HospitalInspections.org

Based on interview and record review, the facility failed to ensure Emergency Services were integrated with Laboratory and Radiology services when:

1. Radiology discrepancies (differences) between the Emergency Department (ED) physician or teleradiologist (radiologist who reads studies on-line), and the facility radiologist were not reviewed to determine whether follow-up care was necessary and appropriate action was taken; and,

2. Urine and wound cultures/sensitivities (determination of bacteria present and effective antibiotic(s)) that were done in the ED and determined to be positive after the patient was discharged home were not reviewed to determine whether follow-up care was necessary and appropriate action was taken.

These failed practices resulted in:

1. Three patients with positive radiological findings not being notified to follow up with their physicians (Patients 9, 12, and 13), and the potential for life threatening radiological findings (fractures, tumors, aneurysms) to go untreated; and,

2. Improper treatment of three patients with infections (Patients 3, 8, and 10) with no follow up communication from the ED, and the potential for life threatening infections to go untreated.

Findings:

1. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated an on-line teleradiology group read the after hours x-rays (done after 7 p.m.). The director stated she did not know if the group read all x-rays or just the Computed Tomography (CT), Ultrasound (US), and Magnetic Resonance Imaging (MRI) studies. She stated the facility radiologist re-read x-rays the next day, but she did not know if all of the radiology procedures were re-read (those read by the teleradiology physician, those read by the ED physician, or both). According to the IDED, if there was a discrepancy between the original x-ray interpretation and the interpretation done by the facility radiologist, the facility radiologist would identify it, but she was, "not sure," what the process was for communicating and resolving x-ray discrepancies.

During a tour of the Radiology Department on May 11, 2015, at 9:25 a.m., accompanied by the Chief Radiology Technologist (CRT) and the Director of Imaging Services (DIS), the CRT stated the ED physicians read all plain films (x-rays) after 7 p.m. on weekdays and after 6 p.m. on weekends.

The CRT stated all CT, US, and MRI studies were read by a teleradiologist during those hours. According to the CRT, all after hours x-rays and radiology studies were re-read the following day by the facility radiologist. The CRT stated ED physicians were required to put their interpretation of the x-ray into the radiology computer system, and teleradiology physicians were required to scan their interpretation into the computer system, so the facility radiologist would be able to see if he/she agreed with the interpretation during the re-read.

The CRT stated if the facility radiologist's interpretation was different than that of the ED physician or the teleradiologist, a discrepancy would be logged in the radiology computer system on the, "discrepancy log."

A review of the discrepancy log on May 11, 2015, indicated hundreds of discrepancies were logged by the facility radiologists, with no evidence they were seen, reviewed, or acted on by the ED providers.

The DIS stated, if an ED physician failed to enter an interpretation of the x-ray into the radiology system, the radiologist would enter that as a discrepancy on the log. According to the DIS, many or all of the logged discrepancies could have been entered as a result of the ED physician failing to enter an interpretation, and may not reflect a positive finding or actual discrepancy.

The CRT stated if the discrepancy was addressed by the ED provider, there was no mechanism for the provider to indicate that on the log, and the discrepancy would not drop off of the log. According to the CRT, there was no way to know if any or all of the discrepancies had been addressed.

The CRT and the DIS stated they did not monitor the contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time). The CRT and the DIS stated monitoring of the process was not their responsibility, it was the responsibility of the ED.

During an interview with Radiologist 1 on May 11, 2015, at 9:40 a.m., the radiologist stated if he saw a discrepancy in the after hours reading of an x-ray or radiology study, he would enter it onto the discrepancy log. He stated if the discrepancy was, "significant," he would call the ED and speak to the provider about it in addition to entering it onto the log.

According to the radiologist, there was not always an interpretation entered into the system by the ED physician, so he had no way of knowing what the ED physician diagnosed the patient with or treated the patient for. The radiologist stated he attended the radiology medical staff committee meetings, and he did not recall any discussions of the radiology discrepancy process.

He stated he did not know if the process was being monitored for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

A review of the contents of the discrepancy log on May 11, 2015, indicated the following:

a. 11 of 11 after hours x-rays ordered by the ED physicians, and completed during the time the ED physicians were required to read them, did not have an initial interpretation documented in the radiology system. There was no mechanism for the facility radiologist to know what the ED physician diagnosed the patient with or treated the patient for.

All 11 interpretations by the facility radiologist were entered onto the discrepancy log in the absence of an initial interpretation by the ED physician. There was no evidence an ED provider reviewed the discrepancies to determine whether the ED physician diagnosed and treated the patients correctly;

b. Patient 9, an 8 year old male, presented to the ED on May 4, 2015, with complaints of fever with shortness of breath and nausea. A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:20 a.m.

