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Based on document review, policy review, medical record review, and interview, the hospital failed to the ensure the medical staff assumed responsibility for quality medical care for 1 of 3 (Patient #1) sampled patients who was discharged from the hospital with preliminary Computerized Tomography (CT) results as normal. Patient #1's mother was contacted by the hospital on 10/21/2021 and instructed to return to the Emergency Department (ED) with Patient #1 STAT (immediately), after an Attending Radiologist reviewed the CT results and issued an addendum to findings that included possible injury to the left carotid artery. Patient #1's condition had deteriorated when he arrived back at the hospital ED on 10/21/2021. Patient #1 suffered a stroke and required a thrombectomy and craniotomy to relieve the pressure in his brain requiring a 27-day inpatient hospitalization.

The findings included:

1. Review of the hospital's Pediatric Radiology contract dated 12/12/2012 revealed, "...Group [radiology] shall furnish pediatric radiology services on a non-exclusive, as needed basis at [Hospital #1], providing such services upon the order of any qualified member of [Hospital #1] medical staff...Group shall retain a sufficient number of duly qualified, board certified and experienced radiologists to provide services to be performed hereunder, including on call at all times for emergency and backup coverage. Services will be provided in a timely manner and pursuant to physician's orders...the Group shall help establish procedures to promote the consistency and quality of all medical services provided...and shall additionally participate and cooperate in HOSPITAL'S overall Joint Commission [accredits medical services] compliance and Quality Assurance Programs in accordance with hospital policies..."

Review of the Resident Supervision policy from the Graduate Medical program Radiology Resident #1 attended revealed, "...Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to each patient; assuring each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine...Levels of Supervision and Definitions...Direct Supervision- the supervising physician is either (a) physically present with the resident during key portions of patient interaction, or (b)...the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology. Indirect Supervision- the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate Direct Supervision..."

Review the Hospital #1's Medical Staff Polices revised 3/17/2021, revealed "...Graduate Medical Education Policies-Supervision of Residents Definitions: Supervising Credentialed Physician (SCP) is a member of the medical staff who has appropriate credentials and privileges to deliver medical services at the hospital... plus a teaching appointment in the graduate medical educational program. General Supervision means that the care or procedure is conducted under the SCP's overall direction and control but the SCP's presence is not required at the time of care....Supervision by Medical Staff: The [named Hospital #1] medical staff assures supervision of graduate medical education residents by a Supervising Credentialed Physician with appropriate clinical privileges for the medical care that is being supervised. Patient care responsibilities are not delegated to residents without proper supervision and meeting the medical-staff responsibilities of the SCP...Written descriptions of the role, responsibilities, and patient care activities of participants in professional graduate education programs are provided to the medical staff by the Office of Graduate Medical Education. These descriptions include identification of the mechanisms by which the participant's supervisor(s) and graduate education program director make decisions about each participant's progressive involvement and independence in specific patient care activities...In the State of Tennessee, residents are Institutionally Licensed Physicians according to Tennessee Annotated Section 63-6-201...Supervision of Residents: An appropriate level of supervision is required of all residents during all clinically relevant educational activities by the SCP...Clinical responsibilities must be conducted in a carefully supervised and graduated manner, tempered by progressive levels of independence to enhance clinical judgment and skill. Although attending physicians who are SCP's remain ultimately responsible for overseeing management decisions, it is the resident's responsibility to communicate significant clinical information to the attending physician or a senior level resident...At all times, patient safety and care is the highest priority. Residents should document their communications with the attendings concerning management decisions...Resident Responsibilities...With each year of training, the degree of responsibility accorded to a resident, both professional and administrative, will be increased progressively... All patients receiving care at [named Hospital #1] are assigned to a member of the active staff as the Attending Physician. The SCP responsible for the care of the patient will provide the appropriate level of supervision based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment demonstrated by the residents being supervised. If quality concerns about patient care arise, those quality concerns will be addressed and assigned to the Attending Physician or the SCP supervising a specific component of management...Supervision Setting/Clinical Activity...Radiology/Pathology...Required Supervision...Oversight-post hoc review with feedback by supervising faculty/resident physician...Minimum Level of Supervision Documentation...All reports verified by departmental attending physician prior to release..."

