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Based on a review of hospital policies, and interviews with staff, the Governing Body failed to ensure the accountability of medical staff for the quality of care provided to patients by ensuring that documented test results were available to practitioners in order to avoid miscommunication between practitioners and render timely emergency medical treatment. The findings include:

On 7/31/10, Patient #2 was admitted to the Emergency Department with a left knee dislocation with injuries to the nerves and vascular systems. An angiogram was performed and interpreted by Radiology staff. Radiology staff identified that they discussed the results of the angiogram by telephone with a physician in the emergency department. However, each practitioner identified differing versions of what the reported angiogram results were. Patient #2 was treated for vasospasm, but was later diagnosed with a 4 cm occlusion of the left popliteal vein, which differed from the preliminary impression. Patient #2 was emergently taken to the operating room on 7/31/10 at 11:19 AM (about 7 hours after the angiogram), and underwent a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy.

Patient #2 ' s clinical record was reviewed with MD #9,Vice President of Risk Management (VP Risk) on 3/3/11 at 12:55 PM. The clinical record failed to include documentation of Resident #1 ' s preliminary angiogram findings. MD #9 identified that Patient #2's preliminary angiogram results were not documented in the Radiology Department or in any other hospital documentation. According to Hospital policy, preliminary radiological findings were to be documented on a consult form and faxed to the Emergency Department. However, interview with MD #6 (Chairman of Radiology) on 3/3/11 at 2 PM identified that members of the Department of Radiology do not document preliminary results of tests. Interviews with MD #9 and MD #10 (Chief of the Medical Staff) on 3/3/11 at 12:55 PM and again on 3/22/11 at 2:55 PM identified that the documentation of preliminary radiological results continued to be an identified problem in the hospital.

Please refer to A49, A528, and A529

Based on a review of hospital policies, and interviews with staff, the Governing Body failed to ensure the accountability of medical staff for the quality of care provided to patients by ensuring that documented test results were available to practitioners in order to avoid miscommunication between practitioners and render timely emergency medical treatment. The findings include:

a. Patient #2 was admitted to the Emergency Department on 7/31/10 with a left knee dislocation with injuries to the nerves and vascular systems. An angiogram was performed and interpreted by a Radiological Resident (Resident #1). Although MD #1 (Emergency Medicine) and Resident #1 identified that they discussed the results of the angiogram by telephone, each practitioner identified differing versions of what the reported angiogram results were. Interview with Radiology Resident #1 on 3/21/11 at 10:02 AM identified that he/she verbally reported occlusion of the popliteal artery, uncertain underlying etiology, question of underlying clot, arterial dissection, or vasospasm. Interview with MD #1 on 3/21/11 at 2 PM identified that when he/she discussed the results with Resident #1, he/she did not recall the Resident mentioning occlusion, but that based on the patient ' s symptoms, the findings could be consistent with spasm. Patient #2 ' s clinical record was reviewed with MD #9 (VP of Risk) on 3/3/11 at 12:55 PM. The clinical record failed to include documentation of Resident #1 ' s preliminary angiogram findings. MD #9 identified that Patient #2's preliminary angiogram results were not documented in the Radiology Department or in any other hospital documentation.

Multiple medical services were involved in the emergency management of Patient #2 (Physicians of Emergency Medicine, Orthopedics, and Vascular Surgery as well as a Surgical Resident and an Orthopedic Physician's Assistant). Each Physician and Resident based their treatment decisions on MD #1 and Resident #1 ' s verbal report of Patient #2's angiogram. Approximately 6 1/2 hours later, Radiologist #1 (with the assistance of an Interventional Radiologist) identified that Patient #2 had a 4 cm occlusion of the left popliteal vein, which differed from the preliminary impression. Patient #2 was emergently taken to the operating room on 7/31/10 at 11:19 AM (about 7 hours after the angiogram), and underwent a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy. Interview with MD #3 (Vascular Surgeon) on 3/21/11 at 9:30 AM identified that he/she was notified that Patient #2's angiogram identified an arterial spasm, and was treated accordingly. MD #3 identified that if he/she had been notified that the angiogram identified possible occlusion, he/she would have surgically intervened immediately, possibly improving Patient #2's outcome by averting or alleviating the multiple medical complications that the patient experienced.

