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.

DESOTO MEMORIAL HOSPITAL 900 N ROBERT AVE ARCADIA, FL 34265 July 30, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on staff interview and policy and medical record review, the hospital failed to maintain and demonstrate evidence of functioning governing body to ensure all physicians are knowledgeable and accountable to the facility policies regarding critical findings of radiological services and were accountable to the governing body to ensure safety and appropriate treatments for all patients in the hospital.
The Director of Radiology who is also the Chief of Staff failed to notify the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction for 1 (Patient #10) of 10 sampled patients. This resulted in the patient not receiving a nasal gastric tube and a surgical consult. This contributed to Patient #10 vomiting, cardiac arrest, and death.

1. The hospital's governing body failed to ensure radiology services were provided per the hospital policy and standard of care The hospital's governing body failed to hold physicians accountable to following policy to ensure the safety of patients. These systemic failures constitute an immediate jeopardy situation. Refer to A049, Medical Staff Accountability.

2. The hospital's Governing Body failed to ensure contracted radiology services followed hospital policy and standard of care. The Governing Body failed to ensure contracted physicians/radiologists were aware of the hospital policy for notification of critical findings. Refer to A083 Contracted Services. These systemic failures constitute an immediate jeopardy situation. Refer to A083, Contracted Services.

On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.
The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview and policy and record review the hospital's governing body failed to ensure radiology services were provided per the hospital policy and standard of care for 1 (Patient #10) of 10 sampled patients. The Director of Radiology who is also the Chief of Staff failed to notify the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction. This resulted in the patient not receiving a nasal gastric (NG) tube and a surgical consult. This contributed to Patient #10 vomiting, cardiac arrest, and death. The hospital's governing body failed to hold physicians accountable to following policy to ensure the safety of patients. These systemic failures constitute an immediate jeopardy situation.
On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.

The findings included:

Review of the hospital policy "Critical Test and Critical Results Notification" (reviewed 3/2019) revealed:
"I. Purpose
To identify those exams which are considered 'Critical' as well as the findings deemed critical, and to ensure expedient communication of test results to the appropriate healthcare provider.
II. Policy
...Diagnostic Imaging test results that identify the following conditions include, but are not limited to:
...Bowel Obst. [obstruction] High Grade/Complete (not previously reported) ...
The interpreting radiologist is responsible to report any critical results to the appropriate healthcare provider within 30 minutes of the critical finding in the event of a Stroke Alert, otherwise in all other critical findings the call must be placed within one (1) hour of the critical finding.
III. Procedure
...In the event the critical result is one of the findings listed above, the call must be placed within one (1) hour.
1. Results will be communicated by telephone to the ordering/covering healthcare provider and a preliminary or final report will be faxed by the radiology service provider.
2. If the patient is an inpatient and the ordering/covering healthcare provider cannot be reached by telephone, the radiology service provider will contact the patient's nurse and report the findings ..."

Review of medical records revealed the following:
Patient #10 arrived at the emergency department (ED) on 10/15/18 at 9:49 a.m., via emergency medical services (EMS) for abdominal pain with nausea and diarrhea for 4 days. At 12:47 p.m., while still in the ED, Patient #10 had a CT of the abdomen and pelvis. The findings were no definite evidence of obstruction. At 2:10 p.m., the patient was sent to the intensive care unit (ICU) due to cardiac instability on an intravenous cardiac medication.
On 10/18/18 at 11:27 a.m., Physician Staff A ordered another CT of the abdomen and pelvis as a routine order for abdominal pain. At 1:36 p.m., the results were scanned into the picture archiving computer system (PACS). At 6:46 p.m., the Medical Director of Radiology read the CT scan and wrote 1. Prominent loops of bowel concerning for obstruction. Clinical coordination recommended. There was no documentation the Medical Director of Radiology notified the attending physician of these findings.
On 10/19/18 at 2:43 a.m., an ICU nurse wrote Patient #10 vomited. Heart rate at 55. CPAP (continuous positive airway pressure) machine removed. Code blue called. At 3:10 a.m., the ICU nurse wrote code blue stopped, (Physician Staff A) notified and family. At 4:26 p.m., Physician Staff A wrote on 10/18/18 "during rounds the patient complained of abdominal pain mainly in the right lower quadrant. CT scan of the abdomen was ordered. I was not notified of the results of the abdominal CT scan."

