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Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to notify a patient of abnormal diagnostic test results for one of one medical record reviewed (MR1).

Findings:

Review on April 12, 2022, of the facility policy, "Patient Test Result Information Act (112) - Administrative," last reviewed March 17, 2022, revealed "... Policy: A significant abnormality identified on an applicable outpatient diagnostic imaging test is communicated by the entity which performed the diagnostic test to the ordering provider and the patient, as per the Pennsylvania Patient Test Result Information Act (Act 112 of 2018). II Definitions: Diagnostic Imaging Service: as defined by the Act, a medical imaging test performed on a patient that is intended to diagnose the presence or absence of a disease, including, but not limited to, a malignancy. Excluded mammography, routine obstetrical ultrasounds, inpatient testing or tests completed in an emergency room. ... Significant Abnormality: a finding by a diagnostic imaging service of an abnormality or anomaly which would cause a reasonably prudent person to seek additional or follow-up medical care within three months. III Procedure: ... B. Upon completion of the diagnostic imaging service, the diagnostic service provider will determine whether a significant abnormality may exist. C. When a significant abnormality is identified upon review by the diagnostic imagining provider, the provider will: 1. Check the 'significant abnormality' box for [Name of Electronic MR] - resulted tests 2. If the provider informs the patient of the test result at the time the test is performed, that conversation is documented in the medical record and a separate notification is not required. D. Provider Notification: Test results automatically populate to the ordering providers [Name of Electronic MR] inbox. E. Patient Notification: 1. Test results with a digital letter populate to MyLVHN for patients registered with the patient portal. 2. At 14 days post-testing date, a letter is generated, printed, and mailed by the Central Access Center to the patient's address. A. The notification letter includes: 1)Name of the ordering health care practitioner 2) Date the test was performed 3) Date the results were sent to the ordering health care practitioner 3. An auto-notification is generated to the patient's [Name of Electronic MR] medical record to indicate that the letter was sent. ..."

Review on April 12, 2022, of MR1 revealed MR1 presented to the Emergency Department (ED) on August 11, 2021, post fall at home. There was provider documentation MR1 was an 81-year-old female who fell August 10, 2021, at home and came to the ED with complaint of right shoulder pain, chest pain, right hip pain, and neck pain. There was provider documentation MR1 was ordered a CT of chest, abdomen, and pelvis without contrast. There was documentation the CT impression showed a colonic mass in the transverse colon with wall thickening and luminal narrowing concerning for neoplasm. The lesions span was a length of approximately 6.0 cm. There was no documentation the abnormal result was disclosed to the patient.

Interview on April 12, 2022, with EMP3, at approximately 1300, confirmed MR1 presented to the facility on August 11, 2021, post fall at home. EMP3 confirmed MR1's abdominal CT scan showed a colonic mass in the transverse colon with wall thickening and luminal narrowing concerning for neoplasm. The lesions span was a length of approximately 6.0 cm. EMP3 confirmed there was no documentation the abnormal result was disclosed to the patient.