According to Hospital policy, preliminary radiological findings were to be documented on a consult form and faxed to the Emergency Department. However, interview with MD #6 (Chairman of Radiology) on 3/3/11 at 2 PM identified that members of the Department of Radiology do not document preliminary results of tests. Interviews with MD #9 and MD #10 (Chief of the Medical Staff) on 3/3/11 at 12:55 PM identified that the Hospital practice had been that results of radiological tests may be reported by a telephone call from the Radiology Department to a practitioner in the Emergency Department, with no preliminary results documented or faxed. MD #9 identified that as of 3/3/11, the practice of not documenting preliminary results was still continuing. Additional interviews with MD #9 and MD #10 on 3/22/11 at 2:55 PM identified that the Hospital documentation of preliminary radiological results continued to be a problem.




15482

b. Review of the record for Patient #8 indicated that the patient presented on 11/13/10 after a motorcycle accident. The record indicated that CT scans of the head, C-spine, abdomen/pelvis and chest were completed. Patient #11 presented on 10/24/10 after a fall and the record indicated that CT scans of the head, C-spine, abdomen/ pelvis and face had been completed. Patient #12 presented on 12/14/10 after a motor vehicle accident and the record indicated that CT scans of the head, C-spine, and abdomen/ pelvis were completed. Patient # 13 presented on 8/31/10 after a dirt bike accident. The clinical record indicated that the patient had multiple x-rays completed. The records for Patients #8, #11, #12, and #13 failed to contain preliminary reports of the radiological procedures performed.

Patient #2 was admitted to the Emergency Department on 7/31/10 with a left knee dislocation that resulted in perineal nerve palsy and a 4 cm occlusion of the left popliteal vein. MD #3 (Vascular Surgeon) was consulted and performed a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy. Review of MD #3's credentialing file (maintained by the Hospital) identified that MD #3 was granted privileges to perform a variety of cardiothoracic surgical procedures. However, MD #3 had not been granted privileges to perform peripheral vascular surgery since his/her reappointment in 2007. MD #3's had been reappointment in 2009 and 2011 failed to include privileges to perform peripheral vascular surgery.
According to the Medical Staff Bylaws in effect on 7/31/10, clinical privileges shall be specifically delineated in writing.
Interviews with MD #9 and MD #10 on 3/3/11 at 12:55 PM identified that MD #3 had previously been privileged to perform peripheral vascular surgery. MD #3 continued to be competent to perform peripheral vascular surgery, and that it was an oversight that MD #3's current privileges did not reflect the privilege to perform peripheral vascular surgery.

Based on clinical record review, review of hospital policies, and interviews with staff for one patient (Patient #2) who sustained a vascular injury as a result of a dislocated left knee, the Hospital failed to ensure that the patient received timely medical and surgical interventions following an angiogram, and failed to ensure that the patient's peripheral vascular status was assessed and/or reassessed. The findings include:
Patient #2 was admitted to the Emergency Department on 7/31/10, evaluated by MD #1 within 9 minutes, and was identified with a left knee dislocation. MD #1 identified that the patient had no sensation or movement in the left lower leg and foot, the foot was dusky in color and the left dorsalis pedis (DP) and posterial tibial (PT) pulses were barely palpable. An X-ray was obtained that identified a frank dislocation of the left knee joint. At 3:15 AM, MD #1 and an Orthopedic Physician's Assistant (PA #1) performed a relocation of the left knee. An angiogram was performed at 4:06 AM and interpreted by a Radiological Resident (Resident #1). However, the Hospital had no documentation of Patient #2's angiogram results. According to Hospital policy, preliminary radiological findings are to be documented on a consult form and faxed to the Emergency Department. Multiple medical services were involved in the emergency management of Patient #2 (Physicians of Emergency Medicine, Orthopedics, and Vascular Surgery as well as a Surgical Resident and an Orthopedic Physician's Assistant ). Each Physician and Resident based their treatment decisions on undocumented results of Patient #2's angiogram. Interview with Radiology Resident #1 on 3/21/11 at 10:02 AM identified that he/she identified occlusion of the popliteal artery, uncertain underlying etiology, question of underlying clot, arterial dissection, or vasospasm. Resident #2 identified that he/she had a discussion with MD #1 who identified Patient #2's left lower leg showed improvement, which was consistent with a diagnosis of vasospasm. According to the clinical record (prior to 5:00 AM), MD #1 identified that the angiogram showed stenosis at the left popliteal artery with some reconstitution distally and the anterior tibial artery was seen proximally but no filling was noted distally. MD #1 consulted with MD #3 (Vascular Surgeon) by telephone regarding the angiogram results. MD #3 recommended initiating Heparin and to admit Patient #2 to the Vascular service. According to the clinical record timed at 7:30 AM, Patient #2 was seen by a Surgical Resident (Resident #2) who admitted the patient to the Vascular Service. Patient #2's clinical record was reviewed with MD #5 on 3/3/11 at 9 AM. Between 7/31/10 at 7:41 AM and 11:05 AM (start of the vascular surgery), the clinical record failed to reflect that a Physician, Resident, or PA assessed Patient #2's vascularization in the left lower leg. At some time prior to 10:31 AM, Radiologist #1 and Resident #1 reviewed Patient #2's angiogram that was performed at 4:06 AM. According to the angiogram report, Radiologist #1 identified that the initial impression of results as reported by Resident #1 differed from Radiologist #1's impression. Radiologist #1 identified that Patient #2 had a 4 cm occlusion of the left popliteal vein with reconstitution distally, and the left anterior tibial artery was opacified only midway through the left lower leg. Radiologist #1 identified that the new impression was discussed with MD #1. A surgical report dated 7/31/10 at 11:19 AM, identified that Patient #2 had originally been diagnosed by angiogram as having a spasm with 2 vessel tibial runoff. However, MD #3 (Vascular Surgeon) identified that the patient had a left popliteal occlusion which required a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy. MD #3 identified that Patient #2 sustained permanent nerve damage at the time of the knee dislocation. However, MD #3 identified that if he/she had been notified that the angiogram identified possible occlusion, he/she would have surgically intervened immediately, possibly improving Patient #2's outcome by averting or alleviating the multiple medical complications that the patient experienced.



