Delayed Diagnostic Test and Treatment for Resident's Injury
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
Penalty
Resources
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Failure to Obtain and Communicate Diagnostic Test Results: A resident with respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, spinal cord infarction, HTN, and GI hemorrhage had a bone biopsy rescheduled and then went out of the facility, but the chart contained no biopsy results. The resident’s representative said January test results were never communicated, and the DON confirmed the facility had not obtained or shared the bone biopsy results with the MD or representative; the Administrator stated there was no policy for obtaining or notifying about diagnostic test results.
Failure to Obtain and Communicate Bone Biopsy Results
Penalty
Summary
The facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner for one resident (#44) reviewed for diagnostic testing. Resident #44 was admitted with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. The annual MDS assessment showed the resident was cognitively impaired, had functional range of motion limitations in both upper and lower extremities, and was dependent for all care and transfers. The medical record showed a progress note dated 01/20/26 indicating a bone biopsy had been rescheduled for 02/03/26, and a note dated 02/03/26 indicated the resident was out of the facility. The record contained no results from the bone biopsy scheduled on 02/03/26. The resident representative stated on 03/16/26 that diagnostic testing results completed in January 2026 had not been communicated. The DON confirmed on 03/18/26 that the bone biopsy results had not been obtained by the facility or communicated to the physician and resident representative. The Administrator stated on 03/19/26 that the facility did not have a policy for obtaining diagnostic testing results or notifying the physician and family representative of those results.
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