The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JOHNS HOPKINS BAYVIEW MEDICAL CENTER 4940 EASTERN AVENUE BALTIMORE, MD 21224 March 1, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the complaint/grievance policy and patient #1 complaint file, the hospital failed to acknowledge receipt of the complaint in a timely manner, the hospital did not notify the patient of follow-up to the complaint, nor once the investigation was completed, did the hospital inform the patient of the results of the investigation or actions taken.

Patient #1 is [AGE] year old female who presented to John Hopkins Bayview Medical Center (JHBMC) following a MVA on 2/7/09. The patient was in the rear passenger seat and seat-belted. The patient was brought in by ambulance and taken to trauma at 11:24 P.M. The patient other medical diagnosis include [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED]. The patient complained of mid-line neck pain/tender to palpation. Patient #1 had CT scan of the the cervical spine without contrast. The CT scan findings documented on the report: disc disease of moderate degree and spondylosis (degenerative arthritis) is present in the C-spine. No fractures, subluxation, or dislocation as seen. The spinal cord appears intact. The impression was that the patient had a left thyroid nodule meeting criteria for biopsy. The patient also had moderate degree of spondylosis and disc disease C-spine. After discharge the patient reported continued neck pain. She had months of physical therapy without relief of pain. The patient had cervical spine x-ray , which revealed a fracture of C2 vertebra that required surgery and physical therapy.

Patient #1 wrote a letter to John Hopkins Bayview Medical Center. The letter was dated 2/7/10. The patient stated she was writing the letter to inform the hospital of the medical error that occurred in the ED. Patient #1 stated she was not seeking compensation, rather an understanding of what happened and corrective actions taken on the hospital part so that no one else faces the same risk. Per the complaint file the complaint was received on 2/9/10. Below please note the timeline of communication between the hospital and the patient.

On 2/7/10 patient #1 sent a letter of complaint to John Hopkins Bayview Medical Center.
On 2/9/10 patient relations left a voice mail message for patient #1.
On 3/8/10 patient relations sent acknowledgement letter to patient #1.
On 4/8/10 patient relations called and reached patient #1.
There was no contact from the hospital with patient #1 until 7 months later the patient called patient relations on 11/29/10 disturbed that she had not received any further follow-up
On 11/29/10 patient relations left voice mail message for patient #1.
On 11/30/10 the patient returned the call to patient relations.
12/2/10 patient relations called patient #1 informing additional input needed.
12/11/10 to 12/18/10 the patient informed the hospital she would be away.
On 12/22/10 patient sent another letter to John Hopkins Bayview Medical Center inquiring about the investigation into her complaint as well as sending along a copy of the first letter sent on 2/7/10.
On 1/7/11 patient relations sent a response letter to patient #1. The letter did not address the patient concern that she was not informed of a C2 fracture evident on the CT scan nor did it address any corrective actions taken.

The hospital complaint/grievance policy and procedure under procedure on page 2, starting with #4. states all grievances received after the inpatient/outpatient visit will be entered into the database and a written acknowledgement of receipt given to the complainant within 7 business days and #5. The appropriate JHMI personnel will investigate the complaint and/or grievance. Upon completion of the investigation, a written or verbal response will be given to the patient and/or patient's representative within 15 to 30 working days of complaint/grievance receipt. Should additional investigation time be required, the patient and/or representative will be notified and kept informed until the investigation is complete. The response may include actions.

Per the above time-line the patient did not receive written acknowledgement of her complaint until 30 days latter instead of the 7 days per policy. Once the acknowledgement letter had been sent to patient #1, the hospital's patient relations contacted the patient by phone, which was 60 days after the initial receipt of the complaint. After this 4/8/10 telephone call from the hospital, it's as if the complaint investigation dropped off the radar. There was no documented contact between the hospital and patient #1, until the patient contacted the hospital on [DATE]. It is evident via the time line that the hospital was not compliant with its own policy and did not meet the requirements in appropriate handling of complaints/grievances.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical records, it was determined that the hospital failed to provide impartial quality oversight in the review of the radiology reports of patient #1 as evidenced by:

Patient #1 is [AGE] year old female who presented to John Hopkins Bayview Medical Center (JHBMC) following a MVA on 2/7/09. The patient was in the rear passenger seat and seat-belted. The patient was brought in by ambulance and taken to trauma at 11:24 P.M. The patient other medical diagnosis include [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED]. The patient complained of mid-line neck pain/tender to palpation. Patient #1 had CT scan of the the cervical spine without contrast. The CT scan findings documented on the report: disc disease of moderate degree and spondylosis (degenerative arthritis) is present in the C-spine. No fractures, subluxation, or dislocation as seen. The spinal cord appears intact. The impression was that the patient had a left thyroid nodule meeting criteria for biopsy. The patient also had moderate degree of spondylosis and disc disease C-spine. After discharge the patient reported continued neck pain. She had months of physical therapy without relief of pain. The patient had cervical spine x-ray, which revealed a fracture of C2 vertebra that required surgery and physical therapy.