14528

Based on medical record reviews, review of hospital medical staff bylaws and interviews for one patient who sustained injury as a result of a surgical procedure (Patient #1), the hospital failed to ensure that the patient's medical issues were addressed prior to discharge. The findings include:

Patient #1 had aggressive, invasive bladder cancer and was admitted to the hospital for removal of the bladder with ileoconduit, removal of lymph nodes, ovaries and partial removal of the vagina. The operative report dated 9/22/10 identified that a loop of the patient's bowel was injured during the surgical procedure performed by MD #1 and #2, MD #3 sutured the injury and MD #4 subsequently repaired the injury by performing an anterior resection with anastomosis of the sigmoid colon using unaffected bowel. The operative report dated 10/5/10 by the patient's attending physician, MD #4, indicated that there was a leak of liquid stool and inflammation in the urethral remnant when the vagina was examined, there were no defects or ruptures of the staple line upon digital rectal exam and the postoperative diagnosis was rectovaginal fistula. An infectious disease consult was obtained to rule out urinary tract infection and pelvic abscess on 10/6/10 and documented that the patient had an episode of hyperglycemia and chills suggestive of sepsis (10/2/10). The consult further identified that the patient had discharge from the vagina suspicious of fecal material, suspicion for pelvic abscess and recommended the continuation of the current antibiotic as well as adding an additional antibiotic.
Patient #1 was discharged to home on Sunday 10/10/10 by the covering surgical attending, MD #20, with VNA services, oral antibiotic medications and without additional testing/treatment/medical interventions for the newly diagnosed rectovaginal fistula.
Discharge documentation from Hospital #2 identified hat the patient had increased vaginal discharge (stool) from 10/10/10 to 10/14/10, weakness and was admitted to Hospital #2 on 10/14/10. The discharge summary further noted that the patient was transferred emergently to the operating room on 10/14/10 for a diverting loop colostomy for treatment of the colovaginal fistula and pelvic abscess most likely from an anastomotic leak.
Interview with MD #4 on 3/3/11 at 10:35 AM identified that the diagnosis of rectovaginal fistula was never confirmed and it was difficult to tell if the patient's vaginal drainage was anal contamination. MD #4 further indicated that scans of the abdomen did not show contrast leakage and if they had, treatment for a small leak would be to wait or to do a temporary colostomy. Interview with MD #1 on 3/5/11 at 12 PM noted that the patient had heavy discharge from the vagina prior to discharge from Hospital #1 and that MD #4 had conveyed that MD #4 was not sure that the patient had a rectovaginal fistula and that the problem may resolve on its own. Hospital #1's medical staff bylaws identified that the care of each patient is the responsibility and privilege of an attending physician of the appropriate section or department.