2. Patient #1 presented to the Emergency Department (ED)on 10/20/2021 with his mother after sustaining an injury to the roof of his mouth when he fell on a sharp plastic toy/object. The Computerized Tomography (CT) results were reviewed by Resident Radiologist #1 on 10/20/2021 at 8:11 PM indicating no vascular injury or hematoma. The Resident Radiologist did not seek supervision from his Attending Radiologist on call. Patient #1 was discharged form the ED with antibiotic prescription on 10/20/2021 at 10:51 PM in stable condition with instructions to follow up with primary care in 2 days and otolaryngologist in 7 days. On 10/21/2021 at 11:45 AM, the Attending Radiology Physican reviewed Patient #1's CT results from 10/20/2021 and documented, "Upon further review, an intimal dissection and thrombosis or pronounced vasospasms of the left internal carotid artery is noted in the vicinity of the aforementioned interstitial emphysema in the left prevertebral space. The occlusion is seen just distal to the bifurcation of the carotid artery..." The findings were reported to the ED Physican and Patient #1's family was directed to return to the hospital. On 10/21/2021 at 1:02 PM, Patient #1 arrived at the ED, received an immediate Medical Screening Exam, when Patient #1's mother reported he had been fussy all night and was not using the right side of his body. The ED Physican ordered a STAT CT angiogram which determined Patient #1 suffered a stroke and had aphasia. Patient #1 was admitted to the intensive care unit after examination by a Nuerosurgeon. On 10/21/2021 at 8:02 PM, Patient #1 required an Thrombectomy. On 10/23/2021, Patient #1 had increased edema on the brain, so a left frontotemporparietal decompressive hemicraniotomy was performed to relieve cranial pressure. Patient #1 remained on the ventilator until 10/31/2021, required extensive Physical Therapy, Occupational therapy and Speech therapy remained hospitalized until 11/18/2021, when he was transferred to a children's hospital in another State that could provide intensive rehabilitation.

The hospital medical staff failed to recognize a life threatening condition for Patient #1 when he presented to the ED on 10/20/2021 which resulted in debilitating deficits that continue to present.

Refer to A347

Based on document review, policy review, medical record review, and interview, the hospital failed to the ensure the medical staff assumed responsibility for quality medical care for 1 of 3 (Patient #1) sampled patients who was discharged from the hospital with preliminary Computerized Tomography (CT) results as normal. Patient #1's mother was contacted by the hospital on 10/21/2021 and instructed to return to the Emergency Department (ED) with Patient #1 IMMEDIATELY (STAT), after an Attending Radiologist reviewed the CT results and issued an addendum to findings that included possible injury to the left carotid artery. Patient #1's condition had deteriorated when he arrived back at the hospital ED on 10/21/2021. Patient #1 suffered a stroke and required a thrombectomy and craniotomy to relieve the pressure in his brain requiring a 27-day inpatient hospitalization.

The findings included:

1. Review of the hospital's Pediatric Radiology contract dated 12/12/2012 revealed, "...Group [radiology] shall furnish pediatric radiology services on a non-exclusive, as needed basis at [Hospital #1], providing such services upon the order of any qualified member of [Hospital #1] medical staff...Group shall retain a sufficient number of duly qualified, board certified and experienced radiologists to provide services to be performed hereunder, including on call at all times for emergency and backup coverage. Services will be provided in a timely manner and pursuant to physician's orders...the Group shall help establish procedures to promote the consistency and quality of all medical services provided...and shall additionally participate and cooperate in HOSPITAL'S overall Joint Commission [accredits medical services] compliance and Quality Assurance Programs in accordance with hospital policies..."

Review of the Resident Supervision policy from the Graduate Medical program Radiology Resident #1 attended revealed, "...Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to each patient; assuring each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine...Levels of Supervision and Definitions...Direct Supervision- the supervising physician is either (a) physically present with the resident during key portions of patient interaction, or (b)...the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology. Indirect Supervision- the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate Direct Supervision..."

