Hill Haven Nursing Home

Based on staff interviews and record reviews it was determined that for two of three residents reviewed for professional standards of quality during an Abbreviated Survey (complaint #NY00088429) completed on 7/9/10, the facility did not provide services that met professional standards of care. The issue involved lack of timely response to diagnostic test results. This affected Residents #1 and #2, resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #1 was admitted on 6/3/10 with diagnoses including end stage renal disease, peripheral vascular disease, a history of a right above-the-knee amputation and left transmetatarsal (fore foot) amputation.

Resident Care Orders, dated 6/23/10, included Doppler (ultrasound of venous blood flow) of the left lower extremity due to swelling and pain to rule out deep vein thrombosis, and on 6/24/10, an order for an arterial Doppler of the left leg. The 24-hour report, dated 6/24/10 on day shift, revealed the arterial Doppler was done on the evening shift with results pending. The preliminary report of the arterial Doppler, dated 6/24/10, revealed, "Flow visualized at anastomosis (site where two blood vessels were joined) only." The 24-hour reports for the 6/27/10 day shift revealed that the physician and nursing supervisor were informed of an increased number of open blisters on the left foot and the chart was flagged for medical review. The 24-hour report, dated 6/28/10 for the evening shift, documented that the resident was transferred to the hospital because the Doppler study showed possible occlusion (lack of blood flow) and large blisters on the left leg.

During an interview on 7/8/10 at 8:50 a.m., the Director of Nursing (DON) remarked that nursing staff had not documented the need to call for the results of Doppler studies on the 24-hour report.

In an interview on 7/8/10 at 1:12 p.m., the Registered Nurse Clinical Leader (RNCL) stated that she is responsible for taking off the physician orders and that results of tests are faxed to the facility. When the results come in, the Nurse Practitioner (NP) is called if needed, otherwise the chart is flagged for medical review. She reported that test results are not usually received until the day after the test is done and that she has never received a preliminary report. The RNCL was not aware of what facility staff would do if a test result did not arrive.

When asked about the Doppler studies on 7/8/10 at 1:26 p.m., the NP stated she ordered the arterial Doppler on 6/24/10 and expected in this case that staff completing the Doppler studies would have stopped to speak to facility staff about preliminary results. She was not aware that a preliminary report was given. The NP further stated that had she been informed of the preliminary reports, she would have alerted the vascular surgeon of the results.

When interviewed on 7/8/10 at 1:52 p.m., the Registered Nurse (RN) Manager stated the RNCL is responsible for the tests and that when she heard during "huddle" (morning report to review issues with residents in a multidisciplinary team meeting) on 6/25/10 that results from the Doppler were still not in, she expected the RNCL to follow-up. She stated they have never had a problem before and never waited more than a shift for results. She further stated that it can be anyone's responsibility from shift to shift to obtain test results. The RN Manager stated that on 6/28/10, she heard that the resident's foot was worse but did not hear that the test results were not back. She stated she took the Doppler test results off the fax machine at approximately 2:15 p.m. on 6/28/10.

When interviewed on 7/8/10 at 3:02 p.m., the x-ray diagnostic company office manager stated that the sonographer gave a blond nurse at the facility a verbal and written preliminary report before she left the facility at 4:00 p.m. She stated the blond nurse was told there were issues with lack of blood flow in part of the leg.

In an interview on 7/8/10 at 4:20 p.m., the South 2 Unit Secretary stated there was no system in place to track if x-rays or Doppler tests have been done and results have been reported to the nursing home.

When interviewed on 7/8/10 at 5:35 p.m., the RN Manager stated she was on the unit when the sonographer completed the Doppler on 6/24/10. The sonographer seemed concerned and did tell her there was a "flow problem." The RN Manager stated she did not consider what the sonographer said to be a preliminary report and did not receive anything in writing.

When interviewed on 7/9/10 at 10:18 a.m., the South 1 Unit Secretary stated that she sometimes gets preliminary reports from the x-ray diagnostic company staff and she gives them to the nurse. The nurse either calls the NP or puts the results on the record flagged for the NP.

2. Resident #2 has diagnoses including diabetes and an ulcer on the left great toe. Resident care orders, dated 6/1/10, included to obtain an x-ray of the left foot to rule out osteomyelitis of the great toe. The NP notes, dated 6/4/10, revealed that the results of the x-ray of the left foot ordered on 6/1/10 were not available and that she would ask nursing to call for the results. The mobile x-ray report, dated 6/1/10, documented that the x-ray was negative for osteomyelitis. Markings on top of the form revealed that it was faxed on 6/7/10. The RNCL's initials and the date 6/7/10 were located on the bottom of the form.

When interviewed on 7/8/10 at 5:35 p.m., the RN Manager stated she did not know who the NP asked to follow up on the x-ray results.

The facility's policy entitled, "Radiology and Other Diagnostic Services," dated December 2004, and "Notification of Medical Staff in Response to Critical Lab Values and Abnormal X-ray Reports," dated July 2008, lacked directions for staff regarding follow-up on missing reports for ordered diagnostic testing.

[10 NYCRR 415.11(c)(3)(i)]