The initial interpretation included right lower lobe infiltrates (pneumonia), splenomegaly (enlarged spleen), a normal appendix, and mesenteric adenitis (inflammation of the lymph nodes in the right side of the abdomen).

A radiology discrepancy report dictated at 8:31 a.m., indicated in addition to the above findings, the facility radiologist saw a masslike density in the right lower lobe of the lung as well as borderline enlargement of the appendix. The radiologist recommended the patient receive follow-up for both of these findings.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 9 indicated no documentation was present regarding the recommendations made by the facility radiologist.

c. Patient 12, a 64 year old female, presented to the ED on May 5, 2015, with complaints of back pain. A two view chest x-ray (CXR) was ordered by the ED physician and completed at 3:40 p.m. There was no initial interpretation completed by the ED physician.

Patient 12 was discharged home by the ED physician at 3:49 a.m., with a diagnosis of thoracic (middle back/chest) strain, and a prescription for a non-narcotic pain reliever.

A radiology discrepancy report dictated at 7:43 a.m., indicated Patient 12 had a 1 cm nodular density (mass) in the anterior chest area. The facility radiologist recommended a CT of the chest to further evaluate the finding.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 12 indicated no documentation was present regarding the recommendations made by the facility radiologist.

d. Patient 13, an 86 year old male, presented to the ED on April 28, 2015, with altered mental status and vomiting.A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:09 a.m.

The initial interpretation included small bowel distention with possible bowel obstruction, distended urinary bladder, and no evidence of abdominal aortic aneurysm (AAA) (a bulge in a section of the aorta, the body's main artery, caused by a weakening of the wall of the artery).

A radiology discrepancy report dictated at 7:07 a.m., indicated, in addition to the above findings, the facility radiologist saw, "In addition to telerad(iology) prelim(inary) findings, there IS an AAA measuring 3.6 cm (centimeters)."

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 13 indicated no documentation was present regarding follow-up for the AAA.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the radiology discrepancy policy, completed in March 2015.

The EDMD stated when there was a, "significant," radiology discrepancy, the facility radiologist called the ED provider and placed the discrepancy on the log. He stated if the discrepancy was not significant, the discrepancy was just put onto the log.

The EDMD stated the ED physicians should be entering their interpretation of x-rays into the radiology computer system, and he had been reminding them of that, but their passwords had recently been inactivated due to a computer problem, and they were not able to get into the system for some time.

According to the EDMD, the mid-level provider (Physician Assistant) should be reviewing the discrepancy log daily. He stated the log was very long, and there was no way to know whether a discrepancy was seen or addressed, as the discrepancy stayed on the log and did not drop off. The EDMD stated a review of the discrepancy, review of treatment that was provided, whether or not follow up care was needed, and whether the patient was contacted for follow-up care should be documented in the electronic medical record (EMR).

According to the EDMD, no monitoring was being done to ensure the system was being followed and was effective in providing continuity of care to patients. He stated there was no monitoring for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

The EDMD stated Patients 9, 12, and 13 should have been contacted by the ED provider to make them aware of the radiologist's findings so they would know to follow up with their primary care physicians.

2. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated when cultures were taken in the ED, the results were not released for 24 to 72 hours. The IDED stated when a culture was positive, the charge nurse (CN) in the ED received a phone call from the lab and took the information regarding the, "critical lab value," over the phone.

According to the IDED, the CN would take the information to the ED physician, who would look up the patient's information, determine whether treatment was indicated, and call the patient if necessary. She stated she did not know if there was a log where the positive cultures were tracked and monitored for follow up.

During a tour of the Laboratory on May 11, 2015, at 10:10 a.m., accompanied by the Laboratory Manager, the manager stated positive blood culture results were considered a critical lab value, so all positive blood culture results were hand delivered to the ED provider on paper, with a second paper placed in a binder in the ED. The manager did not verbalize a system for reporting other positive culture results (urine, wound).

During an interview with the ED Charge Nurse (EDCN 1) on May 11, 2015, at 10:20 a.m., the CN stated there was a blood culture book in the ED that contained positive blood culture information, but they did not look at or hear about any other positive cultures.

The CN stated if the patient was discharged from the ED and a positive culture result (other than blood) was identified after discharge, she did not know what the process was, but the results were not called to or communicated with the ED.

During an interview with the Laboratory Medical Director (LMD) on May 11, 2015, at 10:25 a.m., the LMD stated the lab was not responsible for reporting non-critical results to the ED. He stated the lab did not report positive culture results, with the exception of blood cultures.

The LMD stated the ED physicians had the same responsibility as other physicians who ordered lab tests, and if they ordered the test, they were responsible for reviewing the results when they came in. The LMD stated, "They need to look for them."