Review of Patient #10's autopsy results signed 1/23/19 documented date of death [DATE]. Summary findings included partial small bowel obstruction/ileus (painful obstruction of the small intestine) identified at autopsy. The pathologist determined cause of death: "Partial Small Bowel Obstruction/Ileus due to Acute Diverticulitis [inflammation of small outpouchings in the large intestine] with Colonic [DIAGNOSES REDACTED] [a malignant tumor of the large intestine]".

In an interview on 7/24/19 at 11:56 a.m., the Director of Diagnostic Imaging said the Medical Director of Radiology had problems in the past calling the physicians with his findings. About 2 years ago a patient had a fractured wrist, and because the attending physician was out of town the fracture went untreated for 2 weeks. She said this was by memory and she did not know exactly when this happened or all the details. She confirmed the hospital policy was that critical findings should be called to the attending physician within 30 minutes. She verified a bowel obstruction was noted in hospital policy as a critical finding.

During an interview on 7/25/19 at 12:04 a.m., the Risk Manager acknowledged she was aware of the incident on 10/19/18 with Patient #10. She could not find any documentation an incident report was ever completed. She said she assisted the attending physician in obtaining Patient #10's autopsy. The Risk Manager confirmed the incident was never reported to the Governing Body.

Review of the hospital diagnostic imaging policy "Delineation of Privileges" (reviewed 3/2019) revealed:
"III. Procedure
A. The Medical Director will establish and maintain an effective working relationship with the Medical Staff, Administration, and other Clinical Departments/Services.
B. The Medical Director will develop and/or approve all Diagnostic Imaging Department policies and procedures..."

In an interview on 7/24/19 at 12:20 p.m., the Medical Director of Radiology/Chief of Staff said he had read both CT scans of the abdomen on 10/15/18 and 10/18/18. He had not notified the primary care physician of the possible bowel obstruction on the 10/18/18 abdominal scan. He stated, "If they ordered a CT scan, it is up to them to look for their studies, it is their problem not mine." The Medical Director of Radiology said he was not aware the patient had died from a bowel obstruction and that an autopsy had been performed. After review of the facility's policy related to radiology critical findings, he confirmed he should have notified the physician of the CT results per the facility policy.

During an interview on 7/26/19 at 9:07 a.m., Staff Hospitalist E said if he ordered a routine CT, he would not expect the results for 24 hours. Staff E said to the risk manager, they needed to change policies to ensure physicians were called with critical results. Staff E was then informed there was a policy for reporting critical findings.

During an interview on 7/26/19 at 11:08 a.m., as the Chief of Staff, he said his authority was from was the medical executive committee.

During an interview on 7/26/19 at 11:10 a.m., the Director of Nursing said the Chief of Staff was in charge of the medical executive committee.

During an interview on 7/26/19 at 11:15 a.m., Staff Hospitalist F said if he ordered a routine CT, he would expect to receive the results within an hour. He said he would expect the radiologist to call him if there was a potential for a bowel obstruction. He said he would want the patient to have an NG tube placed before the patient had surgery.

In an interview on 7/26/19 at 12:05 p.m., Staff Physician A said he remembered Patient #10 and had written an order for a CT that was never called back to him. After being read the results of the CT completed on 10/18/18, the physician said he would have expected the radiologist to have called him with the results. He said he would have gotten a surgical consult and placed a NG tube in the patient to prevent him from vomiting.

During an interview on 7/26/19 at 12:17 p.m., Contracted Radiologist C said he was not aware of the hospital policy regarding calling for critical findings. He said he would have to refer to the Director of Diagnostic Imaging. Staff C said he would not necessarily call the physician if he suspected a bowel obstruction.

In an interview on 7/29/19 at approximately 10:10 a.m., the Director of Quality Assurance verified the Medical Director of Radiology/Chief of Staff was not reporting ED complaints and incidents to the Quality Committee.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the hospital's Governing Body failed to ensure contracted radiology services followed hospital policy and standard of care for 1 (Patient #10) of 10 sampled patients. The Medical Director of Radiology failed to notify the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a potential bowel obstruction. As a result Patient #10 did not receive a tube to prevent vomiting or a surgical consult contributing to his cardiac arrest and death. The Governing Body failed to ensure contracted physicians/radiologists were aware of the hospital policy for notification of critical findings. These systemic failures constitute an immediate jeopardy situation.
On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.

