HospitalInspections.org

Based on document review and staff interview, the governing body failed to ensure the facility's policy "COMPLAINT MECHANISM" was followed related to a patient concern regarding the quality of care provided.

Findings include:

1. A complaint was received related to the care provided to patient #1. The facility was notified on 12/11/11 that patient #1 was released with no diagnosis of rib fractures on 12/11/11 and went to facility #2 and was diagnosed with multiple rib fractures and a pneumothorax. There was no follow-up to the complaint.

2. Facility policy titled "COMPLAINT MECHANISM (Guest/Customer Satisfaction)" last reviewed/revised 3/09 states on page 1: "1. Serious - Any matter that, in the perception of (facility #1) staff member, affects the immediately quality of care or safety of the guest, customer, or staff involved."............. "When a serious complaint is received, the (facility #1) hospital staff member will immediately investigate the claim with the assistance of the proper Department director or Supervisor, if available, or the Guest Relations Director to resolve the complaint. All attempts to immediately resolve the complaint should be made. The (facility #1) staff members should complete the Service Recovery Form. The form will be submitted to the Department Director or Supervisor who will forward it to the Director of Risk Management."

3. Staff member #3 (ED director) indicated the following in interview beginning at 11:40 a.m. on 2/1/12:
(A) He/she "dropped the ball" on complaint called in by family of patient #1 and did not follow-up.

Based on document review, the facility failed to ensure hospital wide and radiology policies were reviewed annually.

Findings include:

1. Facility policy titled "COMPLAINT MECHANISM (Guest/Customer Satisfaction)" was last reviewed/revised 3/09.

2. Facility policy titled "CONFIDENTIALITY/RELEASE OF INFORMATION" was last reviewed/revised 10/07.

3. Facility policy titled "DISCREPANCIES WITH RADIOLOGY" was effective 3/1/09 with no review/revision update.

4. Staff member #2 verified the above at 1:20 p.m. on 2/1/12.

Based on document review and staff interview, the facility failed to have an effective quality assurance (QA) program to monitor radiology misreads by the contracted radiology group.

Finding include:

1. Review of patient #1 medical record indicated the following:
(A) He/she presented to the E.D. via ambulance at 3:08 a.m. on 12/11/11 (Sunday) after being a restrained driver in a motor vehicle accident.
(B) A chest x-ray was ordered and M.D. #1 interpreted the chest x-ray as "no rib fractures seen- no pneumo".
(C) The chest x-ray was read by M.D. #2 (contracted radiologist) in radiology at 11:21 a.m. on 12/12/11 as "There are a couple of linear opacities at the left lung base consistent with subsegmental atelectasis. No mediastinal widening, focal contusion, pulmonary edema or pleural effusion is seen. There is no fracture."

2. M.D. #3 indicated the following in interview at 12:40 p.m. on 2/1/12: (request made for him/her to read chest x-ray of patient #1 on 2/1/12)
(A) Chest x-ray of patient #1 revealed acute lateral left 6th and 7th rib fractures. No pneumothorax was seen.

3. Per telephone interview with staff member #5 at facility #2 at 4:30 p.m. on 2/2/12, a 2-view chest x-ray at facility #2 on 12/11/11 confirmed that patient #1 had rib fractures as well as a pneumothorax.

4. Staff member #2 indicated the following in interview beginning at 1:45 p.m. on 2/1/12:
(A) There is no QA conducted by the facility on the contracted radiology service, therefore misreads would not be found.