HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of five (5) medical records (MRs), the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program tracked, trended, and analyzed radiological misreads to identify opportunities for improvement.

Findings:

Review of Patient #4's MR identified that this patient walked into the Emergency Department (ED) on 12/16/2024 at 4:49 PM with a chief complaint of fall. X-rays of the right hand and right wrist, resulted at 7:51 PM, revealed no evidence of acute fractures in the right hand or wrist. A CT (Computed Tomography - medical imaging technique used to obtain internal images of the body) scan of the spine, resulted at 8:25 PM, revealed no acute fracture or traumatic malalignment of the spine. The patient was discharged at 10:00 PM.

Review of the Complaints and Grievances List, dated from 09/01/2024 to 02/23/2025, revealed that Patient #4's spouse submitted a grievance to the facility on 01/22/2025. The grievance alleged that Patient #4 received a MRI (Magnetic Resonance Image) at another facility which revealed a fracture of the spine and right wrist, and that a rigid neck collar had been ordered for the patient.

During interview of Staff J-1 (Radiologist) on 02/25/2025 at 1:56 PM, Staff J-1 shared images of Patient #4's radiological studies. Staff J-1 confirmed that the CT scan of Patient #4's spine had been misread, and that the image revealed a hairline fracture that was not initially identified.

During interview of Staff K-1 (Radiologist) on 02/25/2025 at 2:15PM, Staff K-1 acknowledged that they had misread Patient #4's right hand and wrist X-ray.

Review of the facility's Radiology Policy titled, "Reportable Events Reporting," last reviewed 02/2023, revealed that the policy does not address radiology misreads.

During interview of Staff L-1 (Administrator) on 02/26/2025 at 11:01 AM, Staff L-1 confirmed that Patient #4's radiological images had been misread, and that they had conversations with the involved radiologists about the misinterpretations.

Review of the ED QAPI Meeting Minutes, dated from 01/2025 to 02/2025, identified no documented evidence that the hospital tracked, trended, nor analyzed radiology misreads to identify opportunities for improvement.

On 02/27/2025 at 1:49PM, a request was made for the ED Radiology Department Meeting Minutes. A second request was made on 03/04/2025. Electronic mail from Staff P-1 (Director) dated 03/04/2027 at 10:48 AM revealed, " ...radiology does not keep minutes for case review meetings/QA meetings based on advice of counsel."

During re-interview of Staff L-1 on 02/27/2025 at 2:13 PM, Staff L-1 confirmed the facility did not have a process of tracking, trending, and analyzing radiology misreads.

These findings were shared with Staff Z-1 (Administrator), Staff A-2 (Administrator), and Staff B2 (Administrator) during the Exit Conference on 03/04/2025 at 3:45 PM.