The findings included:

Review of Professional Services Agreement showed the hospital contracted radiology services effective 6/1/13 with automatic one-year extensions. Contract item #1. Engagement included "In no event shall Radiologist or any Physician or Allied Health Professional furnishing services hereunder be deemed to have any relationship with Hospital other than an independent contractor." Item #2.12 included "Radiologist agrees to, and shall cause its Physicians and Allied Health Professionals to, participate in Hospitals' quality assurance program for Radiology Services and Interpretation Services."

Review of the hospital policy "Critical Test and Critical Results Notification" (reviewed 3/2019) revealed:
"I. Purpose
To identify those exams which are considered 'Critical' as well as the findings deemed critical, and to ensure expedient communication of test results to the appropriate healthcare provider.
II. Policy
...Diagnostic Imaging test results that identify the following conditions include, but are not limited to:
...Bowel Obst. [obstruction] High Grade/Complete (not previously reported) ...
The interpreting radiologist is responsible to report any critical results to the appropriate healthcare provider within 30 minutes of the critical finding in the event of a Stroke Alert, otherwise in all other critical findings the call must be placed within one (1) hour of the critical finding.
III. Procedure
...In the event the critical result is one of the findings listed above, the call must be placed within one (1) hour.
1. Results will be communicated by telephone to the ordering/covering healthcare provider and a preliminary or final report will be faxed by the radiology service provider.
2. If the patient is an inpatient and the ordering/covering healthcare provider cannot be reached by telephone, the radiology service provider will contact the patient's nurse and report the findings ..."

Review of medical records revealed the following:
Patient #10 arrived at the emergency department (ED) on 10/15/18 at 9:49 a.m., via emergency medical services (EMS) for abdominal pain with nausea and diarrhea for 4 days. At 12:47 p.m., while still in the ED, Patient #10 had a CT of the abdomen and pelvis. The findings were no definite evidence of obstruction. At 2:10 p.m., the patient was sent to the intensive care unit (ICU) due to cardiac instability on an intravenous cardiac medication.
On 10/18/18 at 11:27 a.m., Physician Staff A ordered another CT of the abdomen and pelvis as a routine order for abdominal pain. At 1:36 p.m., the results were scanned into the picture archiving computer system (PACS). At 6:46 p.m., the Medical Director of Radiology read the CT scan and wrote 1. Prominent loops of bowel concerning for obstruction. Clinical coordination recommended. There was no documentation the Medical Director of Radiology notified the attending physician of these findings.
On 10/19/18 at 2:43 a.m., an ICU nurse wrote Patient #10 vomited. Heart rate at 55. CPAP (continuous positive airway pressure) machine removed. Code blue called. At 3:10 a.m., the ICU nurse wrote code blue stopped, (Physician Staff A) notified and family. At 4:26 p.m., Physician Staff A wrote on 10/18/18 "during rounds the patient complained of abdominal pain mainly in the right lower quadrant. CT scan of the abdomen was ordered. I was not notified of the results of the abdominal CT scan."

Review of Patient #10's autopsy results signed 1/23/19 documented date of death [DATE]. Summary findings included partial small bowel obstruction/ileus (painful obstruction of the small intestine) identified at autopsy. The pathologist determined cause of death: "Partial Small Bowel Obstruction/Ileus due to Acute Diverticulitis [inflammation of small outpouchings in the large intestine] with Colonic [DIAGNOSES REDACTED] [a malignant tumor of the large intestine]".

In an interview on 7/24/19 at 11:56 a.m., the Director of Diagnostic Imaging said the Medical Director of Radiology had problems in the past calling the physicians with his findings. About 2 years ago a patient had a fractured wrist, and because the attending physician was out of town the fracture went untreated for 2 weeks. She said this was by memory and she did not know exactly when this happened or all the details. She confirmed the hospital policy was that critical findings should be called to the attending physician within 30 minutes. She verified a bowel obstruction was noted in hospital policy as a critical finding.

During an interview on 7/25/19 at 12:04 a.m., the Risk Manager acknowledged she was aware of the incident on 10/19/18 with Patient #10. She could not find any documentation an incident report was ever completed. She said she assisted the attending physician in obtaining Patient #10's autopsy. The Risk Manager confirmed the incident was never reported to the Governing Body.

