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Based on review of the facility's current process, medical records, policies and procedures, credential files, staff interviews, and the facility's corrective action plan, it was determined that the facility failed to follow it's policy related to notifying patients that there was a discrepancy between the Emergency Department physician's interpretation and the Radiologist's interpretation of x-rays for 1 of 4 sampled medical records (#2).


Findings were:

Review of the facility's current process revealed the Emergency Department (ED) physician was to enter his/her x-ray interpretation into the PACS (Picture Archiving and Communication System). The Radiologist was to interpret the films and if there was a discrepancy the Radiologist was to notify the ED physician and document the notification. The process revealed the ED physician was responsible for contacting the patient if necessary.

Review of 1 of 4 sampled medical records (#2) revealed the patient presented to the facility after falling at a local Assisted Living Facility with complaints of right hip pain. The physician examined the patient, ordered stat hip and pelvic x-rays, and discharged the patient with a diagnosis of hip contusion. There was no documentation of the physician's interpretation of the x-rays. The patient was discharged at 3:27 a.m. with discharge instructions that indicated that the ED physician had read the patient's x-rays and that a Radiologist would read the films within 24 hours and that if there was a x-ray discrepancy the patient would be notified. At 7:29 a.m., the Radiologist noted that the patient had a broken right hip. There was no documentation that the Radiologist notified the ED physician or that either physician notified the patient.

Review of facility policy entitled "Radiologist Consultation", no policy number, last revised 06/11, revealed "Radiological Findings Requiring Immediate Attention or Discrepancy. It is the responsibility of the Radiologist to inform the Attending Physician and/or other appropriate physician of findings / discrepancy of special importance or consequences to the care of the patient. This shall be done in the following manner: 1) The Radiologist shall notify the Attending Physician promptly after interpreting the radiographs (x-rays) of a patient with significant problem or complication. 2) The Radiologist shall indicate the report and note the communication with the Attending Physician."

Review of facility policy entitled "EMTALA (Emergency Medical Treatment and Active Labor Act) Guidelines for Emergency Department Services", no policy number, last revised 03/10, revealed "all patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis."

Review of 1 of 2 credential files revealed physician #'s (the ED physician who provided the patient's care) "Emergency Room Department Delineation of Privileges" indicated the physician had been privileged to perform "historical and physical examinations, including the ordering and interpretation of diagnostic studies including laboratory, diagnostic imaging (x-rays), and electrocardiographic (test to determine heart activity) examinations as shall normally be considered part of Emergency Medicine".

During an interview at 10:45 a.m. on 08/23/11 in the nursing administrator's office, the Compliance Officer (CO - interview #1) stated that physicians enter x-ray orders into Medhost and then the nurse enters the order into PACS (Picture Archiving and Communication System) which notifies the radiology department of the order. The CO stated that in the patient's case the physician ordered the x-rays stat but the nurse enter the order as routine x-rays. The CO explained that if the nurse had entered the order for the x-rays as a stat procedures the x-rays would have been read immediately by the NightHawk Radiologist and the physician would have received the Radiologist's interpretation before the patient was discharged. The CO stated that the facility had a contract with NightHawk Radiologist to provide interpretations of stat x-rays during the hours the facility did not have a radiologist available. The CO stated the facility did not have a radiologist available Monday through Friday from 9:00 p.m. until 7:00 a.m. The CO stated that all routine x-rays were read the next morning by the facility's radiologist. The CO went on to say that once the radiology department received the routine order the technician had performed the x-rays and that the x-ray images were then available on PACS for the ED physician to review and interpret. The CO stated the ED physician was suppose to interpret the films and enter his/her interpretation in PACS, but that the ED physician who had provided the patient's care had closed his/her notes without entering his/her interpretation into PACS. The CO explained that when the Radiologist arrived later that morning the Radiologist reviewed the films and entered his/her interpretation into the PACS system. The CO stated that if the ED physician had entered his/her interpretation into PACS it would have triggered a discrepancy between the physician's interpretation and the radiologist's interpretation and that the radiologist would have notified the physician and documented the notification. The CO explained that the radiologist had not been aware of the discrepancy because the ED physician had not entered his/her interpretation into PACS. The CO stated that the policy required the Radiologist to notify the ED physician who was then suppose to notify the patient of any x-ray diagnosis changes. The CO stated the facility could not validate whether any of the ED physicians were entering their interpretations of x-rays into the electronic system.