Review the Hospital #1's Medical Staff Polices revised 3/17/2021, revealed "...Graduate Medical Education Policies-Supervision of Residents Definitions: Supervising Credentialed Physician (SCP) is a member of the medical staff who has appropriate credentials and privileges to deliver medical services at the hospital... plus a teaching appointment in the graduate medical educational program. General Supervision means that the care or procedure is conducted under the SCP's overall direction and control but the SCP's presence is not required at the time of care....Supervision by Medical Staff: The [named Hospital #1] medical staff assures supervision of graduate medical education residents by a Supervising Credentialed Physician with appropriate clinical privileges for the medical care that is being supervised. Patient care responsibilities are not delegated to residents without proper supervision and meeting the medical-staff responsibilities of the SCP...Written descriptions of the role, responsibilities, and patient care activities of participants in professional graduate education programs are provided to the medical staff by the Office of Graduate Medical Education. These descriptions include identification of the mechanisms by which the participant's supervisor(s) and graduate education program director make decisions about each participant's progressive involvement and independence in specific patient care activities...In the State of Tennessee, residents are Institutionally Licensed Physicians according to Tennessee Annotated Section 63-6-201...Supervision of Residents: An appropriate level of supervision is required of all residents during all clinically relevant educational activities by the SCP...Clinical responsibilities must be conducted in a carefully supervised and graduated manner, tempered by progressive levels of independence to enhance clinical judgment and skill. Although attending physicians who are SCP's remain ultimately responsible for overseeing management decisions, it is the resident's responsibility to communicate significant clinical information to the attending physician or a senior level resident...At all times, patient safety and care is the highest priority. Residents should document their communications with the attendings concerning management decisions...Resident Responsibilities...With each year of training, the degree of responsibility accorded to a resident, both professional and administrative, will be increased progressively... All patients receiving care at [named Hospital #1] are assigned to a member of the active staff as the Attending Physician. The SCP responsible for the care of the patient will provide the appropriate level of supervision based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment demonstrated by the residents being supervised. If quality concerns about patient care arise, those quality concerns will be addressed and assigned to the Attending Physician or the SCP supervising a specific component of management...Supervision Setting/Clinical Activity...Radiology/Pathology...Required Supervision...Oversight-post hoc review with feedback by supervising faculty/resident physician...Minimum Level of Supervision Documentation...All reports verified by departmental attending physician prior to release..."

2. Medical record review for Patient #1 revealed, a 5 year-old male, presented by private car accompanied by his mother to Hospital #1's ED on 10/20/2021 at 3:50 PM for "other complaint." A triage assessment was completed at 4:10 PM and the patient's mother reported the patient fell while playing with a "plastic toy" resulting in injuries to his lower lip, roof of his mouth, and tooth. The patient's blood pressure was 131/88, Pulse was 90, and Respirations were 24.

A Medical Screening Examination (MSE) was initiated by ED Physician #1 on 10/21/2021 at 5:20 PM. The patient was noted to have a "laceration to the left side of the soft palate and anterior pillar of tonsil which is about an inch wide by 1.5 cm [centimeters] exposing the underlying fascia..." The patient was also noted to have a tooth fracture of the lower right molar. The physician ordered a STAT Basic Metabolic Panel (BMP) and Complete Blood Count (CBC), and a Computerized tomography (CT) scan of the soft tissue/neck with contrast. Orders were also written for a 1 time dose of Morphine 2.5 milligrams (mg) to be given via intravenous catheter (IV).

The CT scan was completed at 6:51 PM. The "Preliminary" results of the scan as interpreted by Radiology Resident #1 on 10/20/2021 at 8:11 PM, revealed the patient had a "Traumatic laceration of the posterior left soft palate and palatine tonsil without identifiable hematoma, vascular injury, or radiopaque foreign body. Remainder of the imaged head, neck, and upper chest are normal. Findings discussed with [ED Physician #1] at 7:57 PM on 10/20/2021 by radiology resident..." The report was "Signed By: [Attending Radiologist.]" The date and time of the Attending Radiologist's signature was not documented.

On 10/20/2021 at 8:14 PM, an Ear, Nose, and Throat (ENT) consult was ordered by ED Physician #1.

