely manner. The x-rays, performed after the resident showed signs of injury, revealed an acute right femoral neck fracture, but the results were not accessed by the facility until several hours after they became available. The delay was compounded by the diagnostic provider's failure to immediately notify the facility of the abnormal findings, as required. The facility also lacked a policy regarding the timely retrieval of x-ray results. Interviews confirmed that the diagnostic provider did not fax or call the facility with the positive results until hours after the report was available, and the facility did not proactively obtain the results until later. This sequence of events resulted in a delay in care for the resident, as the abnormal x-ray findings were not communicated to the practitioner or acted upon promptly.