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Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure emergency services policies were followed for one (#1) of ten patients sampled.

Findings included:

Review of the facility policy "Report Discrepancies" effective 4/2005, stated the designated emergency room physician will monitor the PACS discrepancy file for discrepancies and will note in PACS using the discrepancy follow-up indicator, if the discrepancy is clinically significant or not clinically significant. The designated Emergency Room physician and charge nurse will document the follow up the medical record as appropriate.

Review of the medical record for patient #1 revealed the patient arrived to the ED (Emergency Department) on 7/18/2016 for examination following a fall. Review of the ED physician's examination at 2:52 a.m. revealed the patient complained of left hip pain and left shoulder pain. Physician exam revealed left shoulder and hip diffuse pain with no deformity.

Documentation at 3:22 a.m. by the ED physician noted his interpretation of the left hip x-ray was negative. Documentation at 3:23 a.m. by the ED physician noted his interpretation of the left shoulder x-ray revealed a humeral head fracture with moderate displacement.

Review of the radiologist's dictated report dated 7/18/2016 at 5:52 a.m. of the left shoulder x-ray revealed a displaced fracture of the left humeral neck and a left subclavian venous port in place. Dictated at 5:53 a.m. the radiologist documented the left hip x-ray revealed an acute subcapital left femoral neck fracture.

Review of the medical record revealed the ED physician counseled the patient and family regarding the x-ray results, the plan of treatment to discharge home and the need for follow-up with the orthopedic physician in 1-2 days. Documentation revealed the patient was discharged on 7/18/2016 at 4:47 a.m.

Review of the medical record, on the date of survey, revealed no evidence of an addendum to the ED physician's documentation regarding the left hip x-ray discrepancy or the presence of a subclavian port. Review of the record revealed no evidence of patient follow-up or notification of the radiologist's findings on the left hip x-ray.

An interview was conducted on 8/08/2016 at approximately 3:15 p.m. with the Director of Patient Safety and Quality Outcomes, the Nursing Director of the ED and the Director of Imaging Services confirming the above findings.