During an interview with the Infection Control Practitioner (ICP) on May 11, 2015, at 10:40 a.m., the ICP stated she received a daily report of all positive cultures (blood, wound, urine, nares, stool) that were results for patients throughout the facility, including ED patients. The ICP stated she reviewed the ED patient's culture results for the purposes of reporting to Public Health, but she was not responsible for completing or overseeing the follow-up with the discharged patients.

A review of the Infection Control Positive Culture Worksheet indicated the following:

a. Patient 3, a 59 year old male, presented to the ED on April 24, 2015, with a foley catheter (tube in the bladder to drain urine) and complaints of abdominal pain. A urine test and culture were sent to the lab, the patient was diagnosed with a urinary tract infection, and discharged home with antibiotics.

Culture results, released on April 27, 2015, indicated Patient 3 had two different bacteria growing in his urine (escherichia coli and serratia marcescens), one that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 3 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

b. Patient 8, a 59 year old male, presented to the ED on May 2, 2015, with a foley catheter (tube in the bladder to drain urine) and complaints of groin pain following prostate surgery. The patient was evaluated and discharged home with diagnoses that included groin pain, urinary retention, and dehydration.

Patient 8 returned to the ED on May 3, 2015 (the following day), with complaints of pain when attempting to urinate. Urine was collected and sent for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, and orders to continue taking the medications he was currently on.

Culture results, released on May 5, 2015, indicated Patient 8 had bacteria growing in his urine (proteus mirabilis) that was resistant to multiple antibiotics.

The record for Patient 8 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

c. Patient 10, a 3 year old male, presented to the ED on May 2, 2015, with a history of urinary tract infection. His temperature was 103 degrees Fahrenheit. Urine was collected and sent to the lab for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, and prescribed antibiotics to treat the infection.

Culture results, released on May 4, 2015, indicated Patient 10 had bacteria growing in his urine (pseudomonas aeruginosa) that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 10 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the positive culture policy, completed in March 2015.

The EDMD stated, when there was a positive culture result, the lab was to notify the ED provider or CN, who would communicate the information to the ED mid level provider.

According to the EDMD, the mid level provider would review the information and the medical record, determine whether follow-up should be done, take appropriate action, then document the information in the EMR. The EDMD stated he was not aware the lab was not notifying the ED for positive culture results other than blood cultures.

According to the EDMD, no monitoring was being done to ensure the system put into place was being followed and was effective in providing continuity of care to patients.

The EDMD stated Patients 3 and 10 should have had follow-up care provided, and Patient 8's EMR should have been reviewed for consideration of whether follow-up care was necessary.

The facility policy titled, "Discrepancies, Radiological and Abnormal Cultures," was reviewed on May 11, 2015. The policy indicated the following:

A. The purpose was to establish a procedure for addressing abnormal culture results and radiology discrepancies;

B. Abnormal culture and/or sensitivity results and radiological interpretation discrepancies were to be communicated directly to the ED provider as soon as the results were available to ensure timely and appropriate follow-up and treatment;

C. If an x-ray was read by the radiologist and the result was different than the ED provider's reading, the patient would be contacted (if deemed necessary) by the ED provider;

D. If an abnormal culture and/or sensitivity result was obtained by the laboratory, the ED provider or Registered Nurse (RN) would be notified by the Laboratory Technician with the patient's name and results;

E. The ED provider would review the electronic medical record (EMR) to determine the treatment the patient received. If the treatment was appropriate, no further intervention would be required. If the treatment was not appropriate, the ED provider would contact the patient (by telephone, by mail, or by use of the police) and request that they return to the ED for further evaluation and/or treatment; and,

F. All activities would be documented in the EMR.

Based on interview and record review, the facility failed to ensure Emergency Services were integrated with Laboratory and Radiology services when:

1. Radiology discrepancies (differences) between the Emergency Department (ED) physician or teleradiologist (radiologist who reads studies on-line), and the facility radiologist were not reviewed to determine whether follow-up care was necessary and appropriate action was taken; and,

2. Urine and wound cultures/sensitivities (determination of bacteria present and effective antibiotic(s)) that were done in the ED and determined to be positive after the patient was discharged home were not reviewed to determine whether follow-up care was necessary and appropriate action was taken.

These failed practices resulted in:

1. Three patients with positive radiological findings not being notified to follow up with their physicians (Patients 9, 12, and 13), and the potential for life threatening radiological findings (fractures, tumors, aneurysms) to go untreated; and,

2. Improper treatment of three patients with infections (Patients 3, 8, and 10) with no follow up communication from the ED, and the potential for life threatening infections to go untreated.