The ENT consult was completed by the ENT Resident on 10/20/2021 at 10:28 PM. The ENT Resident documented, "...Superficial abrasion without laceration of the mucosa to the left soft palate, extending superior and medial to the left tonsillar fossa...This patient was discussed with [Attending ENT Physician] who agrees with the following assessment and plan. Patient is a 5 year old male who presents following falling with a plastic toy in his mouth and sustaining an injury to the left soft palate extending superior and medial to the left tonsillar pillar. CT with no evidence of hematoma, vascular injury or radiopaque foreign body. Plan: No acute intervention at this time -Recommend course of amoxicillin [antibiotic] - Follow ENT clinic in 7 days. -Please call with additional questions or concerns..."

On 10/20/2021 at 10:32 PM ED Physician #1 documented, "Assessment: ENT saw the patient bedside and they advise no acute intervention at this time but recommend to DC [discharge] home on amoxicillin for a week and have them follow-up in ENT clinic in the next week...Diagnosis: Laceration of Oral Cavity...Soft Palate Injury..."

Patient #1 was discharged home in stable condition on 10/20/2021 at 10:51 PM with instructions to follow up with Otolaryngology in 7 days and his Primary Care Provider in 2 days.

On 10/21/2021 at 11:45 AM, the Attending Radiologist added an addendum to the CT scan report which read, "Upon further review, an intimal dissection and thrombosis or pronounced vasospasms of the left internal carotid artery is noted in the vicinity of the aforementioned interstitial emphysema in the left prevertebral space. The occlusion is seen just distal to the bifurcation of the carotid artery...The findings of the left internal carotid artery occlusion were reported to [ED Physician #2] in the emergency department at 1135 [11:35 AM] hours 10/21/2021..."

On 10/21/2021 at 12:54 PM, the Attending ENT Physician added an attestation to the initial ENT consultation report which read, "I reviewed the case with the resident by telephone but did not personally examine the patient...Decision to discharge the patient was made based on initial imaging findings as detailed in the note and physical exam. After the patient was discharged but before this entry the initial CT report was amended to describe vascular injury. The patient was contacted and directed to return to the emergency department for evaluation. As of this writing he [Patient#1] is inpatient at this facility..."

On 10/21/2021 at 1:02 PM, Patient #1 returned to the ED. The MSE was started "immediately upon arrival" by ED Physician #2. The physician documented, "The patient presents with altered mental status...onset Overnight. The course/duration of symptoms is constant and worsening. The character of symptoms is agitated...Seen in ED last night [10/20/2021]. Patient presents immediately for CT call back. According to mom, the child was playing last night with a toy, and he fell and the toy sword poked him in the back of the throat. He was seen here last night and was discharged home. The callback was concerning for possible injury to a blood vessel in the back of his throat. Mom states the child has been fussy all night long. She also states that he has not been using the right side of his body. She stated that he's not been acting right or responding correctly..." The physician's physical exam revealed Patient #1 was noted to be in "moderate distress, anxious, and had a Glasgow Coma Scale score of 10. (The Glascow Coma Scale is a tool used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The best response is noted as a level 15. A comatose patient would score 8 or less, and a totally unresponsive patient would score 3.) The patient was no longer able to move his eyes past the midline to the right. ED Physician #2 ordered a STAT CT Angiogram of the head and neck along with a CMP, CBC, and coagulation studies. The physician also requested consults from the Neurology and Neurosurgery teams.

The CT Angiogram of the head completed on 10/21/2021 at 1:46 PM revealed Patient #1 had "complete occlusion of the left M1 segment of left MCA. There is reconstitution of flow within the distal M2 and M3 segments. This is most likely due to vasospasm although follow-up imaging and/or anigiography would be helpful. 2. Loss of gray-white matter differentiation left MCA distribution as well as mild effacement of the left lateral ventricle, concerning for acute infarction..." (The MCA is the largest terminal branch of the internal carotid aorta. The MCA divides into 4 main surgical segments; M1 to M4. The MCA supplies oxygenated blood to specific regions of the brain.)

Patient #1 was evaluated by Neurosurgeon #1 on 10/21/2021 at 3:49 PM. The neurosurgeon documented, "...The patient is drowsy. He does open his eyes to voice. He appears to have a slight left gaze preferency and a right facial droop. The patient appears to be totally aphasic with no speech output. He will withdraw the right side to pain but is otherwise densely hemiparetic on the right. He mimics and moves the left side well...No acute neurosurgical intervention...Recommend STAT neurology consult, MRI of the brain to evaluate stroke burden and neurologic interventional radiology consult for consideration of 4-vessel angiogram...The patient needs to go to the intensive care unit [ICU] for close clinical monitoring...Stroke care recommendations per neurology..."

