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Based on review of documents and staff interviews, it was determined the facility failed to monitor the quality and safety of contract radiological services and implement corrective actions for an adverse patient radiology event.

Findings included:

A review of Patient #1's medical record showed that on 12/13/19, Patient #1 was admitted to the facility on 12/02/19 with a primary diagnosis of respiratory failure, pulmonary hypertension, bilateral lung infiltrates, urinary tract infection, and post aortic graft replacement, and several wounds. Treatment plan included wound care, high flow vapotherm oxygen, and frequent naso-tracheal suctioning. Continued review of the record showed that on 12/13/19 the patient's nasogastric (NG) tube became dislodged and a new tube was reinserted by the primary RN. The RN ordered an x-ray for placement. At 11:38 AM, the abdominal x-ray resulted and read that the NG tube was in the stomach. After the nurse verified placement with the x-ray, the ordered tube feedings were started at 70ml/hour and medications were administered through the NG tube. Patient #1 began to cough with NG tube medication administration and oxygen saturation dropped to 84% (normal 92-100%). The nurse stopped the tube feeding and medications, suctioned the patient, and called respiratory therapy for assistance. Both primary and pulmonary doctors were notified at that time. The respiratory therapist did deep suctioning and noted that tube feeds, along with medications, were being suctioned. The primary RN stated that the patient was sitting upright during administration of the medications. At approximately 1:00 PM, after blood gases were drawn, the patient was placed on bi-pap at 100% FiO2. At approximately 4:00 PM, the primary physician assessed the patient at the bedside. He requested a repeat chest-x-ray. The pulmonologist was at the bedside at approximately 4:20 PM for assessment. Vitals were stable with a heart rate (HR) of 70, blood pressure (BP) 145/78. At 6:15 PM a blood gas was obtained no changes were made at that time. Nursing noted vitals were stable at 7:50 PM. An arterial blood gas (ABG) was obtained at 9:21 PM and showed critical results. The pulmonologist was called and the patient was subsequently intubated. It was during intubation that the respiratory therapist (RT) visualized the NG tube in the vocal cords. The NG tube was removed prior to intubation. At 10:05 PM, the patient's condition deteriorated and a code blue was called. CPR and ACLS protocol was started and at 10:24 PM, the code was stopped. After the code, the RT and primary RN viewed the x-ray that resulted at 9:19 PM. It stated the NG tube was not visible. Continued review showed that on 12/16/19, a request was made to the contracted radiology reading service for the medical director review of both radiology studies performed on December 13, 2019. After review, the medical director identified the NG tube was in the trachea and left main stem bronchus on the film reported on 12/13/19 at 11:38 AM.

An interview with the Director of education on 02/11/20 at 9:30 AM, confirmed the facility completed nursing education on December 20, 2019 related to NG tube verification procedure per Hospital Policy HPC 05-005 CORE: Naso, Gastro and Jejunal Tube Site Care.
A comprehensive review of this policy revealed it addressed site care and not nursing procedures related to insertion and verification of an NG tube. This was confirmed by the Director at the time of the interview.

An interview with the DQM on 02/11/20 at 09:45 AM, revealed prior to the adverse event on 12/13/19, the facility teleradiology contract included 25 radiologists. The DQM confirmed the facility removed two and 23 radiologists were still providing radiology services. A request for the facility's ongoing professional performance evaluations (OPPE's) of the radiologists privileged to provide services for the facility was requested. The facility was unable to provide any evidence they had performed OPPE on the radiologists performing services for the facility. The facility provided the contract radiology company's OPPE for the remaining 23 radiologist providing services for the facility.

A review of the radiology contractor's OPPE for the timeframe of 01/01/19 - 06/30/19, six months, showed professional practice evaluations were based on the radiologist's x-ray reads and assigned a level from one to three as follows:
Level 1 - Most radiologists would report in a similar manner
Level 2 - Minor Discrepancy that some radiologist would report differently, but no change in treatment
Level 3 - Major Discrepancy that most radiologists would report differently and treatment would be different.

A continued review of the contract radiology OPPE, revealed approximately 2% of all exams read were evaluated, and results showed the 23 radiologists were poor performers. There were a total of 192 Level 3 major discrepancy reads that occurred in that six month timeframe.

A review of the facility quality tracking of radiology services showed routine turn around times and STAT turn around times were being tracked. The STAT turn around times failed to meet the facility target/goal 10 of 12 months during 2019.

On 02/11/20 at approximately 10:45 AM, the DQM confirmed the facility had just reviewed the contractor's OPPE and agreed there were poor performers. Additionally, the DQM confirmed that the medical executive committee (MEC) had requested the medical director review all radiology, however, the director stated that was not feasible. The DQM confirmed the facility had taken no further action with the radiology contract and quality of services provided at the time of the interview. The DQM confirmed the facility utilized HPC 05-005 CORE: Naso, Gastro and Jejunal Tube Site Care Policy to train the nursing staff.

Based on staff interview it was determined the facility failed to ensure the medical staff designated radiology staff as qualified to administer procedures.

Findings included:

On 02/11/20 at approximately 3:20 PM, a request was made for a list of radiology staff that had been designated by the Medical Staff as qualified to carryout procedures. The facility Director of Quality Management (DQM), confirmed the facility was unable to provide evidence the Medical Staff had designated the four radiology technician (RT's) at the facility as qualified to administer procedures.