HospitalInspections.org

Based on record review and interview, the hospital failed to provide the patient care in a safe setting, in that, Patient #1 sustained a humerus fracture during an x-ray series in the Radiology Department on 8/20/14.

Findings Included

The 8/20/14 "Multidisciplinary progress note" for Patient #1 reflected, "Apparently while undergoing his shunt series today, his right upper extremity was being placed to assist with imaging...right humerus was fractured when his arm was raised above his head..."

The outpatient radiology order from the doctor did not identify and/or alert the radiology staff of the patient's osteopenic condition.

During an interview on 10/10/14 at 2:40 PM, Personnel #4 was asked about the events that led up to the 8/20/14 injury. Personnel #4 stated, "I gave instructions to the caregiver that we had to position his arms above his head. We moved the patient's arms and then heard a popping noise."

The November 2011 "Patient/Family Rights and Responsibilities" reflected, "TSRHC promotes considerate, respectful and safe care..."

Based on record review and interview, the hospital failed to complete Performance Improvement actions including analysis of medical errors and adverse patient events which affected patient safety and implement preventive actions, in that, preventative actions were not identified and implemented after the injury to Patient #1 during an x-ray series on 8/20/14 where Patient #1 sustained a broken humerus.

Findings Included


The 8/20/14 "Multidisciplinary progress note" for Patient #1 reflected, "Apparently while undergoing his shunt series today, his right upper extremity was being placed to assist with imaging...right humerus was fractured when his arm was raised above his head..."

The 8/20/14 incident report described the injury to Patient #1, follow-up x-rays and treatment by Physician #1. The report was signed by a Quality representative on 9/16/14 as received.

During an interview on 10/10/14 at 12:38 PM, Personnel #1 said she found the staff meeting minutes but, there was no indication of education and was unable to find any other documentation for the department.

During an interview on 10/13/14 at 9:25 AM, Personnel #3 was asked about any Department education or changes following the injury to Patient #1. Personnel #3 stated, "I was not at the August meeting. I was at the September meeting but, not as far as I know."

The June 2014 "Incident Reporting and Risk Management Review" required, "To identify, investigate, and analyze incidents...identify root cause...assuring appropriate follow-up action...Formulating and implementing corrective actions...Tracking and trending aggregate information to support Hospital wide Performance Improvement and Safety activities..."