Failure to Carry Out STAT Hip X-Ray Order After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s STAT order for a right hip X-ray after an unwitnessed fall involving a cognitively impaired, non-ambulatory male resident who required a mechanical lift for transfers and was dependent for all ADLs. Following the fall, the resident was found on a floor mat next to a low bed by a CNA, who summoned the nurse. The LPN in charge performed a head-to-toe assessment, during which the resident complained of right hip pain. The LPN medicated the resident for pain and obtained a provider order for a STAT right hip X-ray, with an expectation that results would be available within 4–6 hours. The resident’s record later documented ongoing right hip pain, facial grimacing, and guarding of the right leg the following morning. Despite the STAT order and the provider’s and DON’s stated expectations that such X-rays be completed and resulted within hours, the ordered X-ray was never performed. The LPN who later transferred the resident to the hospital reported that the transfer occurred because the resident continued to complain of right leg pain and the previously ordered STAT X-ray had not been done. The resident was ultimately sent to a local emergency room approximately eighteen hours after the unwitnessed fall, where imaging revealed a superior laterally displaced comminuted intertrochanteric right femoral fracture. The report states that a reasonable person in the resident’s position would have experienced psychosocial harm related to pain, including facial grimacing and guarding of the right leg, as a result of the failure to carry out the STAT X-ray order.
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