An Operative Report dated 10/21/2021 at 8:02 PM, revealed, Patient #1 "...was playing with a toy sword approximately 24 hours prior to admission where he fell and stabbed himself in the back of his throat. A soft tissue CT neck was obtained at the time and the patient was discharged. He was brought back to the hospital the next day [10/21/2021] with right hemiparesis and aphasia. A CTA [CT angiogram] performed at second presentation did reveal a Left ICA [internal carotid artery] occlusions, a subsequent MRI did show a moderate area of deep nuclear stroke. Given the above, he was brought to the angiography suite for emergent intervention...Complete post traumatic dissection with occlusion of Left ICA, with successful thrombectomy and TICI [thrombolysis in cerebral infarction] 2c revascularization; residual subocclusive thrombus in the intracranial Left ICA..."

An Operative Report dated 10/23/2021 at 8:25 PM, revealed Patient #1 "...was playing with some sort of stick or sword toy and fell on it and it went into his mouth and apparently hurt his palate. He came to [Hospital #1] on the evening of the injury [10/20/2021]. It injured his left carotid artery in the neck. He unfortunately developed a stroke which involved the middle cerebral artery and posterior cerebral artery. He had a thrombectomy done when this was discovered to reopen the vessel and was placed on a heparin drip. He has been hemiplegic on the right and aphasic and sedated on the ventilator. He had a CT scan this morning, which looked a little worse as far as the amount of edema from his strokes, and so decompression was recommended...`" Patient #1 required the performance of a "Left frontotemporoparietal decompressive hemicraniotomy and 10 x 12 cm duraplasty" and "Placement of right frontal intracranial pressure monitor." (A decompressive craniotomy is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed.)

The Discharge Summary dated 11/18/2021 revealed Patient #1 required the use of a ventilator until 10/31/2021, at which time he was extubated and was "able to start rehabilitation." The patient required extensive rehabilitative therapies included Physical Therapy, Speech Therapy, and Occupational Therapy. Patient #1 discharge diagnoses included: Acute Ischemic left MCA stroke, Acute right hemiparesis (paralysis of one side of the body), Acquired aphasia (The condition is attributed to brain damage, especially involving that portion of the brain which controls speech), Posterior Cerebral artery stroke (Cerebral arteries supply oxygenated blood to the occipital of the brain) Cerebral edema, and Hypertension. The summary documented, "...Patient was accepted for inpatient at [Hospital #2]. At this time, the treatment team determined that the patient had reached the maximum benefit of his hospital stay and was ready for discharge for transfer..." Patient #1 was transferred to Hospital #2 for inpatient rehabilitation on 11/18/2021.

3. Review of medical records from Hospital #2 revealed Patient #1 had admission date of 11/18/2021 and discharge date of 12/16/2021. The summary documented the hospital course, "..he participated in PT [Physical Therapy], OT [Occupational Therapy] and SLP [Speech Language Pathology]...Neuro:...Right Hemiplegia, Expressive Aphasia, Dysarthria...helmet when out of bed...Left Hand Discomfort: unclear symptoms in setting of aphasia, patient with occasional flicking of the wrist...Hematology: intimal dissection and thrombosis or pronounced vasospasm of the left internal carotid artery..."
Review of the visual perception assessment dated 12/16/2021 revealed,"...Poor visual motor integration observed in fxl [functional] drawing activities..." Review of the splints/orthotics assessment dated 12/16/2021 revealed Patient #1 required a upper extremity resting hand splint and a shower chair/seat for bathing. Review of the self-care assessment dated 12/16/2021 revealed Patient #1 required moderate assistance with grooming, bathing, dressing, and toileting transfers. Review of the Cognitive/Linguistic assessment dated 12/16/2021 revealed Patient #1 had short- and long-term memory impairments, impaired problem solving skills and impaired attention. The Cognitive/Linguistic assessment further revealed, "Pt [patient] with severely impaired cognitive linguistic skills...Max cues for orientation to time and situation ...participating in below- age level problem solving activities..." Review of the communication assessment dated 12/16/2021 revealed, "Pt presents with global aphasia...severely impaired receptive language skills. Pt following simple 1-step commands in familiar situation (turn page, take a sip, hive five, etc.)...Pt communicates primarily via gestures such as pointing, reaching, shaking head to communicate wants and needs. Pt attempts to verbalize words independently, however verbal expression consists primarily of jargon at this time..." Review of the swallowing assessment dated 12/16/2021 revealed, "Pt presents with mild oropharyngeal dysphagia characterized by reduced tongue control and disorganized tongue movement resulting in premature spillage of thin liquids..." Review of the Fine Motor Assessment dated 12/16/2021 revealed, "...Right side hemiplegia impairing engagement in bimanual coordination tasks...unable to copy simple shapes...poor letter formation. Deficits in visual motor integration limiting hand writing..." Physical therapy recommended the use of a quad cane at discharge to assist with mobility. Occupational therapy recommended continuing outpatient OT 5 times per week at discharge.

