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Based on observation, interview, and document review, the hospital was found out of compliance with the Condition of Participation of Radiologic Services at 42 CFR 482.26. The hospital failed to have systems in place to protect patient safety during radiologic testing. As a result of this system failure, patient safety was compromised and a patient fell off an upright platform during an abdominal x-ray, sustaining fractures to the right lower extremity. The seriousness of the hospital's failure to protect patient safety places the Condition of Participation of Radiologic Services out of compliance. Refer to deficient practice cited at A-535.

Findings include:

Based on observation, interview, and document review, the hospital failed to ensure patient safety during radiologic testing, in 1 of 14 patients reviewed (P1), who fell off an upright platform during an abdominal x-ray and sustained fractures of the right lower extremity.

Based on observation, interview, and document review, the hospital failed to ensure patient safety during radiologic testing, in 1 of 14 patients reviewed (P1), who fell off an upright platform during an abdominal x-ray and sustained fractures of the right lower extremity. Findings include:

P1's emergency department (ED) record indicated that P1 presented to the ED by ambulance, on 03/28/13 at 10:46 p.m., with complaints of abdominal pain. P1 was examined by a physician at 11:00 p.m., who noted that P1 had a long past history of small bowel obstructions. P1 rated the abdominal pain as an 8, on a scale from 1 - 10, and told the physician the pain was similar in nature to the pain s/he had previously experienced with bowel obstructions. P1 was medicated for pain with Morphine 5 mg IV push at 11:31 p.m. P1 was taken to Radiology at 12:27 a.m. for two upright x-rays and two flat x-rays of the abdomen.A Risk Event report, dated 03/29/13, indicated that while Imaging Technician (IT)/(H) was performing P1's upright abdomen image, P1 fell off the x-ray table platform, to the floor. Radiology reports, dated 03/29/13, indicated that P1 sustained a nondisplaced fracture of the right medial malleolus, a displaced fracture of the fourth right phalanx, and a questionable fracture of the right fibular head, as a result of the fall off the x-ray table. P1 also underwent a CT scan of the abdomen on 03/29/13, which revealed that P1 had a small bowel obstruction of the mid to distal ileum. P1 was admitted for hospitalization for treatment of the small bowel obstruction. Observations in Radiology, on 06/27/13 at 2:30 p.m., revealed that the type of x-rays P1 had on 03/29/13 at 12:27 a.m. were obtained with the patient positioned on a standard x-ray table. The x-ray table can be adjusted to a perpendicular position and the patient stands on a platform that is attached to the distal end of the x-ray table. While standing on the platform, the patient is able to lean back against the x-ray table, for truncal support. The platform height is approximately 6 - 8 inches from the floor.

