Delay in Physician Notification and Intervention for Dislocated Hip Arthroplasty
Penalty
Summary
The facility failed to ensure timely notification and intervention for a resident who experienced a significant change in condition. The resident, who had a history of left hip arthroplasty, septic arthritis, and femur necrosis, was observed by therapy staff to have increased pain, an apparent shortening of the left leg, and inability to participate in therapy. An X-ray was ordered and performed, revealing a dislocated left hip arthroplasty. The facility's policy required that diagnostic test results, especially those requiring immediate attention, be communicated to the physician upon receipt and documented in the clinical record. Despite the X-ray result indicating a dislocation being faxed to the facility in the evening, there was no evidence that the result was reported to the physician or addressed by nursing staff until the following afternoon. Interviews with staff revealed that the night shift nurse did not retrieve or act on the faxed results, and the Assistant Director of Nursing only notified the physician the next day. The Director of Nursing confirmed the delay in physician notification and subsequent transfer of the resident to the hospital, and there was no documentation of an incident report or investigation into the delay.