HospitalInspections.org

Based on record review, staff interview, review of hospital administrative documents and review of facility policies and procedures, the facility failed to provide diagnostic radiology services in a safe setting.
One (1) of 1 sampled pediatric patients (Patient 1) was found to have a fracture of the right proximal humerus (top of the arm near the shoulder socket) after having a portable chest X-ray completed by 2 radiology technologists on 9/4/2010.
Patient 1's parent also voiced concerns to the hospital staff immediately after the X-ray was completed about how Patient 1 was handled by the radiology technologists when positioning patient for the X-ray.
As of 9/13/2010, the facility had not completed a timely investigation or root cause analysis regarding the patient injury incident leaving other patients at risk for the same type of incident to occur again.
These findings placed all pediatric patients receiving radiology services in Immediate Jeopardy. After conferring with CMS (Centers for Medicare & Medicaid Services) the hospital Administrative Staff were notified of the determination of Immediate Jeopardy on 9/13/10 at 1:45 PM. The facility census on 9/13/10 was 184 with 3 pediatric patients. The Radiology Department performed the following numbers of procedures on pediatric patients (individuals 18 years and younger): July 2010-467; August 2010-461; and September 1-13, 2010-176.
See A0144 for more details.

Based on record review, staff interview, review of hospital administrative documents and review of facility policies and procedures, the facility failed to provide diagnostic radiology services in a safe setting. One (1) of 1 sampled pediatric patients (Patient 1) was found to have a fracture of the right proximal humerus (top of the arm near the shoulder socket) after having a portable chest X-ray completed by 2 radiology technologists on 9/4/2010.
Patient 1's parent also voiced concerns to the hospital staff immediately after the X-ray was completed about how Patient 1 was handled by the radiology technologists when positioning patient for the X-ray. As of 9/13/10, the facility had not completed an investigation or root cause analysis regarding the patient injury incident leaving other patients at risk for the same type of incident to occur again.
These findings placed all pediatric patients receiving radiology services in Immediate Jeopardy. After conferring with CMS (Centers for Medicare & Medicaid Services) the hospital Administrative Staff were notified of the determination of Immediate Jeopardy on 9/13/10 at 1:45 PM. The facility census on 9/13/10 was 184 with 3 pediatric patients. The Radiology Department performed the following numbers of procedures on pediatric patients (individuals 18 years and younger): July 2010-467; August 2010-461; and September 1-13, 2010-176.

Findings are:
A. Review of the document titled Incident Reporting Information System revealed that on 9/4/10 Patient 1 was having a portable chest X-ray and Patient 1's mother came to the nursing station upset because she offered to help hold the child for the X-ray and was told by the radiology technologists that they did not need her help. After the X-ray was completed Patient 1's mother called the nurse into the room stating she is really upset and picks up patient's right arm and when she lets go it drops to the bed, she then raises the arm above patient's head and patient starts crying. The mother stated that the radiology technologist pulled the patient's arm to move patient from one side of the crib to the other and was also rough with him during the X-ray.

B. Review of Patient 1's medical record showed the following:
Review of H&P (history and physical examination) for Patient 1 revealed patient was admitted to the hospital on 9/2/10 for vomiting and fever. The H & P also revealed that this 2 year old had a very complex medical history with diagnoses of hydrocephalus (build up of fluid inside the skull), seizure disorder, hypothyroidism (condition where your thyroid gland does not produce enough of certain important hormones), developmental delays, dysphagia (difficulty swallowing). Patient 1 was admitted because of progressive vomiting as well as a low-grade fever and treated with intravenous antibiotics for possible aspiration pneumonia.

Review of portable chest X-ray reports dated 9/2/10 and 9/3/10 gave impressions for findings only related to the lungs and heart. However, the X-ray report for 9/4/10 at 10:30 AM noted an "irregularity is questioned of the proximal right humerus. Dedicated three views of the right shoulder recommended to further evaluate the findings". Review of the follow up right shoulder X-ray report dated 9/4/10 revealed the following findings "Slightly impacted proximal humerus fracture. Bones appear osteopenic " [when bones get thin or lose density].

Review of nurses notes dated 9/4/10 at 10:30 PM revealed Patient 1's father was at the hospital "to speak with the person who was involved in the chest X-ray that resulted in his child's arm being broken".

Review of physician progress note dated 9/4/10 at 10:30 AM revealed the physician came to see the patient because of concern with "rough handling" during a chest X-ray causing decreased use of and pain in right arm with movement. Physician's order was for right shoulder X-ray with 3 views to "ensure no fx" (fracture).

C. Interview on 9/13/10 from 10:15 AM to 11:00 AM with RN-C (Registered Nurse-C responsible for the care of Patient 1 on 9/4/10) revealed the following concerning the incident when Patient 1 sustained a fractured humerus:
-Mom came to nurses desk while the radiology technologists were taking chest X-rays and indicated that they did not want her assistance;
-When the procedure was finished the Mom went back into the room;
-Mom came back out of the room and was upset and wanted to show RN-C something;
-Mom said "look at this" and lifted Patient 1's right arm and let it go and the arm dropped, also lifted the right arm up midway towards head and Patient 1 started crying;
-Since physician was still on the pediatric unit RN-C asked the physician to look at Patient 1 which resulted in the order for X-ray of the shoulder.