During an interview at 11:30 a.m. on 08/23/11 in the nursing administrator's office, the Director of Radiology (interview #2) confirmed the above statement and added that he/she had not been aware that there was a problem with the ED physicians entering their x-ray interpretations.

The CO provided the surveyor with the facility's "Interim Corrective Measures" which included the following:
? All x-ray examinations performed on ED patients will be manually logged starting 08/23/11,
? ED physicians and radiologists will be educated on need for initial interpretation of x-ray results by the ED physician starting 08/23/11,
? All x-ray examinations performed on ED patients who have been discharged prior to the provision of a radiologist's interpretation of test results will be reviewed by a member of the radiology department to determine if an initial interpretation has been entered into PACS, if not the ED physician will be contacted and requested to provide an interpretation in PACS,
? ED physicians failing to note an initial interpretation of radiological examinations performed on ED patients discharged prior to the provision of a Radiologist's interpretation of test results will be subject to peer review with findings placed in his/her credential file,
? Each morning the Radiology Manager or designee will review x-ray results for tests performed in the last 24 hour period starting 08/24/11,
? The Radiology Manager or designee will communicate positive findings to the Risk Manager for cross-reference with the patient's discharge diagnosis,
? Weekly PACS reports will be generated by the PACS Administrator and will be provided to the Radiology Director, Chief of Staff, and Compliance Officer for follow-up with ED physicians who fail to enter their initial interpretation results into PACS,
? Patients having been discharged with inaccurate radiology results will be contacted by the Chief of Staff or designee to ensure appropriate follow-up and care appropriate to the injury sustained, and
? Issues identified will be reported to the Medical Executive Committee and Board for consideration during the credentialing process.

The following will be submitted to the Medical Executive Committee for approval and added to the facility's x-ray procedure: the ED physician will enter his/her interpretation of results into PACS, if the ED physician fails to enter his/her interpretation the radiology staff will contact the physician and request that his/her findings be entered into PACS, the Radiologist will then check to see if there were discrepancies between the ED physician's interpretation and his/her findings, the Radiologist will notify the ED physician of any discrepancies and document the notification, and the ED physician will be responsible for notifying the patient.

Three additional medical records were reviewed (#'s 2, 3, and 4) and there were no x-ray discrepancies found between the ED physicians' findings and the Radiologists' findings.

Based on review of the facility's current process, medical records, policies and procedures, staff interviews, and the facility's corrective action plan, it was determined that the facility failed to follow it's policy related to the Radiologist notifying the ED physician that there was a discrepancy between the ED physician's x-ray interpretation and the Radiologist's interpretation of the films for 1 of 4 sampled medical records (#2).


Findings were:

Review of the facility's current process revealed the Emergency Department (ED) physician was to enter his/her x-ray interpretation into the PACS (Picture Archiving and Communication System). The Radiologist was to interpret the films and if there was a discrepancy the Radiologist was to notify the ED physician and document the notification. The process revealed the ED physician was responsible for contacting the patient if necessary.

Review of 1 of 4 sampled medical records (#2) revealed the patient presented to the facility after falling at a local Assisted Living Facility with complaints of right hip pain. The physician examined the patient, ordered stat hip and pelvic x-rays, and discharged the patient with a diagnosis of hip contusion. There was no documentation of the physician's interpretation of the x-rays. The patient was discharged at 3:27 a.m. with discharge instructions that indicated that the ED physician had read the patient's x-rays and that a Radiologist would read the films within 24 hours and that if there was a x-ray discrepancy the patient would be notified. At 7:29 a.m., the Radiologist noted that the patient had a broken right hip. There was no documentation that the Radiologist notified the ED physician or that either physician notified the patient.

Review of facility policy entitled "Radiologist Consultation", no policy number, last revised 06/11, revealed "Radiological Findings Requiring Immediate Attention or Discrepancy. It is the responsibility of the Radiologist to inform the Attending Physician and/or other appropriate physician of findings / discrepancy of special importance or consequences to the care of the patient. This shall be done in the following manner: 1) The Radiologist shall notify the Attending Physician promptly after interpreting the radiographs (x-rays) of a patient with significant problem or complication. 2) The Radiologist shall indicate the report and note the communication with the Attending Physician."

