HospitalInspections.org

Based on information gathered at the time of survey, the Critical Access Hospital (CAH) was determined not to be in compliance with the Condition of Participation: Provision of Services. The following regulatory violations included:

C - 0271 The CAH failed to assure that care and services were provided in accordance with currently established written policies and procedures regarding the provision of care provided by the Radiology Department.

C - 0283 The CAH failed to ensure Radiology services were provided in accordance with acceptable standards of practice during the provision of diagnostic imagery.

Based on observations, interviews and record review the CAH failed to ensure that care and services were provided in accordance with currently established written policies and procedures regarding the provision of care provided by the Radiology Department for 1 of 10 applicable patients. (Patient #1) Findings include:

Per review of Department of Radiology policy Patient Assessment (last reviewed/revised: 6/20/2018) "Policy: Patient assessment is made with the interdisciplinary approach of the physician, Nursing and Imaging Services to provide the most relevant information to allow for the optimum radiological exam and results. Procedure: Assessment of patients in the Radiology Department shall take place in the following manner whenever possible. 1. An order is required for all radiological procedures performed in the radiology department."

Despite the CAH's present policy & procedure, radiological technologists failed on 9/30/18 to take an interdisciplinary approach by consulting with the Emergency Department (ED) provider prior to changing an x-ray procedure. Per interview on 10/30/18 at 2:15 PM, the Director of Radiology - Imaging confirmed the wrong x-rays were taken by a radiology technologist on 9/30/18. Although the ED Provider had ordered 2 views of Patient #1's right humerus after the patient had sustained a fall from his/her bed, the radiology technologist failed to follow the provider's orders. Per interview on 10/31/18 at 4:20 PM the radiology technologist stated when Patient #1 arrived in the Radiology Department the patient complained of left arm pain, not right arm pain. Further discussion with another radiology technologist who was assisting with the x-rays, it was decided to disregard the ED provider's order to perform right humerus x-rays. Instead, x-rays of Patient #1's left humerus were performed. It was further confirmed, although it is not unusual for a radiology technologist to collaborate with ED physicians and/or Physician Assistants regarding adding an additional x-ray when it appears appropriate, it is not acceptable to change or disregard orders for any radiology testing without prior authorization, as per CAH policy. The radiology technologist confirmed after an assessment of the patient, s/he failed to consult with the ordering provider.

Based on observation, interview and record review, the CAH failed to ensure Radiology services were provided in accordance with acceptable standards of practice during the provision of diagnostic imagery for 1 applicable patient. (Patient #1) Findings include:

Per review of ED documentation, Patient #1 was brought to the ED on 9/30/18 at 09:30 after rolling out of bed at a Long Term Care (LTC) facility where the patient resides. The examination by the ED provider, a Physician Assistant (PA), noted Patient #1 was experiencing moderate pain, with a decreased range of motion and bruising of the right arm. An x-ray of Patient #1's right humerus (long bone in upper arm) was ordered by the ED provider. Patient #1 was brought to the Radiology Department and at 12:50 2 views were taken not of the patient's right humerus, but x-rays were taken of the left humerus. Subsequently, the ED provider viewed the x-rays, did not identify the discrepancy in what was ordered, visualized the x-rays as if they were of the patient's right humerus. The ED provider determined the x-rays demonstrated a deformity of Patient #1's humerus, however was diagnosing from views of the left humerus, not the right humerus. As a result, Patient #1's right arm was placed in a sling and the patient was returned to the LTC facility. In addition, it was further noted on 9/30/18 at 13:18 the ED physician also visualized the x-ray, failed to note it was the wrong extremity and agreed with the PA's interpretation that Patient #1 had a"...proximal humerus fracture". Both were unaware what they were visualizing was an old fracture and the wrong extremity.

On 10/2/18, after experiencing increased pain in the right arm with shortness of breath upon inspiration with associated chest pain, the LTC facility again sent Patient #1 to the ED for further evaluation and to rule out potential cardiac symptoms. Examination noted Patient #1's specific symptoms involved the anterior chest wall and anterior aspect of the right upper chest. What had been identified was Patient #1's x-rays taken on 9/30/18 were not of the patient's right humerus, as ordered, but of the left humerus. And it was further identified by the Radiologist, Patient #1 had evidence of a previous fracture of the left humerus, which is what the ED provider had also visualized on 9/30/18, however it was assumed the x-ray was actually of the right humerus as previously noted.

As a result, further x-rays of Patient #1's right ribs and chest were ordered by the ED provider. Cardiac and pulmonary diagnosis were ruled out, however x-rays demonstrated Patient #1 had fractures of the right third, fourth and fifth ribs and lateral right clavicle (collarbone). Pain medication was provided, and the patient was to continue to utilize the right sling, now for the treatment of the right clavicle fracture. Patient #1 was returned to the LTC facility.

Per interview on 10/30/18 at 2:15 PM, the Director of Radiology - Imaging confirmed the wrong x-rays were taken by a radiology technologist on 9/30/18. Reconfirming although the ED Provider had ordered 2 views of Patient #1's right humerus, the radiology technologist failed to follow the provider's orders. Per interview on 10/31/18 at 4:20 PM the radiology technologist stated when Patient #1 arrived in the Radiology Department s/he complained of pain in his/her left arm not the right arm. After further discussion with another radiology technologist who was assisting, a decision was made to disregard the ED provider's order to perform right humerus x-rays and instead x-ray images were taken of Patient #1's left humerus. It was further confirmed, although it is not unusual for a radiology technologist to collaborate with ED physicians and/or PAs regarding adding an additional x-ray image when it appears appropriate, it is not acceptable to change or disregard orders for any radiology testing without prior authorization.

