HospitalInspections.org

Based on medical record review, document review and staff interview, in one (1) of 17 medical records (MR) reviewed, the medical staff did not accurately interpret a preliminary computerized axial tomography (CT) Scan during the patient's visit to the emergency department (ED). (Patient #1)

Findings include:
Patient #1 presented to the ED on September 28, 2015 at 7:26 PM with a complaint of having fallen 2 hours prior to her arrival in the ED. The patient reported headache, right sided jaw pain, knee pain and that she had a broken tooth. She reported a pain score of 7 on a scale of 0, no pain, to 10 the most severe pain. The patient was given Percocet, a narcotic, for pain at 10:03 PM. The patient was sent for a maxillofacial CT Scan without contrast, which was done at 10:13 PM. The preliminary report at 10:58 PM was interpreted as normal. The patient was discharged home that night at 11:51 PM with instructions to follow up with a dentist. The discharge diagnosis was lip laceration.

The scan was read (over read) at 9:21 AM the following morning, which revealed; "there are small radiopaque foreign body within the soft tissue of the upper lip anterior to maxilla in the midline. This may represent a small foreign body within an abrasion and should be correlated clinically." There was no evidence that the patient was informed of this finding.


During interview of Staff #A, the Medical Director of the ED, on January 28, 2016 at 10:50 AM, she stated; "The radiologists did not identify the foreign objects on the preliminary read, and the reading on September 29, 2015 did not identify both objects and the size of the only object that was identified on September 29, 2015.

Based on medical record review, and staff interview in one (1) of 17 medical records reviewed, the facility did not develop and implement policies and procedures to notify
patient(s) of abnormal findings. (Patient #1)

Findings include:

Patient #1 presented to the ED on September 28, 2015 after she had fallen, had broken a tooth and sustained a lip laceration. A preliminary CT - Scan was reported as normal but an over read the following morning, revealed there was a foreign body in her upper lip.
There was no evidence that the patient was informed of this finding.

Per interview, on January 27, 2015 at 11:00 AM, Staff #A, the Medical Director of the ED, stated; sometimes the patients are not informed that foreign bodies were identified in the films. She also stated that it's the mid-level practitioners responsibility to inform the patient of abnormal findings when they are identified.

Staff #A also stated that it is the facility's policy to inform the patients of abnormal findings identified in the over read.

The facility did not provide a copy of the policy, as requested by the surveyor.