During an interview at 10:45 a.m. on 08/23/11 in the nursing administrator's office, the Compliance Officer (CO - interview #1) stated that physicians enter x-ray orders into Medhost and then the nurse enters the order into PACS (Picture Archiving and Communication System) which notifies the radiology department of the order. The CO stated that in the patient's case the physician ordered the x-rays stat but the nurse enter the order as routine x-rays. The CO explained that if the nurse had entered the order for the x-rays as a stat procedures the x-rays would have been read immediately by the NightHawk Radiologist and the physician would have received the Radiologist's interpretation before the patient was discharged. The CO stated that the facility had a contract with NightHawk Radiologist to provide interpretations of stat x-rays during the hours the facility did not have a radiologist available. The CO stated the facility did not have a radiologist available Monday through Friday from 9:00 p.m. until 7:00 a.m. The CO stated that all routine x-rays were read the next morning by the facility's radiologist. The CO went on to say that once the radiology department received the routine order the technician had performed the x-rays and that the x-ray images were then available on PACS for the ED physician to review and interpret. The CO stated the ED physician was suppose to interpret the films and enter his/her interpretation in PACS, but that the ED physician who had provided the patient's care had closed his/her notes without entering his/her interpretation into PACS. The CO explained that when the Radiologist arrived later that morning the Radiologist reviewed the films and entered his/her interpretation into the PACS system. The CO stated that if the ED physician had entered his/her interpretation into PACS it would have triggered a discrepancy between the physician's interpretation and the radiologist's interpretation and that the radiologist would have notified the physician and documented the notification. The CO explained that the radiologist had not been aware of the discrepancy because the ED physician had not entered his/her interpretation into PACS. The CO stated that the policy required the Radiologist to notify the ED physician who was then suppose to notify the patient of any x-ray diagnosis changes. The CO stated the facility could not validate whether any of the ED physicians were entering their interpretations of x-rays into the electronic system.

During an interview at 11:30 a.m. on 08/23/11 in the nursing administrator's office, the Director of Radiology (interview #2) confirmed the above statement and added that he/she had not been aware that there was a problem with the ED physicians entering their x-ray interpretations.

The CO provided the surveyor with the facility's "Interim Corrective Measures" which included the following:
? All x-ray examinations performed on ED patients will be manually logged starting 08/23/11,
? ED physicians and radiologists will be educated on need for initial interpretation of x-ray results by the ED physician starting 08/23/11,
? All x-ray examinations performed on ED patients who have been discharged prior to the provision of a radiologist's interpretation of test results will be reviewed by a member of the radiology department to determine if an initial interpretation has been entered into PACS, if not the ED physician will be contacted and requested to provide an interpretation in PACS,
? ED physicians failing to note an initial interpretation of radiological examinations performed on ED patients discharged prior to the provision of a Radiologist's interpretation of test results will be subject to peer review with findings placed in his/her credential file,
? Each morning the Radiology Manager or designee will review x-ray results for tests performed in the last 24 hour period starting 08/24/11,
? The Radiology Manager or designee will communicate positive findings to the Risk Manager for cross-reference with the patient's discharge diagnosis,
? Weekly PACS reports will be generated by the PACS Administrator and will be provided to the Radiology Director, Chief of Staff, and Compliance Officer for follow-up with ED physicians who fail to enter their initial interpretation results into PACS,
? Patients having been discharged with inaccurate radiology results will be contacted by the Chief of Staff or designee to ensure appropriate follow-up and care appropriate to the injury sustained, and
? Issues identified will be reported to the Medical Executive Committee and Board for consideration during the credentialing process.

The following will be submitted to the Medical Executive Committee for approval and added to the facility's x-ray procedure: the ED physician will enter his/her interpretation of results into PACS, if the ED physician fails to enter his/her interpretation the radiology staff will contact the physician and request that his/her findings be entered into PACS, the Radiologist will then check to see if there were discrepancies between the ED physician's interpretation and his/her findings, the Radiologist will notify the ED physician of any discrepancies and document the notification, and the ED physician will be responsible for notifying the patient.

Three additional medical records were reviewed (#'s 2, 3, and 4) and there were no x-ray discrepancies found between the ED physicians' findings and the Radiologists' findings.

