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Based on clinical record review, review of the Medical Staff Bylaw Rules and Regulations and interviews for 1 of 4 patients (Patient #3) under the care of a resident physician, the medical staff failed to ensure that attending physicians signed and dated the resident physician progress notes in a timely manner, per policy. The finding includes:

Patient #3 was admitted to the hospital on 8/20/15 secondary to experiencing an extended period of abdominal pain and diarrhea. The patient underwent a right hemicolectomy and small bowel resection with a liver biopsy on 8/26/15 secondary to a partially obstructive right colon tumor. Review of resident physician MD #7's CCU surgery progress note dated 8/29/15 at 10:11 AM identified that the attending surgeon (MD #3) failed to sign the Attending Physician Attestation until 10/15/15. A discharge summary and interagency transfer document dated 9/6/15 was completed by resident physician MD #18 and the attending surgeon (MD #3) failed to sign the Attending Physician Attestation until 10/15/15.

The physician progress notes were reviewed with the VP of Quality/CNO on 10/24/16 at 2:55 PM and identified that resident physician notes should be reviewed and signed by an attending physician within an acceptable time frame, in accordance with Medical Records policy.

According to the Medical Staff Bylaw Rules and Regulations, the attending physician's responsibility includes care, treatment and coordination of care with prompt completeness and accuracy of the patient's medical record.

According to the hospital's General Surgery Residency Supervision and Lines of Responsibility, all surgical patients have an attending surgeon who with the assigned resident physicians round on each patient at least once daily and is responsible for the patient's condition, progress, orders and clinical management programs.

The condition for Radiologic Services has not been met. Based on clinical record reviews, interviews, review of hospital and radiology department policies and documentation for 4 of 11 patient records reviewed (Patient's #3, 19, 24, 25), the Radiology Department failed to ensure that radiographic tests were authenticated, read, and/or interpreted timely and/or failed to ensure that critical radiology test results were communicated to the appropriate staff in a timely manner and/or failed to document that the appropriate level of staff were notified resulting in a delay in treatment for Patient #3. The findings includes:

Please see A 529

Based on clinical record reviews, interviews, review of hospital and radiology department policies and documentation for 4 of 11 patient records reviewed (Patient's #3, 19, 24, 25), the radiology department failed to ensure that radiographic tests were authenticated, read, and/or interpreted timely and/or failed to ensure that critical radiology test results were communicated to the appropriate staff in a timely manner and/or failed to document that the appropriate level of staff were notified. The findings includes:

a. Patient #3 was admitted to the hospital on 8/20/15 due to prolonged abdominal pain and diarrhea, and had terminal diagnoses of ascending colon carcinoma with hepatic metastases. Patient #3 was alert, oriented and ambulatory with assistance. On 8/26/15 Patient #3 underwent a liver biopsy and a palliative right hemicolectomy due to a partial obstruction caused by a colon tumor. During the procedure, Patient #3 was noted to have significant adhesions and required a small bowel resection to repair a surgical small bowel perforation. Patient #3 recovered in the Critical Care Unit (CCU) until being transferred to a surgical unit on 8/29/15. Review of the nursing documentation dated 8/29/15 at 3:30 PM identified that RN #4 notified MD #3 (attending surgeon) that Patient #3 complained of severe pain in the abdomen. Pain medication was increased with good effect. In addition, on 8/29/15 at 8:30 PM Patient #3 had a temperature of 100.7 which was reported by RN #4 to MD #4 (surgical resident).

Review of physician progress notes by MD #3 dated 8/30/15 at 1:13 AM identified that Patient #3 was evaluated for pain, additional pain medication was ordered, and the patient was "still with ileus". MD #3 identified to continue with supportive management.

A routine scheduled chest X-ray (CXR) was obtained on 8/30/15 at 4:58 AM per physician order, which identified "free intraperitoneal air suggesting bowel perforation". Review of the CXR report identified that it was authenticated by Radiologist #15 on 8/30/15 at 10:58, finalized at 11:01 AM, and the "floor notified by phone" (time unknown). The CXR report failed to reflect that a physician or the patient care unit RN was notified of the critical radiological test result of free air, per policy.