4. Review of History and Physical from Hospital #1 dated 5/23/2022 revealed, [Patient #1] is here for followup status post a left decompressive hemicraniectomy...for a big stroke back in October 2021. He has injured himself while playing with some of sort of stick or a sword and it hurt his palate, and he came to [named Hospital #1] in the evening of injury, and he had a left carotid artery injury. He developed a stroke, and they did a clot retrieval involving the middle cerebral artery and the posterior cerebral artery. He had thrombectomy done to reopen the vessel, and he was placed on heparin drip. He was hemiplegic and aphasic and sedated on a ventilator. A few days later, he developed worsening edema, and so we elected to do a decompression. He went to rehab, and he has been making a lot of strides. He cannot walk yet on his own, but he is moving his right side some. He just cannot bear weight yet. He does not have any good fine motor. He has more use of his leg than his arm on the right. He also has probably a dense right homonymous hemianopsia which we noted in the hospital. He is saying some words. He is a bit hard to understand, and he seems to understand more than he is able to verbalize. He wears a helmet [to protect the area after the hemicraniectomy] when he is out of bed and around...Physical Exam...His incision is well healed and somewhat sunken ..He does have a dense right homonymous hemianopsia, and he has some movement with his right arm and his right leg, but again the arm is worse than the leg, and he does not have any fine motor...Neurodynamic Assessment...we did do a head CT and of course it looks pretty similar to his preoperative CT where he has a lot of hypodensity damage in his left occipital lobe and temporal lobe and basal ganglia, and there is a small stroke in the thalamus as well. The right ventricle looks like he has some porencephaly involving the right occipital horn. Well, it is hard to say. think it is just hypodensity of the mesial temporal lobe and not porencephaly, but his left ventricle is slightly enlarged compared to the right and is pretty minor, but he does have volume loss of the left hemisphere...Plan...I have gone over this with the grandmother and spent a lot of time with her answering a lot of her questions. I think he is ready for cranioplasty, and so we will try to get this scheduled in the near future. He may need lumbar puncture when he gets flat in order to get the bone on and so I told them about that, but I answered all of their questions...I discussed with the grandmother the indications, risks, and benefits of the surgery and answered all of her questions. I did specifically discuss with her the risk of resorption of the bone flap, which I would estimate to be 30% to 40% in his age group, so we will get this scheduled at their earliest convenience..." Review of the hospital discharge summary dated 5/26/2022 revealed Patient #1 required a Cranioplasty (surgical repair of a bone defect in the skull that's left behind after a previous operation) on 5/24/2022 that was completed without complications. Patient #1 was discharged home in stable condition with instructions to follow up with the neurosurgeon in two weeks. The family was instructed no to submerge the operative site in water for three weeks.

5. In an interview on 10/11/2022 at 12 :45 PM, the Director of Risk Management stated the Radiology services were a contracted service with Hospital #1.