15482



Based on review of clinical records and interview, the facility failed to ensure that the clinical record contained documentation that two patients (Patients #5 and 6) had been reassessed after a change. The findings include the following:

a. Review of Patient #5's clinical record indicated that the patient had an endoscopy with dilatation completed on 2/1/11. The PACU record indicated that at 11:00 AM the patient received Morphine for complaints of pain in the epigastric area. The PACU record indicated that the physician had been called and examined the patient. The patient was sent for an x-ray and an esophogram. Review of the PACU record identified that the patient was sent emergently to the operating room and was found to have a perforated esophagus. Review of the clinical record failed to identify the physician's assessment of the patient and/or the complications that occurred after the endoscopy.

b. Review of Patient #6's clinical record indicated that the patient had an endoscopy with dilation completed on 3/8/11 at 8:30 AM. The record indicated that at 10:10 AM, the patient complained of abdominal pain. An esophogram was performed which identified the patient had a perforated esophagus. The patient was emergently sent to the operating room at 12:15 PM. The clinical record failed to contain a physician's assessment of the patient and/or the complications that occurred after the endoscopy.

Based on clinical record review, review of policies, and interviews with staff for one patient (Patient #2) who sustained a peripheral vascular injury to the left lower extremity, nursing staff failed to ensure that the patient's vascular system was assessed and/or reassessed, and/or for six patients (#2, #3, #5, #6, #12, and #13) failed to ensure that the patient's pain was assessed and/or reassessed in accordance with policy. The findings include:
a. Patient #2 was admitted to the Emergency Department on 7/31/10 at 2:36 AM, identified with a left knee dislocation, had no sensation or movement in the left lower leg and foot (perineal nerve palsy), and the left dorsalis pedis (DP) and posterial tibial (PT) pulses were barely palpable. Between 2:36 AM and 5:00 AM, Patient #2's peripheral vascular system was evaluated by multiple medical practitioners including Physicians of Emergency Medicine, Orthopedics, and Vascular Surgery as well as a Surgical Resident and an Orthopedic Physician's Assistant). Patient #2's clinical record was reviewed with the DNS and APRN #1 on 3/22/11 at 1:40 PM. Between 7/31/10 at 5:00 AM and 9:21 AM, the clinical record lacked documentation that nursing staff evaluated Patient #2's left lower leg and foot. On 7/31/10 at approximately 10:30 AM, Patient #2 was identified with a 4 cm occlusion of the left popliteal vein, and was emergently taken to the operating room and underwent a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy. The hospital policy for assessment and reassessment identified that a patient is reassessed as needed for the nature and severity of the injury.
b. Patient #2's clinical record was reviewed with the DNS on 3/23/11 at 1:30 PM. According to the clinical record, at 3:20 AM, Patient #2 received Morphine 5 mg IV for a pain level of 5 (pain scale 1-10 with 10 being the worst pain). The clinical record failed to identify that Patient #2's pain was reassessed for 1 hour and 55 minutes. At 5:15 AM, Patient #2 identified his/her pain level was a 10, and was medicated with Morphine 5 mg IV. The clinical record failed to identify that Patient #2's pain was reassessed for 2 hours and 49 minutes. At 7:59 AM, Patient #2 identified his/her pain level was a 10, and was medicated with Morphine 7 mg IV. The policy for pain management identified that a patient's pain should be reassessed after each intervention.
c. Review of Patient #3's clinical record indicated that during the period of 10/7/10 through 10/20/10, the patient received pain medication on eleven occasions. Review of the clinical record indicated that on staff failed to reassess the patient's level of pain on eight (8) of those occasions.
d. Review Patient #3's ED record dated 10/7/10 identified that the patient had a pain level of 6 (on a scale of 1-10) at 9:13 PM and a pain level of 5 at 11:13 PM. Review of the record indicated that on 10/10/10 at 2:45 PM the patient had a pain level of "5" and on 10/17/10 at 4:00 AM the patient had a pain level of "5". The clinical record failed to identify that the patient's pain was addressed and/or that an intervention was provided.
e. Patient #3 had a physician's order for Tylenol 2 tablets every six hours for "mild pain". Review of the clinical record dated 10/13/11 identified that the patient had pain, rated as a "5", at 2:40 PM and received Tylenol. At 6:30 PM, four hours later, the patient had a pain level of "5" and was medicated again with Tylenol. The facility failed to ensure that Tylenol was administered every six hours as prescribed.
f. Patient #3 had a physician's order for Tylenol 2 tablets every six hours for "mild pain" and Percocet 1 tablet every eight hours for "moderate pain". The clinical record indicated on 10/13/10 at 6:43 AM, the patient received Tylenol 2 tablets for a pain level of "5" (moderate pain). At 2:40 PM, the patient rated pain as a "5" and received Tylenol. At 6:30 PM, the patient revived Tylenol for a pain level of "5". Review of the facility pain policy indicated that the suggested correlation of pain intensity and the analogue scale are mild pain (1-3), moderate pain (4-6) and severe pain (7-10). The facility failed to ensure that the patient's identified level of pain was addressed i.e., Tylenol was administered for moderate pain levels when the physician's order directed Percocet for moderate pain (4-6).
g. Review of Patient #5's clinical record indicated that the patient had an endoscopy with dilatation completed on 2/1/11. Review of the post anesthesia care unit (PACU) record indicated that the patient arrived to the PACU at 10:14 AM. At 11:00 AM, the patient was in pain with morphine administered. Review of the PACU flow sheet failed to reflect that the location and intensity of pain was documented.
Review of the computerized record indicated that the patient received 2.5 mg of Morphine at 11:17 AM for a pain level of "3" and 2.5 mg of Morphine at 12:51 PM for a pain level of "9". The record failed to identify that the patient's pain level had been reassessed after the administration of the Morphine.
h. Patient #6 had an endoscopy with dilatation completed on 3/8/11. A note at 10:20 AM indicated that the patient complained of severe abdominal and back pain, however, the patient's pain was not rated utilizing the pain scale of 1-10. The nurse's discharge note indicated that the patient received Fentanyl times three and morphine 5 mg intravenously. The note failed to identify a comprehensive pain assessment, the times of pain medication administration and/or that the patient's level of pain had been reassessed after each dose.
i. Review of Patient #12's clinical record indicated that the patient presented to the ED on 12/14/10 following a motor vehicle accident. The clinical record indicated that the patient was experiencing right lower leg pain and left wrist/hand pain. The record indicated that Morphine 5 mg was administered at 7:35 AM, 7:55 AM and 8:05 AM. The patient also received Dilaudid 1 mg at 8:35 AM. The clinical record failed to reflect that the patient's level of pain had been assessed prior to the administration of the medications or reassessed after the administration of the medication.
j. Review of Patient #13's clinical record indicated that the patient presented to the ED on 8/31/10 following a dirt bike accident. The clinical record indicated that the patient complained of neck pain and had a femur fracture. Review of the record indicated that the patient received Fentanyl at 8:20 PM, 8:50 PM, 9:00PM, and 9:35 PM. The patient also received Morphine 5mg intravenously at 10:25 PM and 10:40 PM. The clinical record failed to reflect that the patient's level of pain had been assessed prior to the administration of the medications or reassessed after the administration of the medication. Review of the facility policy indicated that patients should be assessed for pain with each new report of pain and after each intervention.







