Missed Physician X‑Ray Order Leads to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received necessary care and services when a physician‑ordered x‑ray for left lower extremity pain was not obtained, resulting in an eight‑day delay in diagnosis of acute displaced fractures of the distal tibia and fibula. The resident had a history of childhood polio, osteoporosis, and Alzheimer’s dementia, and was care planned as being at risk for bilateral leg pain with interventions including pain assessments and monitoring for non‑verbal pain indicators. A rehabilitation screening identified decreased motorized wheelchair driving ability and the need for out‑of‑bed positioning in a customized wheelchair. On one evening, an LPN documented that the resident experienced pain and grimacing with movement of the left foot and administered acetaminophen. The attending physician assessed the resident on site that day, suspected arthritis, and ordered an x‑ray of the left lower extremity. Despite this order, the x‑ray was not entered into the medical record and was not obtained until eight days later, when hospice staff, during repositioning of the resident’s left lower extremity, noted severe pain, deformity, and swelling below the knee, prompting a STAT x‑ray order. The x‑ray subsequently revealed acute mildly displaced spiral fractures of the distal tibia and fibula with diffuse osseous demineralization, and the resident was later transferred to the emergency department, where the fractures were confirmed. Interviews with the DNS and the physician revealed that the original x‑ray order from the earlier assessment was missed and never entered into the EMR, and that the facility had no written physician’s orders policy or protocol, relying instead on a practice in which providers placed draft orders in the EMR for nurses to finalize, or nurses entered orders for covering providers unfamiliar with the EMR.
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