F0684

G

Failure to Notify Physician of Fracture and Delay in Emergency Care After Fall

Westmont, Illinois Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify a physician of X‑ray results showing a fracture and to ensure timely emergency care for a resident after a fall. The resident had multiple sclerosis, paraplegia, muscle wasting, gait abnormalities, and was dependent on staff for most care, but had no cognitive impairment. She reported that during showering staff positioned her leaning forward in a shower chair, she felt she was not seated properly, and despite voicing concerns she slipped and was assisted to the floor, landing on her weaker leg. A nurse’s note documented that after the fall the resident was found on the shower room floor, reported right knee pain rated 3/10, and an X‑ray of the right knee was ordered and called in to a mobile X‑ray company.

Later that evening, nursing documentation showed that the mobile X‑ray company was contacted again and that the technician arrived before midnight to perform X‑rays of the right knee, right shoulder, and right humerus, with results pending and endorsed to the oncoming shift. On the overnight shift, an LPN documented that the X‑ray results showed a right knee impacted supracondylar fracture of the distal femur and that this information was relayed to the DON, with a note that the DON would have to compare the current diagnosis with the existing one and that this was endorsed to the morning nurse. The LPN stated she did not notify the physician of the fracture, believing the day nurse would do so, and also stated she did not visualize the resident’s leg during her shift. CNA interviews indicated that by the overnight and subsequent shifts the resident’s leg was very swollen, lacked its usual spasms, and appeared twice the size by the second night, with the resident reporting pain and requesting Tylenol.

Over the weekend following the fall, another LPN reported that the resident stayed in bed, that she monitored and managed the resident’s pain, and that she observed swelling of the right knee and documented that the resident reported increased pain with manipulation. A CNA assigned the day after the fall described the resident as emotionally down, concerned about her leg, and reported that the knee was swollen and painful to touch. Despite these findings and the documented X‑ray result of a distal femur fracture, the medical record showed no evidence that the resident’s physician was notified of the X‑ray results until several days later, when the DON documented a change of condition noting the fracture and obtained an order to send the resident to the emergency department. The resident was then transported to the hospital, where records confirmed an acute comminuted and displaced distal femur fracture with large lipohemarthrosis and a subacute proximal fibular diaphysis fracture, and the physician stated he would have expected to be notified of the fracture when the X‑ray results were first available and would have advised hospital transfer at that time. The facility’s own policies required physician notification for accidents/incidents and significant changes in condition, and for falls to be reviewed with care plans evaluated and modified as needed, but the physician was not notified of the fracture result until days after it was known to facility staff.

The DON acknowledged being notified of the fall on the day it occurred and being aware that X‑rays were ordered, but stated that Monday was the first time she spoke with the physician about the fracture. She indicated that the nurse’s note about comparing diagnoses was a misunderstanding related to reportability and that she would have expected the nurse to notify the physician of the X‑ray results. Staff interviews confirmed that the usual expectation was to notify the physician when X‑ray results showed a fracture and to report such events to administration. Despite this, the fracture result was not communicated to the physician until several days after the X‑ray, during which time the resident remained in the facility with a swollen, painful leg and continued transfers and care without physician-directed fracture management or timely emergency evaluation.