In an interview on 7/24/19 at 12:20 p.m., the Medical Director of Radiology said he had read both CT scans of the abdomen on 10/15/18 and 10/18/18. He had not notified the primary care physician of the possible bowel obstruction on the 10/18/18 abdominal scan. He stated, "If they ordered a CT scan, it is up to them to look for their studies, it is their problem not mine." The Medical Director of Radiology said he was not aware the patient had died from a bowel obstruction and that an autopsy had been performed. After review of the facility's policy related to radiology critical findings, he confirmed he should have notified the physician of the CT results per the facility policy.

During an interview on 7/26/19 at 9:07 a.m., Staff Hospitalist E said if he ordered a routine CT, he would not expect the results for 24 hours. Staff E said to the risk manager, they needed to change policies to ensure physicians were called with critical results. Staff E was then informed there was a policy for reporting critical findings.

In an interview on 7/26/19 at 9:30 a.m., Contracted Radiologist Staff B said he would complete a routine CT with in one hour. When asked about the policy on reporting critical findings to the physician, Staff B said 99% of the CTs he reads are from the ER and considered stat. He said if the CT was ordered from the Intensive Care Unit, he said he would call the physician with the results.

During an interview on 7/26/19 at 11:15 a.m., Staff Hospitalist F said if he ordered a routine CT, he would expect to receive the results within an hour. He said he would expect the radiologist to call him if there was a potential for a bowel obstruction. He said he would want the patient to have a nasal gastric (NG) tube placed before the patient had surgery.

In an interview on 7/26/19 at 12:05 p.m., Staff Physician A said he remembered Patient #10 and had written an order for a CT that was never called back to him. After being read the results of the CT completed on 10/18/18, the physician said he would have expected the radiologist to have called him with the results. He said he would have gotten a surgical consult and placed a NG tube in the patient to prevent him from vomiting.

During an interview on 7/26/19 at 12:17 p.m., Contracted Radiologist C said he was not aware of the hospital policy regarding calling for critical findings. He said he would have to refer to the Director of Diagnostic Imaging. Staff C said he would not necessarily call the physician if he suspected a bowel obstruction.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff interview and policy and medical record review, the hospital failed to prevent the neglect of 1 (Patient #10) of 10 patients sampled for risk management. The Medical Director of Radiology failed to notify the attending physician of the results of a computerized tomography (CT) scan of the abdomen showing a possible bowel obstruction. The lack of notification of this condition delayed the patient receiving a nasal gastric tube to prevent vomiting, and a critical surgical consult. This contributed to Patient #10 going into cardiac arrest and dying. Neglecting to notify the attending physician created an immediate jeopardy (IJ) situation for Patient #10 and any patient with critical CT findings that result in a likely neglect to receive necessary medical services.
These systemic failures constitute an immediate jeopardy situation. Refer to A145, Patient Rights - Free from Abuse.

On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.
The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the hospital failed to prevent neglect for 1 (Patient #10) of 10 patients sampled for risk management. The Medical Director of Radiology (who is also the Chief of Staff) failed to notify the attending physician of the results of a computerized tomography (CT) scan (a series of x-rays) of the abdomen showing a possible bowel obstruction. The lack of notification of this condition delayed the patient receiving a nasal gastric (NG) tube to prevent vomiting, and a critical surgical consult. This contributed to Patient #10 going into cardiac arrest and dying. This systemic failure constituted an immediate jeopardy situation.
On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.

The findings included:

Review of medical records revealed the following:
Patient #10 arrived at the emergency department (ED) on 10/15/18 at 9:49 a.m., via emergency medical services (EMS) for abdominal pain with nausea and diarrhea for 4 days. At 12:47 p.m., while still in the ED, Patient #10 had a CT of the abdomen and pelvis. The findings were no definite evidence of obstruction. At 2:10 p.m., the patient was sent to the intensive care unit (ICU) due to cardiac instability on an intravenous cardiac medication.
On 10/18/18 at 11:27 a.m., Physician Staff A ordered another CT of the abdomen and pelvis as a routine order for abdominal pain. At 1:36 p.m., the results were scanned into the picture archiving computer system (PACS). At 6:46 p.m., the Medical Director of Radiology read the CT scan and wrote 1. Prominent loops of bowel concerning for obstruction. Clinical coordination recommended. There was no documentation the Medical Director of Radiology notified the attending physician of these findings.
On 10/19/18 at 2:43 a.m., an ICU nurse wrote Patient #10 vomited. Heart rate at 55. CPAP (continuous positive airway pressure) machine removed. Code blue called. At 3:10 a.m., the ICU nurse wrote code blue stopped, (Physician Staff A) notified and family. At 4:26 p.m., Physician Staff A wrote on 10/18/18 "during rounds the patient complained of abdominal pain mainly in the right lower quadrant. CT scan of the abdomen was ordered. I was not notified of the results of the abdominal CT scan."