Based on staff interview, observations of x-rays performed, and record review, there was a failure by ED providers and Radiologist to accurately identify the correct x-ray views associated with 1 of 10 applicable patients. (Patient #1) Findings include:

Per review of ED documentation, Patient #1 was brought to the ED on 9/30/18 at 09:30 after rolling out of bed at a LTC facility where the patient resides. The examination by the ED provider noted Patient #1 was experiencing moderate pain, with a decreased range of motion and bruising of the right arm. An x-ray of Patient #1's right humerus was ordered by the ED provider. Patient #1 was brought to the Radiology Department and at 12:50 2 views were taken not of the patient's right humerus, but x-rays were taken of the left humerus by radiology staff. Subsequently, the ED provider viewed the x-rays, did not identify the discrepancy in what was ordered, visualized the x-rays as if they were of the patient's right humerus. The ED provider determined the x-ray showed a deformity of Patient #1's humerus, however was diagnosing from views of the left humerus, not the right humerus. As a result, Patient #1's right arm was placed in a sling and the patient was returned to the LTC facility.

Upon further review on 10/30/18 of the x-ray films taken on 9/30/18 what was clearly noted was the letter "L" indicating the x-rays taken were of the left humerus, not of the Patient #1's right humerus. Per interview on 10/31/18 at 10:00 AM the ED PA, confirmed s/he failed to identify the "L" on the x-ray and discrepancy of what had been ordered as compared to what was actually viewed. Per record review it was further noted on 9/30/18 at 13:18 the ED physician also visualized the x-rays, failed to note the films were of the wrong extremity and agreed with the PA's interpretation that Patient #1 had a "...proximal humerus fracture". Both were unaware what they were visualizing was an old fracture and the wrong extremity.

In addition, as per CAH Radiology Department protocol, radiological tests read by other providers are also reviewed for accuracy by CAH's Radiologists. On 9/30/18 at 15:45 a "Final Report" was dictated by a Radiologist who correctly identifies the x-rays viewed to be of the left humerus, notes a deformity consistent with an old fracture. However, the Radiologist failed to recognize within the "Exam Information" that the "Body Part: R Humerus" and "Description: Humerus; right 2 views" was supposed to have been the intended x-rays images. Per interview on 10/31/18 at 1:50 PM the Radiologist confirmed "....it was my mistake" regarding the failure to recognize the discrepancy between the x-ray order and the films reviewed. Of note, the Radiologist completed an Addendum dated 10/4/18 which stated: " It should be noted that the request was for a right humeral series and the left humerus was imaged instead. There will be no charge for the left humeral series".

Based on observation, interview and record review, the Quality Assurance program failed to fully assess and evaluate concerns associated with incorrect x-rays images performed; failure of ED providers and Radiologist to identify the inaccuracy of x-rays images compared to provider's orders; the failure to assess the event for potential harm to a patient; and the failure to implement, in a timely manner, appropriate corrective actions to prevent further radiological adverse events. Findings include:

Per review of ED documentation, Patient #1 was brought to the ED on 9/30/18 at 09:30 after rolling out of bed at a LTC facility where the patient resides. The examination by the ED provider noted Patient #1 was experiencing moderate pain, with a decreased range of motion and bruising of the right arm. An x-ray of Patient #1's right humerus was ordered by the ED provider. Patient #1 was brought to the Radiology Department and at 12:50 2 views were taken not of the patient's right humerus, but x-rays were taken of the left humerus. Subsequently, the ED provider viewed the x-rays, did not identify the discrepancy in what was ordered, visualized the x-rays as if they were of the patient's right humerus. The ED provider determined the x-ray showed a deformity of Patient #1's humerus, however was diagnosing from views of the left humerus, not the right humerus. As a result, Patient #1's right arm was placed in a sling and the patient was returned to the LTC facility.

Upon further review on 10/30/18 of the x-ray films taken on 9/30/18 what was clearly noted was the letter "L" indicating the x-rays taken were of the left humerus, not of the Patient #1's right humerus. Per interview on 10/31/18 at 10:00 AM the ED PA confirmed s/he failed to identify the "L" on the x-rays and the discrepancy of what had been ordered as compared to what was actually viewed. Per record review it was further noted on 9/30/18 at 13:18 the ED physician also visualized the x-rays, failed to note the images were of the wrong extremity and agreed with the PA's interpretation that Patient #1 had "...proximal humerus fracture". Both were unaware what they were visualizing was an old fracture and the wrong extremity.

There was a failure within the SQSS (event reporting system) internal review to identify Patient #1 had experienced increased pain issues and required a second ED visit on 10/2/18. The internal review failed to recognize the significance of the issues associated with the wrong x-rays and incorrect interpretations by providers and the effects experienced by the patient.

In addition, there was a lack of follow-up to ensure the Radiology policies and procedures are consistently being followed by all radiological technologists. Ensuring an interdisciplinary approach is incorporated as needed. Per interview on 10/31/18 at 2:55 the Director for Quality Assurance agreed, the present internal review and action plan was not sufficient to assure the events associated with the wrong x-rays and interpretations were appropriately investigated and corrective actions initiated.