Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
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