Delayed Response to STAT X-ray Order and Failure to Notify Provider of Acute Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident received timely care and treatment as prescribed by the medical provider following a change in condition related to an injury sustained during transport to a dialysis clinic. The resident, who had diagnoses including kidney failure requiring dialysis and a chronic neurological-muscle disease, was dependent on staff for care and required a mechanical lift for transfers. After reporting pain in the left leg following transport, the nurse practitioner assessed the resident and ordered a STAT left hip x-ray and pain medication. However, there was a significant delay in confirming and initiating the x-ray order, with the order being confirmed over four hours after it was entered and the x-ray not completed until 33 hours later. Upon receipt of the x-ray results, which showed an acute hip fracture, nursing staff failed to immediately notify the medical provider as required. The x-ray company reported the fracture to the facility during a shift change, but the nurse on duty did not report the findings to the provider or ensure the information was communicated to the incoming shift. As a result, the resident was not sent to the hospital promptly and was instead transported to dialysis the following day despite having a hip fracture. Interviews with facility staff confirmed that the expected protocol was not followed, including immediate notification of the provider upon receipt of critical results and timely processing of STAT orders. The facility's investigation did not initially identify these delays or failures in communication and order processing. Staff acknowledged that the resident should have been sent to the hospital immediately upon confirmation of the fracture and that the breakdown in communication and delayed response led to a lack of timely medical intervention.