F0684

D

Delay in STAT Diagnostic Imaging and Evaluation After Resident Fall

Dekalb, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly obtain diagnostic imaging and ensure timely evaluation and treatment after a fall. The resident was admitted with a history that included a prior left femur fracture, weakness, history of falls, cognitive communication deficit, and an adjustment disorder with mixed anxiety and depressed mood. On the evening of 12/30/2025, the resident fell in the bathroom while being assisted by a CNA. The CNA reported that the resident had been transferred to the toilet with a gait belt, then stood holding the handrail; when she reached for wipes on the counter, the resident let go of the handrail and fell onto his left side. An RN responded around 6:45 PM, found the resident on the bathroom floor lying on his left side, assessed him, and documented no apparent injuries and no complaints of pain at that time.

On the morning of 12/31/2025, another RN assessed the resident in bed and found him moaning with facial grimacing, with his feet off the bed. When asked, the resident reported left knee pain, and the nurse noted a bruise on the left knee. The nurse stated she did not recall administering any pain medication beyond the resident’s existing order for acetaminophen 650 mg once daily for left lower extremity pain, which was documented as given that day. She reported calling the resident’s primary physician and leaving an urgent note with the medical assistant about the fall but did not receive a response before the end of her shift. No imaging had been obtained at that point, despite the resident’s ongoing pain and known history of falls and prior left femur fracture.

Later on 12/31/2025, the physician saw the resident during a routine visit and was informed of the fall that had occurred approximately two days earlier. The physician observed the resident lying prone toward the left side and endorsing ongoing left lower extremity pain, with minimal relief from acetaminophen, and documented that no imaging studies had been completed to date. The physician ordered STAT x‑rays of the left hip, femur, and knee to evaluate for possible acute injury. A health status note that evening documented receipt of a telephone order for these STAT x‑rays and that the order was processed via a mobile diagnostic provider and entered into the electronic medical record. However, nursing staff reported that the STAT x‑rays were not performed until the following day, 01/01/2026. The diagnostic report from that date showed an acute subcapital left femoral neck fracture. The physician later stated that, had he been informed at the time of the fall, he would have ordered STAT x‑rays then, and he expressed surprise that the STAT imaging ordered on 12/31/2025 was not completed until the next day, resulting in a delay in diagnosis and evaluation of the fracture.