Review of Patient #10's autopsy results signed 1/23/19 documented date of death [DATE]. Summary findings included partial small bowel obstruction/ileus (painful obstruction of the small intestine) identified at autopsy. The pathologist determined cause of death: "Partial Small Bowel Obstruction/Ileus due to Acute Diverticulitis [inflammation of small outpouchings in the large intestine] with Colonic [DIAGNOSES REDACTED] [a malignant tumor of the large intestine]".

In an interview on 7/24/19 at 11:56 a.m., the Director of Diagnostic Imaging said the Medical Director of Radiology had problems in the past calling the physicians with his findings. About 2 years ago a patient had a fractured wrist, and because the attending physician was out of town the fracture went untreated for 2 weeks. She said this was by memory and she did not know exactly when this happened or all the details. She confirmed the hospital policy was that critical findings should be called to the attending physician within 30 minutes. She verified a bowel obstruction was noted in hospital policy as a critical finding.

In an interview on 7/24/19 at 12:20 p.m., the Medical Director of Radiology said he had read both CT scans of the abdomen on 10/15/18 and 10/18/18. He had not notified the primary care physician of the possible bowel obstruction on the 10/18/18 abdominal scan. He stated, "If they ordered a CT scan, it is up to them to look for their studies, it is their problem not mine." The Medical Director of Radiology said he was not aware the patient had died from a bowel obstruction and that an autopsy had been performed. After review of the facility's policy related to radiology critical findings, he confirmed he should have notified the physician of the CT results per the facility policy.

In an interview on 7/26/19 at 12:05 p.m., Staff Physician A said he remembered Patient #10 and had written an order for a CT that was never called back to him. After being read the results of the CT completed on 10/18/18, the physician said he would have expected the radiologist to have called him with the results. He said he would have gotten a surgical consult and placed a NG tube in the patient to prevent him from vomiting.
VIOLATION: QAPI Tag No: A0263
Based on staff interview and policy and medical record review, the hospital failed to ensure radiology services were provided per policy and standard of care for 1 (Patient #10) of 10 patients sampled. The Medical Director of Radiology (who was also the Chief of Staff) failed to notify the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction. This resulted in the patient not receiving a nasal gastric (NG) tube to prevent vomiting and a surgical consult. This contributed to Patient #10 vomiting, cardiac arrest, and death. The QA program failed to ensure radiologists were aware of the hospital policy for notifyng the physician of the critical findings. The QA program failed to prevent neglect and ensure safety of patients. These systemic failures constitute an immediate jeopardy situation. Refer to A286 Patient Safety.

On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.
The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the hospital quality assurance (QA) program failed to ensure radiology services were provided per policy and standard of care for 1 (Patient #10) of 10 patients sampled. The Medical Director of Radiology (who was also the Chief of Staff) failed to notify the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction. This resulted in the patient not receiving a nasal gastric (NG) tube to prevent vomiting and a surgical consult. This contributed to Patient #10 vomiting, cardiac arrest, and death. The QA program failed to ensure radiologists were aware of the hospital policy for notifyng the physician of the critical findings. The QA program failed to prevent neglect and ensure safety of patients. These systemic failures constitute an immediate jeopardy situation.
On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.

