HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that radiological services met the needs of patients in accordance with policy concerning performance of an exam in a timely manner, notifications of a delay in the start of a procedure and notification regarding a critical finding in one of five sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed.

A nurse's note of 10/31/23 at 6:00 PM by RN-A read: "Spoke with (Physician-A - pulmonologist), per (Physician-B - orthopedic)'s order. Order for arterial doppler of left lower extremity ordered." The medical record revealed that this order was placed on 10/31/23 at 6:00 PM by Physician-A as STAT. Medical record documentation revealed that the doppler exam started at 7:10 PM and ended at 7:16 PM on 10/31/23. Thus, the test was started one hour and 10 minutes after it was ordered.

Regarding the facility definition of STAT, a review of facility policy Critical Values Reporting revealed the following: "The target time for completion of: STAT: 30 minutes from received time." Thus, a test should begin within 30 minutes of the order. Since the doppler exam did not start within 30 minutes of the order, the facility was in violation of this policy.

The policy continued: "If any testing delays are anticipated, the floors shall be notified via email to the directors. A person shall be assigned to call all the floors and the message shall be conveyed to the Supervisor in Charge. The House Supervisor shall be notified also." There was no documentation in the medical record indicating that any notifications were made in light of the delay in accordance with policy. During an interview with the Director of Quality on 11/21/23 at 4:44 PM, she said that no notifications of a delay had been made. Thus, the facility was not in compliance with the expectations for notification.

A nurse's note of 10/31/28 at 8:58 PM by RN-B read: "8:58 PM (Physician-C - pulmonologist) return call, still no results of venous doppler since personal of the same refers didn't seen no flow, patient at the moment hemodynamically stable, no bleeding seen at the moment. If results come back and any occlusion or hemodynamic changes call him back. Patient will be under observation monitoring pulses."

The report for Ultrasound - Dup LE (lower extremity) ART (arterial) UNI (unilateral)/LTD (limited) of 10/31/23 at 9:42 PM read: "Impression: Markedly limited evaluation due to recent surgery. Sonographer unable to scan from left common femoral artery to the popliteal artery. Doppler flow not detected in the left peroneal, posterior tibial or dorsalis pedis arteries."

There was no note indicating that the interpreting physician called anyone regarding these findings. The policy mentioned above stated: "Some discretion is required in identifying a critical result, defined as a significant and unexpected finding which warrants an immediate change in the treatment plan, and identified by a radiologist. He/she shall: (1) Immediately notify the referring/ordering physician. If the physician is not available, the radiologist shall provide the results to the licensed personnel responsible for the care of the patient (i.e., charge nurse, nurse caring for the patient." Also: "Definition(s): 'Critical Result' Finding: Diagnosis and/or condition that could a) seriously danger the patient's health or the health of her unborn child; b) cause any loss of normal body functions; or c) cause serious injury to an organ or body part. Examples include, but not limited to, the following: . . . Acute Arterial Vascular Occlusion." The findings as stated can be seen as meeting the definition of acute arterial vascular occlusion.

There was no documentation in the medical record indicating that the radiologist made any calls in response to the finding of a critical result, as required in the policy.

A nurse's note of 11/1/23 at 2:10 AM RN-B read: "02:00 AM pulse & site assessment done. Unable to palpate pedal or dorsalis pedis pulses palpable or on Hel Doppler. Following up arterial doppler report to follow up with (Physician-C - pulmonologist)."

A nurse's note of 11/1/23 at 2:17 AM by RN-B read: "I proceed to call (Physician-C - pulmonologist) notify results of Arterial Peripheral Doppler which called back and order to start a heparin drip low dose no bolus." This was the first indication of physician awareness of the ultrasound report findings of 9:42 PM.

During an interview of the Director of Quality on 11/21/23 at approximately 5:00 PM, she confirmed the preceding.