15482

Based on review of the clinical record, and review of the facility policy the facility failed to ensure that one patient (Patient #3) who was placed in restraints had a corresponding physicians order. The findings include the following:

a. Review of Patient #3's clinical record indicated that the patient was placed in restraints for the period of 10/10/10 through 10/12/10 and 10/15/10 through 10/21/10. Review of the physician's orders for the same period failed to reflect orders for 7 of 10 days that the patient was on restraints (10/11/10, 10/12/10, 10/15/10, 10/16/10, 10/17/10, 10/18/10 and 10/19/10).

Review of the facility policy indicated that each episode of restraints required a physicians order and that each order is valid for only twenty-four hours.

Based on clinical record review and hospital policy, the facility failed to ensure that clinical documentation was complete and accurate in accordance with hospital policy.

a. Review of Patient #5's clinical record indicated that the patient had an endoscopy with dilatation completed on 2/1/11. The PACU record indicated that at 11:00 AM the patient received Morphine for complaints of pain in the epigastric area, was subsequently sent for an x-ray and an esophagram and was then transferred emergently to the operating room for repair of a perforated esophagus. Review of the PACU record indicated that although the anesthesiologist signed the discharge portion of the record, the time was not documented. Interview with the Nurse Manager on 3/21/11 at 1:00PM indicated that the anesthesiologist should sign the record prior to the patient being discharged.

