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6001 KYLE PKWY

KYLE, TX 78640

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on record review and interview, it was determined the facility failed to provide the patient's representative the information needed to make an informed decision regarding the patient's care for 1 of 10 patients [patient #1], when the provider failed to inform the Patient's representative of the chest x-ray results.

Findings were:

Review of Clinical Record revealed Patient #1 presented to the ER on 12/1/24 at 23:47 for worsening fever, cough, abdominal pain, N/V (nausea and vomiting). Rapid Influenza A and B, Coronavirus SARS-CoV-2 Ra and RSV antigen were all negative. A chest X-ray was performed on 12/2/24 at 00:28 that resulted with right upper lobe pneumonia but was not addressed in Patient #1's record.

During an interview on the afternoon of 2/4/25, Staff #1 stated "I cannot comment specifically, but the case was reviewed with me over the phone. It looks like I didn't see the pneumonia. Looks like I just missed it completely. Maybe due to delays with radiology. It was a miss that should have been caught. The other possibility is I could have interpreted the radiology report myself. That's something we do on a busy ER night. And, I may have based my decision on the clinical presentation and felt like the patient could be discharged."

The above was confirmed during an interview with Staff #7 on the afternoon of 2/4/25.