F0684

G

Delayed and Incorrect Imaging Orders Resulting in Untimely Treatment of Femur Fracture

Cincinnati, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely and accurate treatment of a resident’s left leg fracture following a reported unwitnessed fall. The resident had multiple diagnoses, including prior fractures of the left femur, ischemic cardiomyopathy, cerebral infarction, type II diabetes, and heart failure, and was care planned as being at risk for pain with interventions to evaluate the effectiveness of pain interventions. The resident had severely impaired cognition, verbal behaviors, and was dependent on staff for toileting, mechanical lift transfers, and bed mobility. On the date of the incident, the nurse practitioner (NP) acutely evaluated the resident after reports of a possible fall out of bed, with the resident stating he rolled out of bed onto the floor on his right side with knees colliding. There was no nursing documentation of a fall or change-in-plane status. The NP’s documentation regarding the left leg was contradictory, noting both no crepitus or difficulty with passive range of motion (ROM) and that the resident reported pain with passive ROM and did not participate in active ROM. The NP documented that STAT imaging was ordered and gave verbal orders for acetaminophen and a Lidocaine patch, with a plan to re-evaluate the resident in the morning.

Later that afternoon, a registered nurse documented that the resident reported an unwitnessed fall on the previous shift and complained of left knee pain with apparent swelling. The RN notified the NP, who assessed that the resident was unable to participate in ROM to the left leg due to pain and placed new orders for an X-ray to the left leg, a one-time dose of acetaminophen, and a Lidocaine patch to the left leg. However, the actual physician orders entered on that date were for a STAT X-ray of the right hip and a Lidocaine patch to the right posterior hip, along with acetaminophen. X-rays completed that evening were of the right knee and right hip, both showing only modest arthritis and osteoarthritis, respectively. The next day, an untimed progress note documented left knee swelling related to the unwitnessed fall and referenced the right hip X-ray findings. New orders were then placed for X-rays of the left hip and left knee, as well as oral anti-inflammatory medication, a muscle relaxer, and a Lidocaine patch to the left posterior hip for pain.

Despite the orders for left hip and knee imaging being written the day after the initial evaluation, the X-rays of the left knee and hip were not completed until two days later. When performed, the imaging showed the left knee was highly suspicious for a minimally displaced distal femoral metaphyseal fracture, while the left hip showed only mild degenerative changes without acute fracture or dislocation. The NP later documented reviewing the left-sided X-ray results and arranged for the resident to be sent to the hospital for further evaluation of a suspicious, non-confirmed fracture of the left leg. Hospital records showed the resident was admitted and treated for a closed bicondylar fracture of the left distal femur with open reduction and internal fixation. The resident reported having fallen out of bed on the left side while at the facility but could not provide more information due to baseline dementia, and the hospital was unable to obtain further details from facility staff. Interviews confirmed that the NP acknowledged placing the initial orders for the wrong limb and that the facility’s medical director was not informed of the alleged fall, the fracture requiring surgery, or the incorrect orders until a later date. The facility’s policy on attending physician responsibilities required appropriate and timely medical orders and treatments to enable safe, effective continuing care.

Surveyors concluded that the facility failed to ensure timely treatment of the resident’s left leg fracture, resulting in actual harm. The sequence of events included an unwitnessed fall without nursing documentation, contradictory assessment notes, incorrect initial imaging orders for the right side instead of the left, and a delay of several days before the correct left-sided imaging was completed and the fracture identified. This failure affected one resident reviewed for care post fall out of a facility census of 89.