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Based on policy review, medical record review, and interview, the Governing Body failed to ensure contracted radiology services reported critical test results in a timely manner for 1 patient (#1) of 5 patients reviewed with a venous catheter (central line) of 8 patients reviewed.

Refer to A-0084.

Based on policy review, medical record review, and interview, the Governing Body failed to ensure contracted radiology services reported critical test results in a timely manner for 1 patient (#1) of 5 patients reviewed with a venous catheter (central line) of 8 patients reviewed.

The findings include:

Review of facility policy "Critical Test Results/Read Back" revised 2/2015, revealed "...PROCEDURE...1. Critical test results...include but are not limited to Laboratory, Diagnostic Imaging...or other diagnostic test results that require immediate notification and urgent response...3. The Technologist performing the test...or the physician interpreting the results (such as in the case of Diagnostic Imaging), assumes the final responsibility for calling the critical result to the nursing department or physician. Documentation of the phone call should be recorded...Time frame for reporting critical test results...Lab/Imaging to Nursing-15 minutes...Critical Values: The following is a list of critical values/test results...DIAGNOSTIC IMAGING-Any test result that would require urgent response and treatment. Examples including, but not limited to: Pneumothorax, Air in the Abdomen, Intracranial Bleed, High Probability of Pulmonary Embolism, Leaking Aneurysm, Deep Vein Thrombosis..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 5/31/19 with complaint of swelling of both legs and altered mental status. Continued review revealed the patient was admitted to the Intensive Care Unit (ICU) with a diagnosis of Septic Shock (potentially life threatening widespread infection causing organ failure and dangerously low blood pressure).

Medical record review of an ED procedure note dated 5/31/19 at 6:05 PM revealed a Subclavian Venous Catheter (SVC) was placed in the patient's right subclavian vein.

Medical record review of a Diagnostic x-ray report dated 5/31/19 at 6:09 PM revealed "...RIGHT subclavian central line in good position..."

Medical record review of a Physician's Order dated 5/31/19 at 6:34 PM revealed an order for Levophed (medication used to treat life-threatening low blood pressure) 7.5 milliliters per hour. Continued review revealed the medication was administered intravenously through the SVC.

Medical record review of a Computed Tomography Scan (CT) report dated 6/1/19 at 1:52 PM and electronically signed by the Radiologist at 2:42 PM revealed "...IMPRESSON...Tip right subclavian catheter resides within the right subclavian artery..." Continued review revealed no documentation to indicate the nursing unit or the patient's physician was advised the SVC was inserted in an artery and not the vein.

Medical record review of a nurses' note dated 6/1/19 at 5:30 PM revealed "...opened pt's [patient's] chest xray and CT chest [radiology reports] to check CVC [central venous catheter] placement, found that line was in artery and notified [named physician]..." (3 hours and 38 minutes after the CT was completed).

Medical record review of a Discharge Summary dated 6/1/19 at 6:14 PM revealed "...presented to the ED yesterday with what appeared to be septic shock...Patient [Patient #1] required central line placement with aggressive IV resuscitation with pressor support in the form of levophed...was admitted to ICU for further treatment...was on pressors overnight...CTs were done...chest abdomen, pelvis which did reveal the patient's central line is actually placed in her right subclavian artery...In light of the placement of the patient's central venous catheter in the right subclavian artery this will require vascular surgery to intervene...Hospitalist at [named acute care hospital] have been kind enough to accept this patient in transfer for her vascular necessities..."

Medical record review of a Transfer Form dated 6/1/19 at 7:15 PM revealed Patient #1 was transferred to another acute hospital under the care of a vascular surgeon for removal of the SVC from the Right Subclavian Artery.

Interview with the Lead Hospitalist on 7/23/19 at 11:50 AM, in the conference room, confirmed the SVC was inserted into the subclavian artery and not the subclavian vein.

Telephone interview with Registered Nurse (RN) #4 on 7/23/19 at 2:00 PM, confirmed the RN was not notified by the radiology department that Patient #1's SVC was in the artery and not in the vein. Continued interview confirmed she notified the attending physician of the radiology report and the attending physician gave an order to discontinue intravenous fluids administered through the SVC.