The findings included:

Review of the hospital policy "Critical Test and Critical Results Notification" (reviewed 3/2019) revealed:
"I. Purpose
To identify those exams which are considered 'Critical' as well as the findings deemed critical, and to ensure expedient communication of test results to the appropriate healthcare provider.
II. Policy
...Diagnostic Imaging test results that identify the following conditions include, but are not limited to:
...Bowel Obst. [obstruction] High Grade/Complete (not previously reported) ...
The interpreting radiologist is responsible to report any critical results to the appropriate healthcare provider within 30 minutes of the critical finding in the event of a Stroke Alert, otherwise in all other critical findings the call must be placed within one (1) hour of the critical finding.
III. Procedure
...In the event the critical result is one of the findings listed above, the call must be placed within one (1) hour.
1. Results will be communicated by telephone to the ordering/covering healthcare provider and a preliminary or final report will be faxed by the radiology service provider.
2. If the patient is an inpatient and the ordering/covering healthcare provider cannot be reached by telephone, the radiology service provider will contact the patient's nurse and report the findings ..."

Review of medical records revealed the following:
Patient #10 arrived at the emergency department (ED) on 10/15/18 at 9:49 a.m., via emergency medical services (EMS) for abdominal pain with nausea and diarrhea for 4 days. At 12:47 p.m., while still in the ED, Patient #10 had a CT of the abdomen and pelvis. The findings were no definite evidence of obstruction. At 2:10 p.m., the patient was sent to the intensive care unit (ICU) due to cardiac instability on an intravenous cardiac medication.
On 10/18/18 at 11:27 a.m., Physician Staff A ordered another CT of the abdomen and pelvis as a routine order for abdominal pain. At 1:36 p.m., the results were scanned into the picture archiving computer system (PACS). At 6:46 p.m., the Medical Director of Radiology read the CT scan and wrote 1. Prominent loops of bowel concerning for obstruction. Clinical coordination recommended. There was no documentation the Medical Director of Radiology notified the attending physician of these findings.
On 10/19/18 at 2:43 a.m., an ICU nurse wrote Patient #10 vomited. Heart rate at 55. CPAP (continuous positive airway pressure) machine removed. Code blue called. At 3:10 a.m., the ICU nurse wrote code blue stopped, (Physician Staff A) notified and family. At 4:26 p.m., Physician Staff A wrote on 10/18/18 "during rounds the patient complained of abdominal pain mainly in the right lower quadrant. CT scan of the abdomen was ordered. I was not notified of the results of the abdominal CT scan."

Review of Patient #10's autopsy results signed 1/23/19 documented date of death [DATE]. Summary findings included partial small bowel obstruction/ileus (painful obstruction of the small intestine) identified at autopsy. The pathologist determined cause of death: "Partial Small Bowel Obstruction/Ileus due to Acute Diverticulitis [inflammation of small outpouchings in the large intestine] with Colonic [DIAGNOSES REDACTED] [a malignant tumor of the large intestine]".

In an interview on 7/24/19 at 11:56 a.m., the Director of Diagnostic Imaging said Medical Director of Radiology had problems in the past calling the physicians with his findings. About 2 years ago a patient had a fractured wrist, and because the attending physician was out of town the fracture went untreated for 2 weeks. She said this was by memory and she did not know exactly when this happened or all the details. She confirmed the hospital policy was that critical findings should be called to the attending physician within 30 minutes. She verified a bowel obstruction was noted in hospital policy as a critical finding.

During an interview on 7/25/19 at 12:04 a.m., the Risk Manager acknowledged she was aware of the incident on 10/19/18 with Patient #10. She could not find any documentation an incident report was ever completed. She said she assisted the attending physician in obtaining Patient #10's autopsy. The Risk Manager confirmed the incident was never reported to the Governing Body.

In an interview on 7/25/19 at 12:11 p.m., the Director of Quality Assurance said Patient #10's incident had never been reported to her until now. She said she was not aware of the case ever being discussed in any meeting of the Quality Assurance Committee.

In an interview on 7/24/19 at 12:20 p.m., the Medical Director of Radiology said he had read both CT scans of the abdomen on 10/15/18 and 10/18/18. He had not notified the primary care physician of the possible bowel obstruction on the 10/18/18 abdominal scan. He stated, "If they ordered a CT scan, it is up to them to look for their studies, it is their problem not mine." The Medical Director of Radiology said he was not aware the patient had died from a bowel obstruction and that an autopsy had been performed. After review of the facility's policy related to radiology critical findings, he confirmed he should have notified the physician of the CT results per the facility policy.

During an interview on 7/26/19 at 11:08 a.m., as the Chief of Staff, he said his authority was from was the medical executive committee.

During an interview on 7/26/19 at 11:10 a.m., the Director of Nursing said the Chief of Staff was in charge of the medical executive committee.

