Consulate Health Care of Winter Haven was cited for abuse when the facility failed to report an abnormal radiology report. This resulted in the delay of treatment that was necessary for the resident’s recovery after a painful fall.
Initial Fall and Diagnosis
The resident said he had fallen when looking out the window at the birds. After the incident, he complained of shoulder pain. An x-ray was ordered, which revealed an acute impacted fracture to the humerus bone. The results were sent to the nursing home, but staff claimed they were unaware of the x-ray results showing the fracture. The next day, the resident again complained of severe pain. Another x-ray was ordered, and these results showed the same impacted fracture.
A review of all completed and discontinued orders for the resident revealed a completed order for an x-ray in response to his complaints of shoulder and chest pain. Why the staff did not receive the first set of results is unclear. The resident was also experiencing negative symptoms after he fell. The day it happened, he didn’t eat breakfast and vomited during lunch. After vomiting, he became weak and almost fell when being transferred back to his bed. Staff also reported he became less responsive.
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Delay in Treatment an Pain Management
As the resident’s shoulder began to bruise, the night shift nurse stated that the practitioner was aware of the x-rays and would be in to evaluate the resident in the afternoon. The resident was administered Tylenol to alleviate the pain while waiting for treatment. He was out of sorts, and he could not even remember the fall occurring.
During an interview with the facility’s administrator, he stated the nurse on the afternoon shift told him the only report she saw was the chest x-ray. He stated the facility received the report from the first x-ray after they ordered a new one. The administrator stated he discovered that neither the afternoon nor night shift nurse knew of the results from the first shoulder x-ray. However, the administrator said the night shift nurse had received a call from the radiology facility asking them if they had received the x-ray reports, and the nurse told them yes.
Staff Interviews and Communication Breakdowns
Another interview was conducted with a Registered Nurse (RN) who was caring for the resident. The RN said she was told by the day shift nurse that the advanced registered nurse practitioner (ARNP) had ordered an x-ray of the shoulder because the resident complained of pain. She stated she did receive the chest x-ray results, which came back negative; the resident did not have a chest injury. She confirmed she did not call the ARNP with the results. The day shift nurse stated she gave report to the night shift nurse; she gave her the chest x-ray results and told her they were still waiting for other results. She asked the night shift nurse to call the doctor or wait until the ARNP came in to see the resident the next morning and show her the results. Normally, she would have called the doctor to give the results, but she was trying to finish charting.
The expectation of the facility is to file a report after a fall, do an assessment of the resident, and notify the provider to make sure all of the circumstances are documented in the medical record. The administrator confirmed that a fall report was not done at the time of the incident because the nurse aide hadn’t reported it to the nurse and had only told the ARNP. The administrator stated the ARNP assumed the nurse was aware of the fall.
An interview with a newer staff member revealed she received the chest x-ray report from the afternoon shift nurse. The afternoon shift nurse also told the newer staff member that the ARNP would be in to see the resident. So, she took the x-ray report and put it at the bottom of her medication cart. This way, she would remember to pass it on to the next shift. She remembered reviewing the report and noting the negative result.
What the afternoon shift nurse didn’t tell her was that a shoulder x-ray was ordered in addition to the chest x-ray. The Director of Nursing (DON) called the new staff member the next day to ask about the x-ray on the shoulder; she stated she’d never received a shoulder x-ray and wasn’t even aware the resident had fallen. However, another nurse said that she HAD received the report, but thought the DON was referring to the chest x-ray, not the shoulder. Because of this lack of communication and proper organization, the resident continued suffering from the pain of this injury.
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Administrator’s Further Comments
A later interview with the administrator revealed she was told by a nurse that the resident was nauseated, weak, and vomited at lunch. She didn’t recall ever being told of lab or x-ray results by the nurse. The expectation is that nursing staff notify the ARNP of x-ray results within a 24 hour period. If the resident’s condition is abnormal, the ARNP should be notified within a few hours. Because the staff in charge of the resident didn’t know what was going on, he did not receive the care he needed. A severe lack of communication caused him to suffer unnecessarily. Because the facility failed to follow protocol after a fall and inform the ARNP of x-ray results, he didn’t receive the care he desperately needed.
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