Delay in STAT X-ray Following Resident Fall
Penalty
Summary
The facility failed to obtain timely diagnostic services to meet the needs of a resident who experienced a fall. The resident, who had diagnoses including a right femur fracture and Alzheimer's Disease, fell and staff documented that a Certified Registered Nurse Practitioner (CRNP) was notified and ordered a STAT x-ray of the right hip at 9:20 PM. Despite the STAT order, which indicates the need for immediate action, the x-ray was not performed until the following day at 12:09 PM by the contracted mobile x-ray provider. The x-ray revealed a right subcapital hip fracture and osteopenia. Further review indicated that the delay occurred because the x-ray order was entered incorrectly as a one-time only order instead of STAT. The facility's contracted x-ray provider stated that their turnaround time for STAT requests is four hours. The deficiency was cited under 28 Pa. Code 211.12 (d) (5) for failing to ensure prompt diagnostic services were obtained to meet the resident's needs.