In addition, review of the History Medical Examination and Order form dated 2/1/11 identified that although a physician signed the discharge section of the form at 7:00 AM, the form was not completed in its entirety.

b. Review of Patient #6's clinical record indicated that the patient had an endoscopy with dilatation completed on 3/8/11 at 8:50. Review of the PACU discharge record indicated that the patient was sent emergently to the operating room at 12:15 PM. The patient was found to have a perforated esophagus. Review of the PACU record indicated that the anesthesiologist had signed the discharge portion of the record that identified the patient was stable, abdomen soft, and his/her condition was unchanged from pre-procedure. The record failed to reflect the time that the anesthesiologist assessed the patient and documented in the discharge section. Interview with the Nurse Manager on 3/21/11 at 1:00PM indicated that the anesthesiologist should sign the record prior to the patient being discharged.

In addition, review of Patient #6's History Medical Examination and Order form dated 3/8/11 identified that the RN signed the preprinted order for administration of Lactated Ringers at 7:40 AM, however, the order failed to include the infusion rate. Review of the record and interview with the Manager indicated that the RN wrote the order which was subsequently signed by the physician at 9:00 AM.

c. Patient #15 had a upper endoscopy with dilation on 3/10/11 at 9:00 AM. Review of the PACU record indicated that the anesthesiologist had signed the discharge portion of the record however the record failed to reflect the time that the anesthesiologist assessed the patient and signed the discharge section of the record indicating the patient was ready for discharge.

d. Patient #16 was admitted to the GI Lab on 3/8/11 for a Endoscopy with dilation which was completed at 9:15 AM. Review of physician's orders dated 3/8/11 and signed at 10:00 AM (after the procedure) directed Lactated Ringers. The order failed to include the rate of infusion. The RN signed the order at 9:45 AM, prior to the physician's order. Review of the PACU record indicated that the anesthesiologist had signed the discharge portion of the record however the record failed to reflect the time that the anesthesiologist assessed the patient and signed the discharge section of the record indicating the patient was ready for discharge.

Based on clinical record review, review of hospital policies, and interviews with staff, the Hospital failed to ensure that preliminary radiological reports were documented and/or accurate. The findings include:
a. Patient #2 had an angiogram performed on 7/31/10 at 4:06 AM that was interpreted by a Radiological Resident (Resident #1). Although MD #1 (Emergency Medicine Physician) and Resident #1 identified that they discussed the results of the angiogram by telephone, the Hospital had no documentation of Patient #2's preliminary angiogram results. Multiple medical services were involved in the emergency management of Patient #2 and based their treatment decisions on undocumented equivocal results of Patient #2's angiogram.
According to Hospital policy, preliminary radiological findings were to be documented on a consult form and faxed to the Emergency Department. However, interview with MD #6 (Chairman of Radiology) on 3/3/11 at 2 PM identified that members of the Department of Radiology do not document preliminary results of tests. Interviews with MD #9 and MD #10 on 3/3/11 at 12:55 PM identified that the Hospital practice had been that reporting results of radiological tests may at times occur by a telephone call from the Radiology Department to a practitioner in the Emergency Department, with no preliminary results documented or faxed. MD #9 and MD #10 identified that the Hospital had been aware that documentation of preliminary radiological reports was a problem. On 3/21/11 and 3/22/11, 8 additional clinical records of patients who received radiological testing were reviewed. For 4 patients (Patients #8, #11, #12, 13) radiological reports were reviewed, and failed to have documented preliminary radiological results.
According to the Medical Staff Bylaws in effect on 7/31/10, the Department Chairmen shall develop and implement policies and procedures that guide and support the provision of services. The Department Chairmen shall also be responsible for keeping departmental records readily available.
b. Patient #2 had 2 X-rays taken of the left knee on 7/31/10; one at 3:08 AM (prior to the left knee reduction), and one at 4:17 AM (after the knee reduction). Review of the two reports identified that the reason for the exam, report, and impression of findings were not reflective of the actual examinations. Interview with the Chairman of Radiology on 3/3/11 at 2 PM identified that a clerical error was made, which transposed the information in the 2 reports. The X-ray taken at 3:08 AM should have identified a frank dislocation, and the X-ray taken at 4:17 AM should have identified status post closed reduction with no fracture.



