Failure to Complete Ordered Lumbar X-Ray and Notify Providers After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered radiology services were completed or alternative arrangements made after a resident sustained a fall with resulting back pain. The resident fell backwards from a wheelchair onto the floor, landing on his back, and subsequently complained of lower back pain. A nurse practitioner ordered a lumbar X-ray to be completed in the facility, with a physician order specifying 2–3 views of the lower lumbar area related to trauma and pain. When the X-ray technician arrived, the study could not be completed due to weight concerns and the technician stated that an additional tech and a special board would be needed to hold the resident. The X-ray staff did not return to complete the ordered study, and the lumbar X-ray was never performed in the facility. The resident continued to complain of back pain and was later transferred to a local hospital due to worsening pain, where he was diagnosed with a thoracic vertebral fracture. Facility progress notes for the day the X-ray attempt failed contained no documentation that the physician, nurse practitioners, or the resident’s POA were notified that the ordered X-ray was not completed. An LPN confirmed she did not notify the POA or either nurse practitioner that the X-ray was not done. The POA and both nurse practitioners reported they were not informed until the following day, shortly before or on the day the resident was sent to the hospital, that the X-ray had not been completed as ordered. This failure occurred despite a facility policy stating it will provide appropriate diagnostic services, including radiology, in accordance with state and federal guidelines.
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