Based on review of the facility's current process, medical records, staff interviews, and the facility's corrective action plan, it was determined that the facility failed to follow it's procedure related to following physician's orders for for 1 of 4 sampled medical records (#2).


Findings were:

Review of the facility's current process revealed the Emergency Department (ED) physician was to enter his/her order into the Medhost system (electronic medical record) and that the order was then to be entered into PACS (Picture Archiving and Communication System). The order would then be received by the radiology staff who would perform the procedure.

Review of 1 of 4 sampled medical records (#2) revealed the patient presented to the facility after falling at a local Assisted Living Facility with complaints of right hip pain. The physician examined the patient, entered an order for a stat stat hip and pelvic x-ray into Medhost. The nurse then noted that he/she ordered routine hip and pelvic x-rays. The x-rays were performed, and the physician noted that the patient was diagnosis of hip contusion and discharged to the Assisted Living Facility. There was no documentation of the physician's interpretation of the x-rays. The patient was discharged at 3:27 a.m. with discharge instructions that indicated that the ED physician had read the patient's x-rays and that a Radiologist would read the films within 24 hours and that if there was a x-ray discrepancy the patient would be notified. At 7:29 a.m., the Radiologist noted that the patient had a broken right hip. There was no documentation that the Radiologist notified the ED physician or that either physician notified the patient.

During an interview at 10:45 a.m. on 08/23/11 in the nursing administrator's office, the Compliance Officer (CO - interview #1) stated that physicians enter x-ray orders into Medhost and then the nurse enters the order into PACS (Picture Archiving and Communication System) which notifies the radiology department of the order. The CO stated that in the patient's case the physician ordered the x-rays stat but the nurse enter the order as routine x-rays. The CO explained that if the nurse had entered the order for the x-rays as a stat procedures the x-rays would have been read immediately by the NightHawk Radiologist and the physician would have received the Radiologist's interpretation before the patient was discharged. The CO stated that the facility had a contract with NightHawk Radiologist to provide interpretations of stat x-rays during the hours the facility did not have a radiologist available. The CO stated the facility did not have a radiologist available Monday through Friday from 9:00 p.m. until 7:00 a.m. The CO stated that all routine x-rays were read the next morning by the facility's radiologist.

The CO provided the surveyor with the facility's "Interim Corrective Measures" which included the following:
? All x-ray examinations performed on ED patients will be manually logged starting 08/23/11,
? ED physicians and radiologists will be educated on need for initial interpretation of x-ray results by the ED physician starting 08/23/11,
? All x-ray examinations performed on ED patients who have been discharged prior to the provision of a radiologist's interpretation of test results will be reviewed by a member of the radiology department to determine if an initial interpretation has been entered into PACS, if not the ED physician will be contacted and requested to provide an interpretation in PACS,
? ED physicians failing to note an initial interpretation of radiological examinations performed on ED patients discharged prior to the provision of a Radiologist's interpretation of test results will be subject to peer review with findings placed in his/her credential file,
? Each morning the Radiology Manager or designee will review x-ray results for tests performed in the last 24 hour period starting 08/24/11,
? The Radiology Manager or designee will communicate positive findings to the Risk Manager for cross-reference with the patient's discharge diagnosis,
? Weekly PACS reports will be generated by the PACS Administrator and will be provided to the Radiology Director, Chief of Staff, and Compliance Officer for follow-up with ED physicians who fail to enter their initial interpretation results into PACS,
? Patients having been discharged with inaccurate radiology results will be contacted by the Chief of Staff or designee to ensure appropriate follow-up and care appropriate to the injury sustained, and
? Issues identified will be reported to the Medical Executive Committee and Board for consideration during the credentialing process.

The following will be submitted to the Medical Executive Committee for approval and added to the facility's x-ray procedure: the ED physician will enter his/her interpretation of results into PACS, if the ED physician fails to enter his/her interpretation the radiology staff will contact the physician and request that his/her findings be entered into PACS, the Radiologist will then check to see if there were discrepancies between the ED physician's interpretation and his/her findings, the Radiologist will notify the ED physician of any discrepancies and document the notification, and the ED physician will be responsible for notifying the patient.

Three additional medical records were reviewed (#'s 2, 3, and 4) and there were no x-ray discrepancies found between the ED physicians' findings and the Radiologists' findings.