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The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.

Findings included:

The Hospital failed for one patient (Patient #1) in a sample of eleven patients to ensure the QAPI Program developed, implemented and monitored a corrective action plan to reduce the severity or seriousness in communication Computerized Tomography (CT) scan findings following Patient #1's adverse patient event.

Refer to TAG: A-0283.

Based on records reviewed and interview the Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure the Quality Assessment and Improvement (QAPI) Program developed, implemented and monitored a corrective action plan to reduce the severity or seriousness in communication of Computerized Tomography (CT) scan findings following Patient #1's adverse patient event.

Findings include:

Review of the Department of Public Health's Health Care Facility Reporting System, dated 5/29/22, indicated the Hospital reported a delay in treatment regarding a lung mass identified in Patient #1's right lung on 1/15/22.

Review of the Hospital's Internal Investigation indicated that Patient #1 was admitted in January 2022, and on 1/15/22, a Computerized Tomography (CT) scan revealed a seven to eight centimeters (cm) right lung mass associated with mediastinal adenopathy. Patient #1 was discharged on 2/3/22, without outpatient care coordination regarding the lung mass identified on 1/15/22. The Hospital discussed the lung mass findings and delay of treatment with Patient #1 during his/her next admission in March 2022.

Further review of the Hospital's Internal Investigation of Patient #1's delay of treatment indicated there was no documentation to support the Hospital developed or implemented any corrective actions to prevent future potential of adverse incidents.

During an interview with the Patient Safety and Quality staff members on 3/21/23 at 2:30 P.M., and throughout the Survey, they said the Hospital completed a root case analysis of Patient #1's delay in treatment; however, the Hospital's QAPI Program did not develop or implement any system corrective actions.

The Condition of Participation: Radiological Services was out of compliance.

Findings included:

Review of the Department of Public Health ' s Health Care Facility Reporting System, dated 5/29/22, indicated the Hospital Reported a delay in treatment regarding a lung mass identified on a Computerized Tomography (CT) scan findings in Patient #1 ' s right lung on 1/15/22.

Refer to TAG: A-0529

Based on records reviewed and interview the Hospital failed for one patient (Patient #1) in a sample of ten patients to ensure the radiological findings on 1/15/22, from a Computerized Tomography (CT) scan which revealed a seven to eight centimeters (cm) right lung mass associated with mediastinal adenopathy (enlargement of lymph nodes in the central part of the lungs) was interpreted by a provider and communicated with Patient #1 to meet his/her treatment needs.

Findings Include:

Review of the Department of Public Health ' s Health Care Facility Reporting System (HCFRS), dated 5/29/22, indicated the Hospital reported a delay in treatment regarding a lung mass identified on a Computerized Tomography (CT) scan finding in Patient #1's right lung on 1/15/22.

The Hospital ' s Internal Investigation indicated that in December 2021, an x-ray revealed Patient #1 has right lung opacity. Patient #1 was admitted in January 2022, and on 1/15/22, a Computerized Tomography (CT) Scan revealed a seven to eight centimeters (cm) right lung mass associated with mediastinal adenopathy. Patient #1 was discharged on 2/3/22, without a provider interpreting the radiological results, communicating the findings with Patient #1, or discussing outpatient care coordination regarding the lung mass identified on 1/15/22.

Further review of the Investigation indicated the Hospital discussed the lung mass findings and delay of treatment with Patient #1 during his/her next admission in March 2022, approximately three months later.