15482

Based on review of clinical records and interview, the facility failed to ensure that IV fluids were administered as ordered and/or that the clinical records reflected fluids administered. The findings include the following:

a. Review of Patient #5's clinical record indicated that the patient had an endoscopy with dilatation completed on 2/1/11. Review of the History Medical Examination and Order form dated 2/1/11 at 7:00 AM directed Lactated Ringers at 50 cc/hr. Review of the anesthesia order sheet directed Lactated Ringers at 30 cc/hr. Review of the PACU record indicated that the patient received 800 cc's of fluid. The record failed to reflect when the IV had been hung and/or at what rate. The record also failed to reflect the amount of fluid infused in the OR and the amount infused in the PACU.

b. Review of Patient #6's History Medical Examination and Order form dated 3/8/11 at 9:00 AM directed Lactated Ringers however, failed to have a rate of infusion designated. Review of the anesthesia order sheet directed Lactated Ringers at 30 cc/hr. The record failed to reflect when the IV had been hung and/or at what rate.

c. Review of Patient #15's History Medical Examination and Order form dated 2/10/11 at 9:00 AM directed Lactated Ringers at 50 cc/hr. Review of the anesthesia order sheet directed Lactated Ringers at 30 cc's hr. The record failed to reflect when the IV had been hung and/or at what rate.

d. Review of Patient #16's History Medical Examination and Order form dated 2/24/11 at 10:00 AM directed Lactated Ringers at keep vein open (KVO). Review of the anesthesia order sheet dated 2/24/11 at 10:00 AM directed Lactated Ringers at 30 cc's/hr. The record failed to reflect when the IV had been hung and/or at what rate.

e. Review of Patient #17's physician's orders dated 3/8/11 directed Lactated Ringers, however the order failed to have a rate designated. Review of the anesthesia order sheet dated 3/4/11 directed Lactated Ringers at 30 cc's/hr. The record failed to reflect when the IV had been hung and/or at what rate.

Based on clinical record review and review of hospital policies, for one patient (Patient #2) who sustained a vascular injury as a result of a dislocated left knee, the Department of Radiology failed to ensure that results of radiological tests were accurately communicated and documented, in order to ensure that the patient received appropriate and timely intervention. The findings include:

On 7/31/10, Patient #2 was admitted to the Emergency Department with a left knee dislocation with injuries to the nerves and vascular systems. An angiogram was performed and interpreted by Radiology staff. Radiology staff identified that they discussed the results of the angiogram by telephone with a physician in the emergency department. However, each practitioner identified differing versions of what the reported angiogram results were. Patient #2 was treated for vasospasm, but was later diagnosed with a 4 cm occlusion of the left popliteal vein, which differed from the preliminary impression. Patient #2 was emergently taken to the operating room on 7/31/10 at 11:19 AM (about 7 hours after the angiogram), and underwent a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy.

Patient #2 ' s clinical record was reviewed with MD #9 (VP of Risk) on 3/3/11 at 12:55 PM. The clinical record failed to include documentation of Resident #1 ' s preliminary angiogram findings. MD #9 identified that Patient #2's preliminary angiogram results were not documented in the Radiology Department or in any other hospital documentation. According to Hospital policy, preliminary radiological findings were to be documented on a consult form and faxed to the Emergency Department. However, interview with MD #6 (Chairman of Radiology) on 3/3/11 at 2 PM identified that members of the Department of Radiology do not document preliminary results of tests. Interviews with MD #9 and MD #10 (Chief of the Medical Staff) on 3/3/11 at 12:55 PM and again on 3/22/11 at 2:55 PM identified that the documentation of preliminary radiological results continued to be an identified problem in the hospital. .

Please refer to A529

Based on clinical record review, review of hospital policies, and interviews with staff for one patient (Patient #2) who sustained a vascular injury as a result of a dislocated left knee, the Department of Radiology failed to ensure that radiological services met the needs of the patient, and failed to ensure that radiological reports were accurate. The findings include:

Patient #2 was admitted to the Emergency Department on 7/31/10 with a left knee dislocation with injuries to the nerves and vascular systems. An angiogram was performed and interpreted by a Radiological Resident (Resident #1). Although MD #1 (Emergency Medicine) and Resident #1 identified that they discussed the results of the angiogram by telephone, each practitioner identified differing versions of what the reported angiogram results were. Interview with Radiology Resident #1 on 3/21/11 at 10:02 AM identified that he/she verbally reported occlusion of the popliteal artery, uncertain underlying etiology, question of underlying clot, arterial dissection, or vasospasm. Interview with MD #1 on 3/21/11 at 2 PM identified that when he/she discussed the results with Resident #1, he/she did not recall the Resident mentioning occlusion, but that based on the patient ' s symptoms, the findings could be consistent with spasm. Patient #2 ' s clinical record was reviewed with MD #9 (VP of Risk) on 3/3/11 at 12:55 PM. The clinical record failed to include documentation of Resident #1 ' s preliminary angiogram findings. MD #9 identified that Patient #2's preliminary angiogram results were not documented in the Radiology Department or in any other hospital documentation.

