HospitalInspections.org

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services, only personnel designated as qualified by the medical staff used the radiologic equipment and administered procedures; and policies are written, approved and implemented through the medical staff to ensure patient safety.

Findings:

1. On the morning of 1/24/12 Staff A and B told surveyors the facility had a contract for imaging with a off campus facility. Surveyors reviewed the contract on the morning of 1/24/12. The contract does not stipulate the radiologists are qualified according to State and Federal guidelines. There is no documentation the radiologists are credentialed, privileged, and meet qualifications necessary for radiology appointment.

2. There are no policies written and approved through medical staff stipulating what tests will be performed off campus.

3. There are no policies written and approved through medical staff indicating how and with whom patient's were to transported to the off site facility. There were no policies indicating who and how care will be provided by the hospital while the patients are off site and during transport to and from the facility.

4. These findings were reviewed with administration at the exit conference. No further documentation was provided.

5. Review of hospital documents did not indicate a radiologist oversaw the radiology services.

6. There were no policies developed and approved by the medical staff to designate which personnel are qualified to use the radiological equipment and administer procedures.

At the time of the revisit 1/24/2012, this standard remained not met.

Based on review of policy and procedure, medical records, and interviews with staff, the hospital failed to maintain records for all radiology procedures performed.

Findings:

1. On 1/24/2012 surveyors requested radiology policies. According to Staff A and B, radiology services are provided under contract. The facility did not have policies and procedures reviewed and approved through the medical staff on how x-ray films will be stored and retrieved.

2. On 1/24/2012 this finding was reviewed with Staff A. No further documentation was provided.

At the time of the revisit on 1/24/2012 this standard remained not met.

Based on review of policy and procedure and interviews with staff, the facility failed to have a process to maintain films and scans. On 1/24/2012 Staff A provided surveyors a copy of a contract with a imaging provider. There was no documentation included in the contract stipulating image storage and time frame. This finding was reviewed at the exit conference and no further documentation was provided.