Findings:

1. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated an on-line teleradiology group read the after hours x-rays (done after 7 p.m.). The director stated she did not know if the group read all x-rays or just the Computed Tomography (CT), Ultrasound (US), and Magnetic Resonance Imaging (MRI) studies. She stated the facility radiologist re-read x-rays the next day, but she did not know if all of the radiology procedures were re-read (those read by the teleradiology physician, those read by the ED physician, or both). According to the IDED, if there was a discrepancy between the original x-ray interpretation and the interpretation done by the facility radiologist, the facility radiologist would identify it, but she was, "not sure," what the process was for communicating and resolving x-ray discrepancies.

During a tour of the Radiology Department on May 11, 2015, at 9:25 a.m., accompanied by the Chief Radiology Technologist (CRT) and the Director of Imaging Services (DIS), the CRT stated the ED physicians read all plain films (x-rays) after 7 p.m. on weekdays and after 6 p.m. on weekends.

The CRT stated all CT, US, and MRI studies were read by a teleradiologist during those hours. According to the CRT, all after hours x-rays and radiology studies were re-read the following day by the facility radiologist. The CRT stated ED physicians were required to put their interpretation of the x-ray into the radiology computer system, and teleradiology physicians were required to scan their interpretation into the computer system, so the facility radiologist would be able to see if he/she agreed with the interpretation during the re-read.

The CRT stated if the facility radiologist's interpretation was different than that of the ED physician or the teleradiologist, a discrepancy would be logged in the radiology computer system on the, "discrepancy log."

A review of the discrepancy log on May 11, 2015, indicated hundreds of discrepancies were logged by the facility radiologists, with no evidence they were seen, reviewed, or acted on by the ED providers.

The DIS stated, if an ED physician failed to enter an interpretation of the x-ray into the radiology system, the radiologist would enter that as a discrepancy on the log. According to the DIS, many or all of the logged discrepancies could have been entered as a result of the ED physician failing to enter an interpretation, and may not reflect a positive finding or actual discrepancy.

The CRT stated if the discrepancy was addressed by the ED provider, there was no mechanism for the provider to indicate that on the log, and the discrepancy would not drop off of the log. According to the CRT, there was no way to know if any or all of the discrepancies had been addressed.

The CRT and the DIS stated they did not monitor the contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time). The CRT and the DIS stated monitoring of the process was not their responsibility, it was the responsibility of the ED.

During an interview with Radiologist 1 on May 11, 2015, at 9:40 a.m., the radiologist stated if he saw a discrepancy in the after hours reading of an x-ray or radiology study, he would enter it onto the discrepancy log. He stated if the discrepancy was, "significant," he would call the ED and speak to the provider about it in addition to entering it onto the log.

According to the radiologist, there was not always an interpretation entered into the system by the ED physician, so he had no way of knowing what the ED physician diagnosed the patient with or treated the patient for. The radiologist stated he attended the radiology medical staff committee meetings, and he did not recall any discussions of the radiology discrepancy process.

He stated he did not know if the process was being monitored for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

A review of the contents of the discrepancy log on May 11, 2015, indicated the following:

a. 11 of 11 after hours x-rays ordered by the ED physicians, and completed during the time the ED physicians were required to read them, did not have an initial interpretation documented in the radiology system. There was no mechanism for the facility radiologist to know what the ED physician diagnosed the patient with or treated the patient for.

All 11 interpretations by the facility radiologist were entered onto the discrepancy log in the absence of an initial interpretation by the ED physician. There was no evidence an ED provider reviewed the discrepancies to determine whether the ED physician diagnosed and treated the patients correctly;

b. Patient 9, an 8 year old male, presented to the ED on May 4, 2015, with complaints of fever with shortness of breath and nausea. A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:20 a.m.

The initial interpretation included right lower lobe infiltrates (pneumonia), splenomegaly (enlarged spleen), a normal appendix, and mesenteric adenitis (inflammation of the lymph nodes in the right side of the abdomen).

A radiology discrepancy report dictated at 8:31 a.m., indicated in addition to the above findings, the facility radiologist saw a masslike density in the right lower lobe of the lung as well as borderline enlargement of the appendix. The radiologist recommended the patient receive follow-up for both of these findings.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 9 indicated no documentation was present regarding the recommendations made by the facility radiologist.

c. Patient 12, a 64 year old female, presented to the ED on May 5, 2015, with complaints of back pain. A two view chest x-ray (CXR) was ordered by the ED physician and completed at 3:40 p.m. There was no initial interpretation completed by the ED physician.

Patient 12 was discharged home by the ED physician at 3:49 a.m., with a diagnosis of thoracic (middle back/chest) strain, and a prescription for a non-narcotic pain reliever.

A radiology discrepancy report dictated at 7:43 a.m., indicated Patient 12 had a 1 cm nodular density (mass) in the anterior chest area. The facility radiologist recommended a CT of the chest to further evaluate the finding.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 12 indicated no documentation was present regarding the recommen