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Delay in diagnosis of hip fracture

A 90-year-old woman with end-stage Alzheimer’s disease fell at the assisted living facility where she resided. Following the fall, she began to report severe right hip pain.

Physician action
The patient was treated by an advanced practice registered nurse (APRN) who was employed by an internal medicine physician, the defendant in this case. The physician owned and operated a corporation that provided care to patients in residential facilities.

The APRN visited the patient the day after the fall, and ordered an x-ray of the hip. The x-ray report, faxed on the following day according to a fax notification sheet included in the medical records, revealed a displaced right femoral neck fracture. It was unclear whether the APRN received or reviewed the x-ray report. The physician did not visit the patient, and the APRN prescribed physical therapy for the patient’s right hip pain.

Due to continued reports of pain, a lumbar series was ordered. The results indicated degenerative changes in the spine. During this time, the physical therapist noted in the chart that the patient had a three-inch leg length discrepancy and sug­gested that the patient may have a hip fracture. The therapist also mentioned that the patient was developing decubiti on her heels. The APRN then ordered a podiatry consultation.

Approximately one month after the fall, the patient’s family decided to take the pa­tient to the emergency department, where a repeat hip x-ray revealed a hip fracture. An orthopedic surgeon performed a right bipolar hemiarthroplasty. The patient also received treatment for bilateral heel decubiti including padding, a special mattress, and debridement.

While hospitalized, the patient was evaluated for swallowing problems. The fam­ily desired no aggressive treatments for this condition, and she was subsequently discharged to hospice care. Approximately two months after the fall, she developed aspiration pneumonia and died.

The patient’s family filed a lawsuit against the internal medicine physician, the resi­dential facility, and the APRN. The allegations included:

  • vicarious liability of the supervising physician for the actions of the APRN;
  • disregard for the patient amounting to gross negligence;
  • failure by the APRN to properly read the initial x-ray report;
  • failure by the APRN to obtain an orthopedic consult;
  • delay in diagnosis of the hip fracture; and
  • inappropriate performance of physical therapy.

Legal implications
The concept of vicarious liability allows liability for allegations of liability to extend be­yond the original defendant to persons or entities responsible for the negligent actions of persons under their supervision. The APRN in this case was an employee of the physician, and therefore the physician was vicariously liable for the APN’s actions or omissions.

Two specialists, board certified in internal medicine, reviewed this case. Both were critical of the APRN and of the physician for inadequate training and supervision of the APRN. They were also critical of the physician for not diagnosing the hip fracture. Neither the APRN nor the physician reviewed and/or appropriately interpreted the x-ray report, which noted the hip fracture.

One of the experts indicated that there is a 40-50% one-year mortality rate in a patient such as this one suffering a hip fracture. However, both experts agreed that, had this pa­tient’s hip fracture been treated sooner, her risk of mortality and/or morbidity would have been significantly less.

During testimony, the APRN admitted that her care was negligent, and a judge ruled that the physician and his corporation were vicariously liable for her actions. In addition, the following issues were significant:

  • physician’s lack of supervision of the APRN;
  • lack of a signed collaborative agreement designating the responsibilities of the APN;
  • no written policies and procedures outlining the scope of services to be provided by the APN; and
  • lack of documentation in the medical record of physician review of the APN’s care.

This case was settled on behalf of the internal medicine physician. The residential care facility and the APRN also settled their cases.


Risk management considerations
APRNs provide a broad range of health services. However, there are specific care standards outlined in the Texas Administrative Code for which physicians are responsible. As demonstrated in this case, the physician had not established these practice parameters. The Texas Administrative Code indicates that mechanisms should be implemented that provide the authority for the medical aspects of care rendered to patients by APRNs. Proto­cols or other written authorization:

  • should be jointly developed by the APRN and the supervising physician(s);
  • should be signed by both the APRN and the physician(s);
  • should be reviewed and re-signed at least annually; and
  • should be made available to verify authority to provide medical aspects of care. (1)

In addition to establishing protocols, the following recommendations may help limit exposure to claims related to care provided by an APRN.

  1. Before hiring an APRN, review his or her background as thoroughly as you would any physician. Check the applicant’s credentials and verify experience, education, licensure, and certification as required by law.
  2. Verify the competence of the APRN through personal observation, chart review, and regular meetings. Document performance before allowing the APRN to treat patients.
  3. Establish an “open door” policy that allows an APRN to discuss questions about treat­ment and keep physicians informed about the management of patients.

Protocols related to the interpretation and communication of diagnostic tests help promote optimal patient care. In this case, if there was any communication between the APRN and the physician regarding the x-ray report, it was not documented. With established protocols, improved communication, and thorough documenta­tion, the outcome of this case may have been different.



Texas Administrative Code Title 22, Part 11, Chapter 221, Rule 221.12 and 221.13.Available at$ext.ViewTAC?tac_view=4&ti=22&pt=11&ch=221&rl=Y .