Multiple medical services were involved in the emergency management of Patient #2 (Physicians of Emergency Medicine, Orthopedics, and Vascular Surgery as well as a Surgical Resident and an Orthopedic Physician's Assistant). Each Physician and Resident based their treatment decisions on MD #1 and Resident #1 ' s verbal report of Patient #2's angiogram. Approximately 6 1/2 hours later, Radiologist #1 (with the assistance of an Interventional Radiologist) identified that Patient #2 had a 4 cm occlusion of the left popliteal vein, which differed from the preliminary impression. Patient #2 was emergently taken to the operating room on 7/31/10 at 11:19 AM (about 7 hours after the angiogram), and underwent a left femoral popliteal reverse saphenous vein bypass and a tricompartmental fasciotomy. Interview with MD #3 (Vascular Surgeon) on 3/21/11 at 9:30 AM identified that he/she was notified that Patient #2's angiogram identified an arterial spasm, and was treated accordingly. MD #3 identified that if he/she had been notified that the angiogram identified possible occlusion, he/she would have surgically intervened immediately, possibly improving Patient #2's outcome by averting or alleviating the multiple medical complications that the patient experienced.

According to Hospital policy, preliminary radiological findings were to be documented on a consult form and faxed to the Emergency Department. However, interview with MD #6 (Chairman of Radiology) on 3/3/11 at 2 PM identified that members of the Department of Radiology do not document preliminary results of tests. Interviews with MD #9 and MD #10 (Chief of the Medical Staff) on 3/3/11 at 12:55 PM identified that the Hospital practice had been that results of radiological tests may be reported by a telephone call from the Radiology Department to a practitioner in the Emergency Department, with no preliminary results documented or faxed. MD #9 identified that as of 3/3/11, the practice of not documenting preliminary results was still continuing. Additional interviews with MD #9 and MD #10 on 3/22/11 at 2:55 PM identified that the Hospital documentation of preliminary radiological results continued to be a problem. According to the Medical Staff Bylaws in effect on 7/31/10, the Department Chairmen shall develop and implement policies and procedures that guide and support the provision of services. The Department Chairmen shall also be responsible for keeping departmental records readily available.

b. Patient #2 had 2 X-rays taken of the left knee on 7/31/10; one at 3:08 AM (prior to the left knee reduction), and one at 4:17 AM (after the knee reduction). Review of the two reports identified that the reason for the exam, report, and impression of findings were not reflective of the actual examinations. Interview with the Chairman of Radiology on 3/3/11 at 2 PM identified that a clerical error was made, which transposed the information in the 2 reports. The X-ray taken at 3:08 AM should have identified a frank dislocation, and the X-ray taken at 4:17 AM should have identified status post closed reduction with no fracture.

Based on review of clinical records, interview and review of the facility policy, the facility failed to ensure that for three of five patients (Patient's #5, 6, 15, 16, and 17) having GI procedures, that consents were comprehensive and/or complete. The findings include the following:

a. Review of the clinical record for Patient #5 indicated that on 2/1/11 the patient had an endoscopy with dilatation performed. Review of the record indicated that the consent was completed on 1/21/11. The signed consent identified that the patient was having a gastroscopy and failed to identify the potential dilation and/or risks of the procedure. Interview with the MD#8 on 3/22/11 at 10:00 AM indicated that he did not recall going over the risks of the procedure and that the option of dilation was not discussed with the patient. The clinical record indicated that the patient sustained an esophageal perforation following dilation.

b. Review of the clinical record for Patient #16 indicated that the patient had an endoscopy with dilatation completed on 2/18/11. Review of the record indicated that the consent was completed on 2/18/11. The signed consent identified that the patient was having an endoscopy with biopsies, however, failed to identify the potential dilation.

c. Review of the clinical record for Patient #17 indicated that the patient had an endoscopy with dilatation completed on 3/4/11. Review of the record indicated that the consent was completed on 3/4/11. The signed consent identified that the patient was having a colonoscopy and upper endoscopy and failed to identify the potential dilation.

d. Review of Patient #14's clinical record identified that the patient was a six-year old that presented to the ED after a fall. The record indicated that the patient had a skull fracture requiring surgical intervention. Review of the record identified that the consent dated 9/17/10 for a debridment of a compound skull fracture failed to have a parent and/or guardian's signature.

Review of hospital policy indicated that the consent form documents the discussion between the physician and patient related to the nature of the procedure to be performed.