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Based on a review of the discharge planning policy and review of the patient record, it is revealed that on the recommendation of radiology staff, patient #1 needed a CT to better assess to his lung function. However, patient did not receive a CT and was admitted to another hospital on the same day he was discharged from Union Hospital of Cecil County .


Patient #2 is a male in his late 50's who presented to the hospital ED with an altered mental status, and low blood pressure. Patient #2 has a pain pump, and there appeared to be some issue with the pump which caused sedation and hypoventilation. Patient #2 is also on continuous oxygen at home due to chronic congestive obstructive pulmonary disease (COPD). Due to his poor respiratory status on presentation, he was intubated and mechanically ventilated.


An initial chest x-ray report on presentation revealed a patchy opacity in the left lung and left basilar pneumonia. The report documented "Significantly limited exam secondary to body habitus and patient positioning." Patient #2 has kyphosis (curvature of the spine) which makes for difficulty when imaging the lungs. The radiology report revealed "Given limitations of x-ray examination, a CT (computed tomography) may be considered as clinically indicated for a more definitive characterization." However, a CT was never ordered.


Patient #2 was admitted and treated. Two days later, which was also two days prior to discharge, another chest x-ray was ordered. The x-ray report states "Chest 2 views" " The study is extremely limited and basically nondiagnostic. CT scan is recommended." The Impression states "Essentially nondiagnostic examination. CT scan would be helpful for lung field evaluation." A CT was never ordered or done. Therefore, the actual status of patient #2's lungs was unknown at the time of discharge.



A Discharge Summary written on the day of discharge states in part, "Chest x-ray done on (two days earlier) within normal limits." However, and as shown, this is not accurate. Outwardly, patient #2 appeared to be in no distress on the day of discharge. However, following discharge, patient #2 became short of breath and went to another hospital where he was admitted for the next 12 days, in part, with clinical signs of volume overload.


While it is not an imperative to have followed the recommendation for a CT to better visualize patient #2 ' s lungs; 1) the discharge summary was in error regarding his lungs being within normal limits, 2) without the CT, the hospital could not fully evaluate the result of treatment; and 3) consequently, the hospital could not verify patient #2's stability at the time of discharge.