Review of the clinical record dated 8/30/15 from 11:00 AM to 3:00 PM failed to identify that the results of Patient #3's CXR were communicated to appropriate staff and were not acted upon.

Review of RN #3's nursing documentation dated 8/30/15 at 3:00 PM identified that Patient #3's labs and chest x-ray reported to residents (resident physicians).

Review of RN #4's nursing documentation dated 8/30/15 at 3:15 PM identified that RN #4 notified MD #5 of "AM lab results/CXR results" - free air suggestive of bowel perforation and a right pleural effusion. Additionally, RN #4's nursing documentation dated 8/30/15 further identified that Patient #3 complained of burning pain in the abdomen and additional laboratory blood work was communicated to MD #6 (Chief Resident).

Review of physician orders dated 8/30/15 identified that at 4:50 PM STAT laboratory blood testing and type and screen (blood Bank) were ordered by MD #6. MD #6 then ordered an abdominal (KUB) radiological test 5:15 PM to rule out free air. The KUB report dated 8/30/16 at 5:50 PM confirmed free intraperitoneal air located below the diaphragm.

Patient #3 was taken to the operating room emergently on 8/30/15 by 6:30 PM for an exploratory laparotomy due to the presence of free air under the diaphragm. Operative notes dated 8/30/15 identified that a small bowel perforation was found in an area of adhesions near the site of the 8/26/15 perforation. During the procedure purulent fluid was noted in the right lower quadrant of the abdomen necessitating an abdominal wash-out, partial small and large bowel obstructions were noted, and large serosal tears required resection. Following the surgical procedures Patient #3 was admitted to the CCU in critical condition and on a ventilator. Between 8/31/15 and 9/6/15 Patient #3 was treated for septic shock and remained on the ventilator. On 9/6/15, following discussion with family, Patient #3 was removed from the ventilator and placed under hospice care.

Radiologist #15 who authenticated/read/ interpreted Patient #3's chest x-ray on 8/30/15 at 4:58 AM is no longer working at the hospital and was unavailable for interview.

Interview with the Chief of Radiology on 10/24/16 at 12:45 PM identified that routine orders are mostly read/interpreted within 2-3 hours but in general, it can be up to 24 hours. The timing of the read is dependent on how it is ordered, as "STAT" orders are read first. Those ordered as routine or "timed" are read throughout the day. The Chief of Radiology identified that a critical value (such as free air) would not be identified until the X-ray was read. Once known, then the Radiologist would attempt to contact the ordering physician. In regards to Patient #3, the expectation would be that Radiologist #15 or designee communicated directly to a physician or RN involved in the care of Patient #3 once the free air was identified, per policy.

Interview with the Clinical Director of Quality (MD #16 on 9/6/16 at approximately 1:45 PM identified that the radiology computerized system documentation identified that a call was made by radiology Clerical Staff (CS) #1 to CS #2 on the patient's surgical unit on 8/30/15 at 10:58 AM.

Interview with CS #2 on 9/6/16 at 2:15 PM identified that he/she had no recall of taking such a call, however, stated he/she would "get the patient's nurse" (RN #3) if he/she had taken such a call.

Interview with RN #3 on 9/6/16 at approximately 2:25 PM, identified that he/she did not recall receiving notification of Patient #3's CXR results. However, if he/she had, he/she would have immediately notified the Resident Physician.

Interviews with MD's #4, #5 and #7 (resident physicians) identified that none of the physician's recalled being alerted to this radiology critical value on 8/30/15.

Interview with MD #3 (attending surgeon) on 9/6/16 at 12:30 PM identified that he/she saw the patient in the early morning of 8/30/15 and was not made aware of the CXR results of free intraperitoneal air until notified by MD #6 sometime between 1:00 PM and 5:00 PM.

Interview with RN #4 (3-11 shift RN) on 9/16/16 at 1:00 PM identified that he/she became aware of Patient #3's CXR and laboratory results at 3:15 PM and reported them to MD #5.