During an interview on 7/26/19 at 9:07 a.m., Staff Hospitalist E said if he ordered a routine CT, he would not expect the results for 24 hours. Staff E said to the risk manager, they needed to change policies to ensure physicians were called with critical results. Staff E was then informed there was a policy for reporting critical findings.

During an interview on 7/26/19 at 11:15 a.m., Staff Hospitalist F said if he ordered a routine CT, he would expect to receive the results within an hour. He said he would expect the radiologist to call him if there was a potential for a bowel obstruction. He said he would want the patient to have an NG tube placed before the patient had surgery.

In an interview on 7/26/19 at 12:05 p.m., Staff Physician A said he remembered Patient #10 and had written an order for a CT that was never called back to him. After being read the results of the CT completed on 10/18/18, the physician said he would have expected the radiologist to have called him with the results. He said he would have gotten a surgical consult and placed a NG tube in the patient to prevent him from vomiting.

During an interview on 7/26/19 at 12:17 p.m., Contracted Radiologist C said he was not aware of the hospital policy regarding calling for critical findings. He said he would have to refer to the Director of Diagnostic Imaging. Staff C said he would not necessarily call the physician if he suspected a bowel obstruction.

Review of radiology variances record used for QAPI, Patient #10 delayed CT results on 10/18/19 was not included 2018 Radiology Events with assessments.

In an interview on 7/29/19 at approximately 10:00 a.m., the Risk Manager verified she had not looked for a trend in late radiology reports from the incidents and ED complaints in 2019.

In an interview on 7/29/19 at approximately 10:10 a.m., the Director of Quality Assurance verified the Medical Director of Radiology/Chief of Staff was not reporting ED complaints and incidents to the Quality Committee.
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
Based on staff interview and policy and medical record review, the hospital failed to provide radiology services per the policy and standard of care for 1 (Patient #10) of 10 patients sampled. The Medical Director of Radiology failed to notifying the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction resulting in the lack of patient receiving a nasal gastric tube to prevent vomiting and a surgical consult. This contributed to Patient #10's vomiting, his cardiac arrest, and death. The hospital failed to ensure radiologists were aware of hospital policy for notifying the physician of a critical finding. These systemic failures constitute an immediate jeopardy situation. Refer to A529 Scope of Radiologic Services.

On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.
The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.
VIOLATION: SCOPE OF RADIOLOGIC SERVICES Tag No: A0529
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview and policy and medical record review, the hospital failed to provide radiology services per the policy and standard of care for 1 (Patient #10) of 10 patients sampled. The Medical Director of Radiology failed to notifying the attending physician of a critical change in the results of a computerized tomography (CT) of the abdomen showing a possible bowel obstruction resulting in the lack of patient receiving a nasal gastric (NG) tube to prevent vomiting and a surgical consult. This contributed to Patient #10 vomiting, his cardiac arrest, and death. The hospital failed to ensure radiologists were aware of hospital policy for notifying the physician of a critical finding. These systemic failures constitute an immediate jeopardy situation.
On 7/29/19 at 6:00 p.m., the Administrator was informed of the IJ situation which began 10/18/18. The jeopardy was determined removed 7/30/19.

The findings included:

Review of the hospital policy "Critical Test and Critical Results Notification" (reviewed 3/2019) revealed:
"I. Purpose
To identify those exams which are considered 'Critical' as well as the findings deemed critical, and to ensure expedient communication of test results to the appropriate healthcare provider.
II. Policy
...Diagnostic Imaging test results that identify the following conditions include, but are not limited to:
...Bowel Obst. [obstruction] High Grade/Complete (not previously reported) ...
The interpreting radiologist is responsible to report any critical results to the appropriate healthcare provider within 30 minutes of the critical finding in the event of a Stroke Alert, otherwise in all other critical findings the call must be placed within one (1) hour of the critical finding.
III. Procedure
...In the event the critical result is one of the findings listed above, the call must be placed within one (1) hour.
1. Results will be communicated by telephone to the ordering/covering healthcare provider and a preliminary or final report will be faxed by the radiology service provider.
2. If the patient is an inpatient and the ordering/covering healthcare provider cannot be reached by telephone, the radiology service provider will contact the patient's nurse and report the findings ..."

