HospitalInspections.org

Based on the review of one of thirteen medical records (Patients (P)2), review of facility policy, and staff interviews, it was determined that the facility failed to ensure ultrasounds are interpreted by a vascular provider within 24 hours as required by facility policy.

Findings include:

Facility policy titled, "Radiology Critical Test_Critical Test Results," effective on 10/14/25, stated " ...4. Vascular Testing Specific Procedures and Critical Results ...The assigned Vascular Provider has 24 hours from the time the critical/positive study is completed to confirm (electronically sign) the final interpretation ..."

On 11/13/25 at 12:50 PM, medical record review was conducted with Staff (S)1, S2, and S3. The following medical record containing a STAT (to be done immediately) vascular ultrasound order lacked evidence of interpretation by a vascular provider within 24 hours of the exam completion.

P2's medical record contained a STAT Ultrasound Doppler Venous Legs Bilateral order signed on 10/27/25 at 1:19 PM. The exam was performed on 10/27/25 at 1:41 PM. The result, which showed " ...a normal venous duplex examination of bilateral lower extremities with no evidence of DVT[deep vein thrombosis, blood clot in the vein] ..." was dictated and electronically signed on 10/29/25 at 10:39 AM.

Upon interview, S1 confirmed that the STAT ultrasound tests reviewed should have been read and signed by the vascular provider within 24 hours, in accordance with facility policy. S1 clarified that it was not stated in the old policy, but it was generally expected that the providers complete them within 24 hours. S1 stated the requirement is now explicitly stated in the most updated policy reviewed.