IT/(H) was interviewed on 07/01/13 at 7:05 a.m. S/he stated that on 03/28/13, the Radiology Department was notified via the electronic medical record (EMR) that P1 needed two upright views and two flat views of the abdomen. The only information that the Radiology Department receives via the EMR is the patient's name, type of x-ray, and indication for the exam (i.e., abdominal pain). When IT/(H) went to the ED to transport P1, P1 said s/he didn't feel well. IT/(H) checked with RN/(G) about P1's status and whether P1 was ready for transport. RN/(G) reported that P1 should be able to stand for the x-rays, that P1 complained a lot. RN/(G) did not mention that s/he had medicated P1 with Morphine. IT/(H) then transported P1 to Radiology on a stretcher for the x-rays. IT/(H) assisted P1 off the stretcher onto the x-ray table and platform, which was adjusted to the upright position. IT/(H) took the first upright exposure and while s/he was changing cassettes for the second exposure, P1 said s/he was dizzy and felt like s/he was going to "pass out." IT/(H) was five feet away in the control area and immediately went over to P1. IT/(H) grabbed the stretcher and pulled it over to where P1 was, so s/he could assist P1 onto the stretcher. IT/(H) asked P1 to step down off the platform. P1 stepped down with her right foot. P1's left foot was still on the platform. P1's right knee buckled during the process and s/he started to slide to the floor. IT/(H)'s attempt to brace P1 was unsuccessful. P1 slid to a seated position on the platform. P1's right knee was bent backwards and P1's right foot was stuck underneath the platform. IT/(H) dislodged P1's foot and assisted P1 to the floor. IT/(H) then ran to the phone and called the ED for staff assistance. RN/(G), Physician/(E), and a security officer responded. After Physician/(E) evaluated P1, staff transferred P1 to the stretcher with a mechanical lift. A CT scan of the patient's abdomen was completed afterward, which revealed P1 had a small bowel obstruction.RN/(G) was interviewed on 07/01/13 at 7:40 a.m. She stated that P1 arrived in the ED by ambulance with complaints of abdominal pain, which had persisted throughout the day. P1 was alert and oriented and provided her own health history. P1 was examined by the physician within 15 minutes of arrival. The physician ordered abdominal x-rays, based on the patient's chief complaint and history of small bowel obstructions. IT/(H) came to the ED to transport P1 to Radiology. IT/(H) asked RN/(G) about P1's status. RN/(G) usually tells the technicians if a patient has received narcotic medication or any medication which might compromise their cognition or balance. RN/(G) could not recall if s/he told IT/(H) that P1 had received Morphine after arriving in the ED. RN/(G) told IT/(H) to ask P1 whether or not P1 could stand for the x-rays. After P1 went to Radiology, RN/(G) received a phone call from IT/(H) requesting staff assistance in Radiology because P1 had fallen during the x-ray. When RN/(G) responded to the scene, P1 was on the floor of the x-ray room, flat on her back with her legs straight out. P1 was alert and was verbalizing that she felt weak and dizzy. Additional staff responded and they transferred P1 onto the stretcher with a mechanical lift.

P1 was interviewed on 07/01/13 at 10:00 a.m. P1 stated that s/he has a history of 24 bowel obstructions. On the morning of 03/28/13, P1 had abdominal pain similar to the pain s/he has previously experienced with bowel obstructions. P1 was also dizzy, especially with any movement, like rolling from side to side. By 10:00 p.m., the pain had not subsided so P1 called an ambulance and went to the hospital. The ED nurse medicated P1 with Morphine to control the pain. P1 told the ED nurse several times that s/he felt dizzy and had been dizzy all day. The technician from Radiology came to the ED to take P1 for x-rays. After P1 arrived in Radiology, the technician assisted P1 off the stretcher, to a standing position, onto the x-ray table and platform. P1 told the technician that s/he felt weak and dizzy but no staff remained with P1. P1 had requested that his/her family member be present by his/her side but hospital staff denied this request. P1 stood alone on the x-ray platform while the technician stepped away to take the x-ray. P1 called out to the technician and told the technician again that s/he was dizzy. The technician came to P1's side and told P1 that one more upright x-ray was needed. P1 reiterated that s/he was very dizzy and felt like s/he was going to faint. P1 closed her eyes. When P1 opened his/her eyes, P1 was laying on the floor. P1's right leg was bent backwards. Several other staff came into the x-ray room and got P1 off the floor with a lifting machine. P1 was lifted onto a stretcher and taken to an inpatient room. P1 was admitted for hospitalization due to the small bowel obstruction. The next day staff x-rayed P1's right leg. P1 had a broken toe, a broken ankle, and a broken fibula. P1 stated that s/he felt hospital staff should not have left him/her unattended in the x-ray room.The discharge summary, dated 04/03/13, indicated that the fractures to P1's right lower extremity were treated with a brace and immobilized to protect the foot. Outpatient physical and occupational therapies were recommended to improve strength, mobility, and activities of daily living.

Interim Imaging Manager/(C) was interviewed on 06/27/13 at 2:00 p.m. and Emergency Department Manager/(D) was interviewed on 06/27/13 at 2:55 p.m. Both managers stated that prior to the event involving P1 on 03/29/13, the hospital did not have a standardized reporting procedure for patient hand-off, between ED staff and Radiology staff, where significant information pertaining to the patient's safety was communicated during the transition of care between work units. The hospital's Patient Falls Policy, dated 05/01/13, defined a fall as "an unplanned descent to the floor." Although the policy addressed patients at risk for falls in care areas such as "inpatients, nursery, pediatrics, peri-operative services, outpatient/ambulatory services, and ED," the policy did not address patients at risk for falls in Radiology.