Interview with MD #6 (third year resident at the time) on 9/7/16 at 2:05 PM, identified that he/she did not recall who called him or the time of the call to tell him about Patient #3's abnormal CXR. However, to confirm that finding, he/she ordered an immediate (STAT) abdominal (KUB) x-ray to verify the finding, which did confirm free intraperitoneal air located below the diaphragm. MD #6 stated that once verified, the attending surgeon was notified and Patient #3 was taken to surgery.

A Department of Radiology policy for critical test results in effect in 2015 identified that once critical values (free air) are found by a radiologist, the radiologist or the office clerical staff will contact the ordering/referring or covering physician, within one hour.


b. Patient #19 was admitted through the emergency department on 9/24/16 with shortness of breath and recent diagnoses of A-Fib, cardiomegaly, fluid overload and was transferred to the critical care unit. On 9/25/16 at 5:55 PM a physician ordered a routine CTA (computed tomography angiography) of the chest secondary to "patient has pleuritic chest pain concerning for PE" (pulmonary embolism). The CTA of the chest was completed at 9:18 PM. The report was not authenticated and finalized until 9/26/16 at 5:24 AM (8 hours later). Review of the CTA report findings/impression identified numerous bilateral pulmonary emboli (PE) within distal main pulmonary arteries as well as within bilateral segmental and sub-segmental pulmonary arterial emboli and ground-glass opacity within the right middle lobe that may be secondary to pulmonary infarct versus inflammatory or infectious process. Review of the CTA report failed to identify that the radiologist contacted the ordering physician to report the critical value finding, per policy.
Review of nurse's notes dated 9/25/16 at 10:20 PM identified that a radiologist called to report the results of the CTA as bilateral diffuse PE's. Although the results were reported to MD #17, review of physician progress notes dated 9/25/16 failed to identify/document the CTA critical value findings and failed to identify if a change in treatment was warranted.
On 9/26/16 at 8:18 AM (10 hours later) the results of the CTA are identified in a physician progress note as unprovoked PE's requiring continued anticoagulation therapy and need for further evaluation to assess for acquired versus inherited thrombophilia.
Correspondence with MD #17 on 10/24/16 identified that the patient was receiving appropriate medical care, there was no change in clinical status, and there was no need to address this in an interval progress note.
Interview with the Chief of Radiology on 10/24/16 at 12:45 PM identified that in review of Patient #19's CTA report, he/she was unable to tell if the CTA results were communicated to another MD or RN.


c. Patient #24 was treated in the emergency department on 9/8/16 post fall at home resulting in a head injury. The patient was taken to the operating room emergently to treat a large left subdural hematoma with a significant midline shift. In addition, a CTA of the chest was performed on 9/8/16 at 11:51 AM that identified bilateral pulmonary emboli. Although the report identified that "findings discussed with [staff first name] from the E.R.", the report did not document that the ordering physician was notified of this critical value, per hospital policy. On 9/12/16 at 5:47 AM a physician's order was placed for a CXR for suspected pneumothorax which was completed at 5:56 AM and authenticated at 12:54 PM (more than 6 hours later). Review of the CXR report identified a "small to moderate size" right pneumothorax and that a "message of the findings was left with [staff first name] from CCU". However, the report did not document that the ordering physician was notified of this critical value, per hospital policy.
Interview with the Chief of Radiology on 10/24/16 at 12:45 PM identified that in review of Patient #24's CTA report, he/she was unable to tell if the CTA results were communicated to another MD or RN.


d. Patient #25 was treated in the emergency department on 9/8/16 for complaints of shortness of breath and leg pain. A physician's order dated 9/8/16 at 10:39 AM requested a CTA of the chest secondary to the shortness of breath. The CTA was completed at 11:51 AM and identified bilateral pulmonary emboli. The report identified that "findings were discussed with [staff first name] from the E. R." however, failed to reflect that the ordering physician had been notified of the critical value, per policy.
Patient #25 was admitted to the hospital for treatment of deep vein thrombosis and bilateral pulmonary emboli. Heparin protocol was initiated.
Interview with the Chief of Radiology on 10/24/16 at 12:45 PM identified that in review of Patient #25's CTA report, he/she was unable to tell if the CTA results were communicated to another MD or RN.