Interview with the Lead Hospitalist on 7/24/19 at 11:43 AM, in the conference room, confirmed the Radiologist was expected to advise the nursing unit or the ordering provider immediately when misplaced central lines were identified during radiology testing.

Interview with the Regional Performance Improvement Manager on 7/24/19 at 11:45 AM, in the conference room, confirmed there was no documentation the critical radiology test result was communicated to the nursing unit or the ordering provider and confirmed the facility failed to follow the policy for reporting critical test results.

Telephone interview with Radiologist #1 on 7/24/19 at 12:15 PM, confirmed the Chest CT scan was a critical test result and should have been communicated with the nurse on the unit.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a critical radiology result for placement of a central line was reported in a timely manner for 1 patient (#1) of 1 patient of 5 patients reviewed for central venous catheters of 8 patients reviewed.

The findings include:

Review of facility policy "Critical Test Results/Read Back" revised 2/2015, revealed "...PROCEDURE...1. Critical test results...include but are not limited to Laboratory, Diagnostic Imaging...or other diagnostic test results that require immediate notification and urgent response...3. The Technologist performing the test...or the physician interpreting the results (such as in the case of Diagnostic Imaging), assumes the final responsibility for calling the critical result to the nursing department or physician. Documentation of the phone call should be recorded...Time frame for reporting critical test results...Lab/Imaging to Nursing-15 minutes...Critical Values: The following is a list of critical values/test results...DIAGNOSTIC IMAGING-Any test result that would require urgent response and treatment. Examples including, but not limited to: Pneumothorax, Air in the Abdomen, Intracranial Bleed, High Probability of Pulmonary Embolism, Leaking Aneurysm, Deep Vein Thrombosis..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 5/31/19 with complaint of swelling of both legs and altered mental status. Continued review revealed the patient was admitted to the Intensive Care Unit (ICU) with a diagnosis of Septic Shock (potentially life threatening widespread infection causing organ failure and dangerously low blood pressure).

Medical record review of an ED procedure note dated 5/31/19 at 6:05 PM revealed a Subclavian Venous Catheter (SVC) was placed in the patient's right subclavian vein.

Medical record review of a Diagnostic x-ray report dated 5/31/19 at 6:09 PM revealed "...RIGHT subclavian central line in good position..."

Medical record review of a Computed Tomography Scan (CT) report dated 6/1/19 at 1:52 PM and electronically signed by the Radiologist at 2:42 PM revealed "...IMPRESSON...Tip right subclavian catheter resides within the right subclavian artery..." Continued review revealed no documentation to indicate the nursing unit or the patient's physician was advised the SVC was inserted in an artery and not the vein.

Medical record review of a nurses' note dated 6/1/19 at 5:30 PM revealed "...opened pt's [patient's] chest xray and CT chest [radiology reports] to check CVC [central venous catheter] placement, found that line was in artery and notified [named physician]..." (3 hours and 38 minutes after the CT was completed).

Interview with the Lead Hospitalist on 7/24/19 at 11:43 AM, in the conference room, confirmed the Radiologist was expected to advise the nursing unit or the ordering provider immediately when misplaced central lines were identified during radiology testing.

Telephone interview with Registered Nurse (RN) #4 on 7/23/19 at 2:00 PM, confirmed the RN was not notified by the radiology department that Patient #1's SVC was in the artery and not in the vein. Continued interview confirmed the attending physician was notified of the radiology report by the RN.

Interview with the Regional Performance Improvement Manager on 7/24/19 at 11:45 AM, in the conference room, confirmed there was no documentation the critical radiology test result was communicated to the nursing unit or the ordering provider and confirmed the facility failed to follow the policy for reporting critical test results.

Telephone interview with Radiologist #1 on 7/24/19 at 12:15 PM, confirmed the CT scan report should have been communicated with the nurse on the unit or the ordering physician.