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Based on review of the medical record, Event Report, facilty policy and interviews, it was determined the radiology technologist failed to notify the physician when Patient Identifier (PI ) # 1 had a change in condition in the Radiology Department on 1/13/15. This affected one of ten sampled patients, but has the potential to affect all patients served.

Findings Include:

Policy and Procedure Review:
Subject: Assessment of Patients
Effective: 1/09
Revised: 1/15
Debarment: Medical Imaging

Policy: Technologists and nursing personnel shall assess the patient during the examination. Any changes to assessment shall be reported to the Radiologist and/or, if necessary, the ordering physician.

Medical Record Review: PI # 1 was admitted to the hospital on 12/17/14 with diagnoses to include Chest Pain, Coronary Artery Disease, Fever and Urinary Tract Infection.

A review of the Narrative Notes documented on 1/3/14 at 19:30 revealed PI # 1 was, "A O (Alert, Oriented) x 3.

A review of the Narrative Notes documented on 1/3/14 at 23:25 revealed, "Patient (PI # 1) assisted x 2 to w/c (wheelchair) and O2 (Oxygen) set up to travel. NAD (No apparent distress). Patient off floor to x ray."

A review of the Narrative Notes documented at 00:50 revealed, "Patient back to room and assisted back to bed...Radiology Tech (Technician) reports patient became weak in x ray and was assisted to floor upon knees. No bruises noted. NAD."

There was no documentation in the medical record the radiology technician notified the physician of the patient's fall.

A review of the Event Report dated 1/3/15 and documented by the Radiology Technician, Employee Identifier (EI) # 1 revealed: Patient (PI # 1) standing with left shoulder against the wall. I was facing the patient and holding underneath the arms. (PI # 1) legs suddenly became weak and slowly slid as I was trying to sit (him/her) in the wheelchair. (PI # 1) fell forward onto knees and I held the patient upright and called for lifting help. Reported to nurse when taken back to room.


Interview with Radiology Technician, Employee Identifier (EI) # 1, on 2/18/15 at 2:55 PM: According to EI # 1, she went to PI # 1's room on 1/3/15 and transported the patient to radiology because a chest x-ray (PA and Lateral) had been ordered. This type of x-ray requires the patient to stand so the x-ray had to be done in the Radiology Department.

Once PI # 1 was in the Radiology Department, EI # 1 said she placed the wheelchair at the back of PI #1's knees in case the patient needed to sit down during the x-ray. According to EI # 1, the patient "kind of buckled" and the patient's body came forward (toward the technician) and she "eased PI # 1 down slowly." EI # 1 called the Emergency Department and nurse came to help her put PI # 1 back in the wheelchair. EI # 1 denied leaving PI # 1 unattended during the x-ray. EI # 1 said she took the patient back to the room via wheelchair and informed the RN about the incident. The technologist stated she did not notify PI # 1's physician about the incident.

Interview with the Registered Nurse (RN) / EI # 2, on 2/19/15 at 12:18 PM:

The RN was assigned to PI # 1 on 1/3/15 on the 7:00 PM to 7:00 AM Shift. The RN was asked if he notified the patient's physician after the fall in radiology and the RN said, "No. I was under the impression she (Radiology Technologist) did because she did the incident report."