HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 records (Pt #1) reviewed for safety precautions in radiology, the Hospital failed to ensure that seizure precautions were in place during a Computed Tomography (CT) to prevent injury.

Findings include:

1. A request was made for a policy or procedure for suicide precautions during a CT. No policy or procedure for seizure precautions during testing was presented.

2. The clinical record of Pt. #1 was reviewed on 9/18/2024. Pt. #1 presented to the Emergency Department on 8/16/2024 at 11:36 am, with a "Chief Complaint" of "fever." A medical screening exam was conducted at 11:47 am and indicated, "... past medical history (PMH) of seizure... Mother reports that patient has been holding right arm in elbow position and wrist flexed for the last three weeks. Mother believes that it started after Levaquin (antibiotic) administration. Mother denies any known specific trauma or recent seizures... Physical Exam ... Appearance: He is ill-appearing ... Musculoskeletal ... Comments: Mother reports that patient has been holding right arm in elbow position and wrist flexed for the last three weeks. Positive distal pulses. No overlying skin changes ... Motor: Tremor (Right arm) present. Comments: Right elbow and wrist flexed, and fingers extended..." A CT chest was ordered. The CT chest without contrast was completed at 2:53 PM which revealed, "Impression: 1. Bibasilar atelectasis and/or pneumonia. No significant change. 2. Trace right pleural effusion suggested. 3. Mild cardiomegaly ... 5. Interval comminuted fracture of the right humeral head/neck. Recommend correlation with radiographs ... Addendum: The patient's right humeral fracture is noted on the scout tomogram (x-ray imaging used to determine placement of pt for CT scans- scout is done by the CT machine and is done just prior to the CT scan). The scout tomogram was performed prior to the patient hitting her upper extremity on the gantry according to the technologist."

3. The Adverse Event and Sentinel event logs for 6/1/24-9/18/24 were reviewed. A sentinel event related to Pt #1 was filed. When requesting additional information related to the Sentinel Event, the Chief Nurse Executive (E #3) stated, "That is part of the PSO Protected Safety Organization (PSO)." Facility denied request.

4. An interview was conducted on 9/23/24 at 12:00 PM with radiology technician (E #13). E #13 stated, "I use straps for dementia patients, people that are moving around a bunch or confused or I'm just afraid that they're going to fall off the table, but I've seen (Pt #1) many times and (Pt #1) always just lays there. I did not use straps. When placing (Pt #1) on the table, (Pt #1's) head was in the head holder and the head goes in first. (Pt #1's) arms were on (Pt #1's) belly. We had scanned (Pt #1)'s head and neck and was doing the chest, abdomen, and pelvis. I scouted (Pt #1) and so he was in and out twice. In between the localizer and the actual CT scan, I don't know if (Pt #1) had a seizure or what happened but whenever I hit for the table to start moving, (Pt #1) brought his right hand up and (Pt #1's) elbow kind of got caught in between the gantry and it kind of pulled arm up and so immediately I go out there and I brought (Pt #1) out of the scanner because (Pt #1) arm was like jammed. I looked at (Pt #1's) arm and (Pt #1) was moaning a little bit. I did not see any redness, swelling or any obvious injury after the incident. I told the ER doctor what happened. I know that the radiologist did an addendum to see if it was broken in the scout images and the radiologist stated that it was broken before (Pt #1's) arm got caught in the scan."