The patient had her CT scan performed at JHBMC on 2/8/09. The images were reviewed and findings dictated by a radiologist on 2/8/09 at 12:53 A.M. The second radiologist reviewed the images and findings and agreed with the first physician as evidenced by the statement "Images and dictation were personally reviewed by attending radiologist, his name, staff identification number and electronically signed by both reviewers." This information was conveyed to the attending physician in the ED who discharge the patient with inaccurate information. The C2 fracture was not acknowledged on the radiology report.

Per the hospital investigation, when the patient complained to the hospital in February 2010, the CT scan was reviewed by the Chairman of the Department of Radiology. The retrospective review revealed the following findings: "According to the radiologist/department chair, the cervical CT demonstrated a corticated defect in the lamina of C2, bilaterally. In addition there was a slight cortical defect in the posterior odontoid. No swelling was evident around C1 or C2. The radiologist reported that those findings were suggestive of a relatively distant fracture - rather than an acute fracture of C2. The bony defects were not appreciated due to lack of soft tissue swelling, which is expected in an acute fracture." This quality retrospective review was also performed by the Chairman of the department, who in fact performed the second read within twenty-four hours of the initial read and agreed with the findings of the initial review. The practice of allowing the Chairman of the department who had initially performed one of the reviews of the films to do the quality review does not provide objective, unbiased oversight of the care being provided.

The radiology standard of practice is to report all abnormal findings. The radiologist may expound on the findings noting for example if the finding is acute or evidence of degenerative process. The patient was not informed of the C2 fracture regardless of whether it was acute or distant, which led to a delay in diagnosis.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical records, it was determined that the hospital failed to provide impartial quality oversight in the review of the radiology reports of patient #1 as evidenced by:

Patient #1 is [AGE] year old female who presented to John Hopkins Bayview Medical Center (JHBMC) following a MVA on 2/7/09. The patient was in the rear passenger seat and seat-belted. The patient was brought in by ambulance and taken to trauma at 11:24 P.M. The patient other medical diagnosis include [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED]. The patient complained of mid-line neck pain/tender to palpation. Patient #1 had CT scan of the the cervical spine without contrast. The CT scan findings documented on the report: disc disease of moderate degree and spondylosis (degenerative arthritis) is present in the C-spine. No fractures, subluxation, or dislocation as seen. The spinal cord appears intact. The impression was that the patient had a left thyroid nodule meeting criteria for biopsy. The patient also had moderate degree of spondylosis and disc disease C-spine. After discharge the patient reported continued neck pain. She had months of physical therapy without relief of pain. The patient had cervical spine x-ray, which revealed a fracture of C2 vertebra that required surgery and physical therapy.

The patient had her CT scan performed at JHBMC on 2/8/09. The images were reviewed and findings dictated by a radiologist on 2/8/09 at 12:53 A.M. The second radiologist reviewed the images and findings and agreed with the first physician as evidenced by the statement "Images and dictation were personally reviewed by attending radiologist, his name, staff identification number and electronically signed by both reviewers." This information was conveyed to the attending physician in the ED who discharge the patient with inaccurate information. The C2 fracture was not acknowledged on the radiology report.

Per the hospital investigation, when the patient complained to the hospital in February 2010, the CT scan was reviewed by the Chairman of the Department of Radiology. The retrospective review revealed the following findings: "According to the radiologist/department chair, the cervical CT demonstrated a corticated defect in the lamina of C2, bilaterally. In addition there was a slight cortical defect in the posterior odontoid. No swelling was evident around C1 or C2. The radiologist reported that those findings were suggestive of a relatively distant fracture - rather than an acute fracture of C2. The bony defects were not appreciated due to lack of soft tissue swelling, which is expected in an acute fracture." This quality retrospective review was also performed by the Chairman of the department, who in fact performed the second read within twenty-four hours of the initial read and agreed with the findings of the initial review. The practice of allowing the Chairman of the department who had initially performed one of the reviews of the films to do the quality review does not provide objective, unbiased oversight of the care being provided.

The radiology standard of practice is to report all abnormal findings. The radiologist may expound on the findings noting for example if the finding is acute or evidence of degenerative process. The patient was not informed of the C2 fracture regardless of whether it was acute or distant, which led to a delay in diagnosis.