Review of medical records revealed the following:
Patient #10 arrived at the emergency department (ED) on 10/15/18 at 9:49 a.m., via emergency medical services (EMS) for abdominal pain with nausea and diarrhea for 4 days. At 12:47 p.m., while still in the ED, Patient #10 had a CT of the abdomen and pelvis. The findings were no definite evidence of obstruction. At 2:10 p.m., the patient was sent to the intensive care unit (ICU) due to cardiac instability on an intravenous cardiac medication.
On 10/18/18 at 11:27 a.m., Physician Staff A ordered another CT of the abdomen and pelvis as a routine order for abdominal pain. At 1:36 p.m., the results were scanned into the picture archiving computer system (PACS). At 6:46 p.m., the Medical Director of Radiology read the CT scan and wrote 1. Prominent loops of bowel concerning for obstruction. Clinical coordination recommended. There was no documentation the Medical Director of Radiology notified the attending physician of these findings.
On 10/19/18 at 2:43 a.m., an ICU nurse wrote Patient #10 vomited. Heart rate at 55. CPAP (continuous positive airway pressure) machine removed. Code blue called. At 3:10 a.m., the ICU nurse wrote code blue stopped, (Physician Staff A) notified and family. At 4:26 p.m., Physician Staff A wrote on 10/18/18 "during rounds the patient complained of abdominal pain mainly in the right lower quadrant. CT scan of the abdomen was ordered. I was not notified of the results of the abdominal CT scan."

Review of Patient #10's autopsy results signed 1/23/19 documented date of death [DATE]. Summary findings included partial small bowel obstruction/ileus (painful obstruction of the small intestine) identified at autopsy. The pathologist determined cause of death: "Partial Small Bowel Obstruction/Ileus due to Acute Diverticulitis [inflammation of small outpouchings in the large intestine] with Colonic [DIAGNOSES REDACTED] [a malignant tumor of the large intestine]".

In an interview on 7/26/19 at 9:30 a.m., Contracted Radiologist Staff B said he would complete a routine CT with in one hour. When asked about the policy on reporting critical findings to the physician, Staff B said 99% of the CTs he reads are from the ER and considered stat. He said if the CT was ordered from the Intensive Care Unit, he said he would call the physician with the results.

In an interview on 7/24/19 at 12:20 p.m., the Medical Director of Radiology said he had read both CT scans of the abdomen on 10/15/18 and 10/18/18. He had not notified the primary care physician of the possible bowel obstruction on the 10/18/18 abdominal scan. He stated, "If they ordered a CT scan, it is up to them to look for their studies, it is their problem not mine." The Medical Director of Radiology said he was not aware the patient had died from a bowel obstruction and that an autopsy had been performed. After review of the facility's policy related to radiology critical findings, he confirmed he should have notified the physician of the CT results per the facility policy.

In an interview on 7/24/19 at 11:56 a.m., the Director of Diagnostic Imaging said the Medical Director of Radiology had problems in the past calling the physicians with his findings. About 2 years ago a patient had a fractured wrist, and because the attending physician was out of town the fracture went untreated for 2 weeks. She said this was by memory and she did not know exactly when this happened or all the details. She confirmed the hospital policy was that critical findings should be called to the attending physician within 30 minutes. She verified a bowel obstruction was noted in hospital policy as a critical finding.

In an interview on 7/26/19 at 12:05 p.m., Staff Physician A said he remembered Patient #10 and had written an order for a CT that was never called back to him. After being read the results of the CT completed on 10/18/18, the physician said he would have expected the radiologist to have called him with the results. He said he would have gotten a surgical consult and placed a NG tube in the patient to prevent him from vomiting.

During an interview on 7/26/19 at 12:17 p.m., Contracted Radiologist C said he was not aware of the hospital policy regarding calling for critical findings. He said he would have to refer to the Director of Diagnostic Imaging. Staff C said he would not necessarily call the physician if he suspected a bowel obstruction.

Review of radiology variances record used for QAPI, Patient #10 delayed CT results on 10/18/19 was not included 2018 Radiology Events with assessments.

In an interview on 7/29/19 at approximately 10:00 a.m., the Risk Manager verified she had not looked for a trend in late radiology reports from the incidents and ED complaints in 2019.

In an interview on 7/29/19 at approximately 10:10 a.m., the Director of Quality Assurance verified the Medical Director of Radiology was not reporting ED complaints and incidents to the Quality Committee.