D. Interview with RT-A on 9/13/10 from 12:45 PM to 1:20 PM revealed the following concerning the taking of the portable chest X-ray for Patient 1 on 9/4/10:
-Went to take chest X-ray around 10:00 AM with RT-B;
-Mom was in room with Patient 1;
-Asked Mom if Patient 1 had any restrictions on arm movement and was told no but Mom said that child would not like it;
-Both RT-A and RT-B put on lead aprons;
-When positioning Patient 1, patient would arch back and pull arms down;
-Mom stepped out of room for a short time then came back in;
-While trying to position Patient 1 for the lateral, lead apron slid off RT-A's shoulder;
-Patient 1's Mom asked if she could help;
-RT-A said no because there were no more lead aprons;
-Mom did assist by picking child up in between X-rays and by repositioning the feeding tube;
-After they finished taking X-rays Mom picked child up and child was a little fussy but not bending and arching like at the beginning.

Interview with RT-B on 9/13/10 from 12:00 Noon to 12:40 PM revealed this additional information:
-Children around age 2 do not like to be put in position for chest x-rays;
-Patient 1 had to be repositioned about 8 times, because of squirming and twisting which is not unusual;
-Patient 1 seemed very strong;
-Have done x-rays that way many times;
-There was no indication to them that patient was hurt when they left the room.

E. Review of the policy and procedure titled Ethics/Patient Rights with last revision date of 10/07 revealed that the patient and/or person who has legal responsibility to make decisions have the right to:
-Participate in the development and implementation of your plan of care; and
-Considerate and respectful care, provided in a safe environment.
Patient 1's rights were violated when Mother was not allowed to help with holding the patient during a chest X-ray.

Review of the policy and procedure titled Holding Patients During Radiation Exposure with a last reviewed date of December 2009 revealed the following procedure:
"If a human holder must be used...Choose a person to hold the patient or film who is not a radiation worker, who is at least 18 years of age, and is certain that there is no chance of being pregnant...No unintended portion of the patient's body nor any portion of the person holding the patient or film shall be struck by the primary radiation beam unless protected by...lead shielding." RT-A and RT-B failed to follow this policy and procedure by not having a non-radiation worker holding the patient.

Review of the policy and procedure titled Unanticipated Outcomes of Care - Policy with a last reviewed date of November 2009 revealed this definition for an Unanticipated Outcome of Care was: "A result that causes patient harm and that differs from what was expected to occur following a treatment, medical or surgical procedure, or other intervention." The policy also states that "...staff involved in any potential incident of mistreatment, abuse or neglect, will be removed from direct patient care until the investigation is complete." Facility staff failed to remove the radiology technologists from direct patient care following this incident until an investigation was complete. The documentation in the nurses notes and the Incident Reporting Information System document alleged "rough handling" of Patient 1 i.e. potential mistreatment of this patient.

F. Interview on 9/13/10 at 11:05 AM with the RN House Supervisor-D on duty on 9/4/10 revealed being notified of the incident with Patient 1 by RT-A. During interview RN house Supervisor-D indicated knowing that the policy is to suspend staff pending an investigation if a patient is injured by staff; however, did not think of this as abuse and not intentional so no one brought up suspension. Interview with the Administrator on Call (Administrator - E) on 9/13/10 at 10:15 AM revealed it "did not occur to me to suspend employees".

Interview with the Director of Performance Improvement, Director of Radiology, Vice President of Ancillary Services and the Director of Pediatrics on 9/13/10 from 9:45 AM to 10:15 PM revealed that a mini root cause analysis (RCA) was completed at the time of the incident with Patient 1's father and staff. Consensus from this group was that the Radiology Technologists should have let Patient 1's mother help with positioning during the X-ray. Director of Performance Improvement, during this interview indicated that they are getting ready to call the mother and to complete a full RCA (9 days after the incident happened). When asked what changes have been made since this incident the response was "not a lot other than discussion" with the 2 Radiology Technologists. On 9/13/10 RT-A and RT-B involved in the incident were still working even though no additional training or competency testing had been completed and no additional education and training had been provided to the House Supervisor or the Administrator on Call regarding placing staff on Administrative Leave if any mistreatment/abuse/neglect even suspected. The facility had failed to complete a full investigation/root cause analysis and enact any necessay changes thus placing all pediatric patients receiving radiology services in Immediate Jeopardy.

G. The facility developed a new Action Plan to address the Immediate Jeopardy conditions on 9/13/10. The Action Plan included: placing Radiology Technologists A and B on Administrative Leave until completion of competency regarding safe patient handling and patient rights; House Supervisor to complete education on placing staff on Administrative Leave if any mistreatment/abuse/neglect is even suspected as outlined in the facility policy and education on patient rights; plan to immediately complete a full RCA (root cause analysis) and identify further elements for Action Plan. The Immediate Jeopardy was abated on 9/13/10 at 3:30 PM.