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Based on interviews and documentation review the Hospital failed to ensure that an action plan was developed to address the lack of communication and/or documentation of noncritical imaging study discrepancies.

Findings included:

The medical record and documentation review determined that on 12/10/09 the Patient went to the Primary Care Physician (PCP) with complaints of upper abdominal pain, nausea, and fatty food intolerance. The PCP ordered an ultrasound (imaging study that uses sound waves that bounce back and provide images interpreted by a Radiologist).

The Chief of Radiology was interviewed on 3/31/10 at 11:00 A.M. and throughout the survey. The Chief said ultrasounds were more effective in diagnosing gallstones than other imaging studies.

A tour of the Radiology's Department's area where radiology reports were read was conducted on 3/31/10 with the Chief of Radiology and the Director of Quality and Safety. Demonstration and observation determined that when imaging studies were read the requisition and previous images were readily available for comparison/review. Observation of the requisition, completed by the PCP requested the ultrasound to evaluate gallstones. Observation determined the Patient did not have any previous imaging studies for comparison/review.

Review of the requisition for the ultrasound indicated that the ultrasound was requested to evaluate gallstones.

The Radiology Report, dated 12/14/09, indicated that the ultrasound was performed and was read as the Patient having a stone-packed gallbladder.

The Radiologist who interpreted the ultrasound (Radiologist #1) was interviewed on 3/31/10 at 1:15 P.M. Radiologist #1 reported reviewing the requisition and checking for previous images for comparison however; none were available. Radiologist #1 reported reviewing the sonographer's (who performed the ultrasound) worksheet which indicated the presence of gallstones. Radiologist #1 said based on the information available and observation the ultrasound was read as a stone-packed gallbladder.

The Patient's Primary Care Physician (PCP) was interviewed on 3/31/10 at 12:00 P.M. The PCP said that on 12/21/09 the Patient came to the office with complaints of lower left quadrant abdominal pain. The PCP reported sending the Patient to the Hospital's Emergency Department (ED) for further evaluation and did not communicate with the ED regarding the Patient.

Review of the ED documentation, dated 12/21/09, indicated that ED was not aware of the Patient's other symptoms or possible impending gallbladder surgery.

The medical record documentation indicated that on 12/21/09 the Patient went to the Emergency Department (ED) for evaluation at which time a computerized axial tomography (CT) scan (radiographic technique that selects a level in the body and blurs out structures above and below that level) was performed.

The Radiology Report, dated 12/21/10, indicated that the CT scan images were compared to the 12/14/09 ultrasound. The Report indicated the Patient was a post cholecystectomy (removal of the gallbladder).

The Radiologist who read the CT scan (Radiologist #2) was interviewed on 3/31/10 at 10:30 A.M. Radiologist #2 reported not remembering specifics regarding the report. Radiologist
#2 reported the practice was to notify if the discrepancy indicated there was worsening or if the discrepancy was critical.

The surveyor requested the Hospital's policy related to communicating radiology discrepancies and was informed there was no policy.

Review of the medical record documentation indicated that on 1/21/10 the Patient was scheduled for a laparoscopic cholecystectomy which was performed. During the surgery adhesions were released however; there was no gallbladder.

The Hospital conducted an investigation. Review of the investigation findings determined the Hospital identified there was a failure to communicate the imaging study discrepancy however; review of the corrective action plan indicated there was no action developed to address communicating discrepancies.

Based on interviews and documentation review the Hospital failed to ensure the effectiveness of the corrected automatic transmission function in the electronic medical record system.

Findings included:

The Hospital reported the Patient went to the Primary Care Physician (PCP) with complaints of upper abdominal pain, nausea, and fatty food intolerance. The PCP ordered an ultrasound that was performed and was read as the Patient had a stone-packed gallbladder. A surgical consult was scheduled. Prior to the consult the Patient returned to the PCP and complained of left lower quadrant abdominal pain. The PCPsent the Patient to the Emergency Department (ED) for evaluation. Diagnostic testing included a computed tomography (CT) scan was performed. The CT scan was compared to the ultrasound and noted a post cholecystectomy. There were no acute findings and the Patient was discharged to home. Several weeks later the Patient went for the surgical consult as scheduled and again reported having upper abdominal pain with nausea and intolerance of fatty foods. A laparoscopic cholecystectomy was scheduled and was performed. During the surgical procedure adhesions were lysed but no gallbladder was found.

The Director of Quality and Patient Safety was interviewed on 3/31/10 at 12:45 P.M. and throughout the survey. The Director said during the investigation it was determined that radiology reports generated through the ED were not automatically transmitted to the PCP via the Hospital's electronic medical record system. The Director said a patch was put into the system to ensure the reports were automatically transmitted to the PCP if the PCP was identified. The Director said the patch was a temporary solution until the company from whom the system was purchased could permanently correct the transmission function.

During the survey the Surveyor asked the Hospital to provide documented proof of the effectiveness of the function by pulling off randomly selected radiology reports generated through the ED during February and March, 2010 (10 from each month).

The Hospital was able to provide evidence that radiology reports were being automatically transmitted in February, 2010 however; could not provide any for March, 2010.

The Director of Quality and Patient Safety said while performing the random audit for the Surveyor they determined the patch stopped functioning in March, 2010. The Director said the function had not been tested for effectiveness prior to the survey.

Based on documentation review the Hospital failed to ensure that the Surgical Register/Log was completed with the required elements.

Findings included:

Review of the Hospital's Operating List, dated 1/21/10, indicated that the list was generated from data entered into the electronic medical record. The List presented by the Hospital did not include: the total time of the surgery; the name(s) of assistants (if applicable); the name(s) of the circulating nurse and scrub technician; the type of anesthesia used; the name of the Anesthesiologist, or the pre and post-operative diagnoses.