HospitalInspections.org

Based on a review of facility and external documentation, as well as staff and patient interviews, the facility failed to ensure that only personnel designated by the medical staff may administer and interpret procedures, and thus failed to provide radiologic services according to the needs of the patients.

Findings were:

A review of emergency department records revealed that for 1 of 3 patients requiring radiologic services [Patient #1], the patient received those services off-site at a facility that had no affiliation with the hospital. This was due to the hospital's CT-scan being non-functional for approximately one and a half days in April, 2014. An off-site free-standing emergency center performed CT-scans on the patient and an unaffiliated radiologist at the emergency center interpreted the results. Though the CT-scan had been repaired the date of this survey, there was no policy or procedure in place that would ensure the same event would not occur in the future.

Patient #1 was brought to the facility emergency department on 4/8/14 at 7:43 p.m. via EMS after a motor vehicle collision. Emergency Department (ED) Physician Documentation stated the following under the HPI [History of Present Illness], in part, "The patient was a driver of a car. The patient was restrained by a lap belt, with a shoulder harness. The vehicle did not rollover. Onset: The symptoms/episode began/occurred just prior to arrival. Associated injuries: The patient sustained injury to the head, contusion, injury to the chest, contusion, injury to the abdomen..."

An ED Physician Documentation entry at 2:51 a.m. on 4/9/14 stated, "ED course: CT scanner was down, and patient needed to be transported for CT scans, resulting in delay." Physician Orders included, "CT-Chest W/Contrast, CT-ABD Pelvis Dye, CT-Head WO Contrast, CT-Cervical Spin WO Cont." The ED Physician Documentation included the following entries:
"04/08 [8:51 p.m.] Ct-Cerv Spin Wo Cont
04/09 [02:47 a.m.] Interpretation: NAD [no active disease]
04/08 [8:51 p.m.] Ct-Head Wo Contrast
04/09 [02:47 a.m.] Interpretation: NAD
04/08 [8:51 p.m.] Ct-Abd Pelvis Dye
04/09 [02:47 a.m.] Interpretation: NAD
04/08 [8:51 p.m.] Ct-Chest W- Contrast
04/09 [02:47 a.m.] Interpretation: NAD..."

Final Radiology Reports from a nearby free-standing emergency center, were as follows:
1. "Examination: CT chest pulmonary angiogram, 4/8/2014 10:50 PM ...Findings: Lungs: Mild dependent atelectasis. No pneumothoraces or pleural fluid collection. Chest wall: Normal. Heart: Normal. Mediastinum: No adenopathy. Pulmonary arteries: Normal central contrast opacified pulmonary arteries. Small emboli in second and third order branches may be missed. Contrast opacification is satisfactory. Aorta: Normal for age. Bones: Normal for age. Limited abdomen: Unremarkable.
Impression: No findings to indicate pulmonary embolism. Small emboli in second and third order branches may be missed. No acute intrathoracic abnormality."
2. "Technique: Cervical CT scan with sagittal and coronal reformats, 4/8/2014 10:41 PM ...Findings: Alignment: Normal. Bones: Normal vertebral height without fracture. Disk spaces: Preserved. Soft tissues: Normal.
Impression: No defined cervical fracture or displacement."
3. "CT head without contrast, 4/8/2014 10:33 PM ...Findings: No acute intracranial hemorrhage, abnormal extra-axial fluid collections, mass lesion or midline shift. Nonspecific white matter lucencies most likely due to chronic microvascular disease. No diminished attenuation to suggest an acute infarction. Probable small right sublenticular cyst. Paranasal sinuses: Normal. Soft tissues: Normal. Calvarium: Normal. Changes of acute infarction less than 24-48 hours may be missed.
Impression: No acute intracranial abnormality."
4. "CT Cervical Spine, 4/8/2014 10:41:38 PM. Findings: Lung bases: Normal. Liver: Normal. Biliary: Normal. Spleen: Normal. Pancreas: Normal. Adrenal glands: Normal. Kidneys: Normal. Abdominal wall: Normal. Retroperitoneum: Normal. Bowel/mesentery: No bowel dilatation, wall thickening or obstruction. Nonvisualized appendix. No free air. No inflammatory changes of the abdomen or pelvis. Aorta: Normal caliber. Normal for age. Pelvis: Normal. Musculoskeletal: Normal for age.
Impression: No findings to indicate acute intra-abdominal or pelvic abnormality."

Each of the above CT-scans was signed as follows: "Thank you for allowing us to participate in the care of your patient. Dictated and Authenticated by: [External Staff #1]. 4/9/2014." Times of the signature ranged between 12:09 a.m. and 12:53 a.m.

In a telephone interview with Patient #1's husband, on the morning of 8/5/14 at 11:16 a.m., he stated in part, "I beat the ambulance to the hospital that night. I got there at the hospital and wasn't allowed to see her until she got back in the room. They said they needed to do an x-ray or MRI or something, but their machine was broken that night. They were transporting people by ambulance to another place - another building somewhere, where they were doing the x-rays or MRIs. So they took her off to the other facility. I left - I took my son home - then came back. I was maybe gone an hour and a half or so. She was back in the room when I got there. They said they'd done the x-ray or whatever..."

In an interview with Staff #3, the physician caring for Ms. Babyak in the Emergency Department, on the afternoon of 8/5/14 in the facility front administrative office, when asked about patients being sent to nearby emergency center due to the CT-scan at the hospital not functioning, he stated, "I know there's an agreement in place with the emergency center. Apparently their radiologist read the scans. I didn't sign the results, but I did chart that I'd seen them in the patient record."

In an interview with the hospital Chief Quality Officer, on the afternoon of 8/5/14 in the facility front administrative office, she stated, "I can say that it was their [the emergency center's] radiologist who interpreted those scans. [External Staff #1] is not on our medical staff and is not credentialed through our facility...There is no written agreement that we have with any particular facility about accepting our patients if we have a problem with a certain piece of equipment. We do have that policy about it though. "

In an interview with the facility Imaging Director, on the afternoon of 8/5/14 in his office, he stated, "Since we only have one CT-scan, if it goes down we have to send people out to various places...We have an agreement with them...Once the radiologist has read the findings, we get back a printout of the exam and a burned CD with the findings and images. Our CT-scanner was down for a day and a half that time in April." When asked if he thought the number of issues with the scanner was excessive, he stated, "It's old and we have a pretty heavy volume of patients going through. I think it's really not that bad considering. Our up time with the scanner is probably at least 90%. We have a contract and [that company] does all the preventive maintenance on it."

Hospital policy #DT-2, entitled CT Downtime Procedure, effective 5/01/2014, stated in part:
"CT Downtime Procedure...
2. Admin OC [on call] - If downtime is to be longer than 2 hours notify - CPEC [Cedar Park Emergency Center], Capital EMS for CT support
3. Exams will continue to be ordered in Medhost
4. CD, written report returned to Director Imaging Service's once patient care is completed unless the patient is transferred.
5. Communication of CT status will be updated by the Director of Imaging Services to minimize miscommunications."

There was no written contract or agreement with the nearby emergency center available for review on the date of the survey.