In an interview on 10/11/2022 at 1:12 PM, the Associate Chief of Operations for Radiology Group (ACORG) verified Radiology Resident #1 remained in the Residency program. The ACORG explained the Graduate Medical Program consisted of total 5 years with the first year classified as an Intern and Residency consisting of 4 years. The ACORG stated that in October 2021(when Patient #1 presented for care) Resident #1 was a second year Resident and would have required Indirect Supervison. The ACORG stated "Attendings are available at night via telephone..." She further stated Attending physicians can come in after hours to look at Imaging, if needed. The ACORG explained the process, "Residents do a preliminary read of imaging and the following morning, an Attending physician comes on-site to review all cases from the prior night..." The ACORG stated if the Attending physician agrees with the results, they sign off. The ACORG stated, "If they [Attending] don't agree...make an addendum [to the results] and contact provider [ED Physician] to take care of patient. The ACORG verified for Patient #1 when the Attending Physician reviewed the results the following morning an addendum was made and the Patient was asked to return to the hospital ED.

In an interview on 10/11/2022 at 1:30 PM, the ACORG reported to the survey team the Attending Radiologist was not available for interview due to being subpoenaed regarding a case involving Patient #1.

In an interview on 10/11/2022 at 1:40 PM, the surveyors asked what actions had been implemented after Patient #1 was discharged home with preliminary CT results, that later resulted in his return to the ED, requiring hospitalization due to a stroke. The Director of Performance for the Contracted Radiology Group stated we had some conversations at the end of the year, QA conference about things that could have been done differently. The Director of Quality stated, "it [the incident with Patient #1] went to hospital Senior Leadership, there was a meeting May 3, 2022 with Senior Leadership and Radiology...home work stations were ordered, they will start this Friday [10/14/2022]..." When asked if any changes had been implemented prior to 10/11/2022, the ACORG stated, "Not that I am aware of..." The ACORG stated the home work stations would make the resolution better and Radiologists would be able to do everything they could at the hospital from home. The Director of Risk Management stated she could not share much of the documentation because it was protected under attorney work privilege.

In an interview on 10/11/2022 at 1:50 PM, the Director of Risk Management stated that all Physicians and Residents the survey team requested to interview regarding Patient #1 were not available due to a summons for pending court case.

In an interview on 10/11/2022 at 2:20 PM, the survey team again requested any action plans the hospital had implemented after the incident involving Patient #1's misdiagnosed emergency medical condition. The Director of Performance for the Contracted Radiology Group presented the surveyors with the following action plan: "Action plan for Radiology Overread Event 1. Home workstations have been purchased and are being deployed over the next two weeks for the radiology physician team. Currently working with the radiologist to determine how to modify their schedules to provide more coverage- should start deploying on Friday (10/14/2022). A teleradiology contracted service for weekend service (Friday 7 pm til Monday 8 AM) is estimated to go live on 12/6/2022...An 'Always Call List' is being developed and will be implemented [no date provided]. Working with Neuroradiology to expand their after hours coverage." No documented actions were implemented as of 10/11/2022 during the onsite visit.

In an interview on 10/11/2022 at 2:47 PM, the surveyor asked how a patient could be safely discharged from the ED, by an ED Physician, if the radiology results had not been reviewed and approved by the Attending Radiologist. The Director of Risk Management stated, "We do that all the time with labs, cultures not resulted...in this case [Patient #1] the ENT consulted, and the ED Physician can read [CT] results...Both thought it was safe to discharge the patient." When asked if the ACORG could return to the Quality office to answer the question, the team was informed the ACORG had been subpoenaed and was no longer available for interview.

In an interview on 10/11/2022 at 3:10 PM, the hospital Director of Quality reported there was no reference to supervision of Resident physicians in the hospital by-laws, but could be found in the Medical Staff policies.

In an interview on 10/22/2022 at 3:10 PM, the Director of Performance for the Contracted Radiology Group stated Residents were not credentialed physicians.

In an interview on 10/11/2022 at 3:20 PM, the Director of Performance for the Contracted Radiology Group stated the Physician Program Director for the Graduate Medical School was not available for interview regarding Radiology Resident #1's performance/education/responsibilities

In an interview on 10/11/2022 at 4:40 PM, the Hospital's Director of Accreditation stated the Graduate Medical School was unable to provide any documentation regarding Radiology Resident #1's training and education file, pursuant the state law Patient Protection and Quality Improvement Act of 2014. The survey team was not granted access to any information regarding Radiology Resident #1.