HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff developed the nursing care plan for one of 12 sampled patients (Patient 9) who received the blood transfusion, creating the risk of not providing necessary care and services to meet the care needs for this patient.

Findings:

Review of the hospital's P&P titled Interdisciplinary Plan of Care dated 2/28/24, showed the following:

* Patient problems identified in the plan of care are reviewed by all disciplines caring for the patient.

* The plan of care is updated every 72 hours or when there is a change in the patient's condition. Updates are done by any discipline providing care to the patient.

* The plan of care consists of patient problems, expected outcomes, goals, and interventions/approaches.

On 4/17/25, Patient 9's medical record was reviewed. Patient 9's medical record showed Patient 9 was admitted to the hospital on 4/10/25.

Review of the physician's order dated 4/14/25 at 1833 hours, showed to administer blood product scheduled on 4/15/25 at 1400 hour

Review of the Transfusion Information dated 4/15/25, showed the blood transfusion was started at 1311 hours and ended at 1405 hours.

The Interdisciplinary Plan of Care for Patient 9 was reviewed. However, further review of Patient 9's medical record failed to show the nursing care plan for the blood transfusion.

On 4/18/25 at 1105 hours, the CNO and Director of Quality verified the above findings.

Based on interview and record review, the hospital failed to ensure the written guideline related to transporting patients to other hospital for the MRI examination included the expected turnaround time for the STAT and routine MRIs orders. This failure had the potential to affect overall health and safety of the patients receiving radiologic services.

Findings:

Review of the hospital's P&P titled STAT Diagnostic Testing dated 9/27/23, showed the following:

* Definition of Terms:

- STAT: Tests ordered with an expected turnaround time of approximately one hour.

- ASAP: Tests ordered with an expected turnaround time of approximately two to four hours.

- Routine: Tests generally completed within four to six hours in normal course of the business. Routine imaging studies have a 12- 24 hours turnaround time.

* Policy:

- STAT services are provided on STAT ordered procedures (usually in the case of emergency) within one hour from the time of receipt until the result is released to the unit.

- In the Imaging Services Departments, STAT services are provided on STAT ordered procedures (usually in the case of emergency) in an expected turnaround of approximately one hour from the receipt of order in the Imaging Services clerical department with the exception of head CT's. Turnaround times can be impacted by internal and external variables such as length of exams and equipment. CT scans and diagnostic radiology are available 24 hours, seven days a week.

- For after hours and/or holidays the Nuclear Medicine, MRI, and Ultrasound departments are on call on a 24/7 basis based on patient needs. Time frames can vary due to the re-opening of the department for the exam.

On 4/16/25 at 1000 hours, the Director of Imaging Services was interviewed. When asked, Director of Imaging Services stated the MRI in house was broken since 1/17/25. The Director of Imaging Services stated the MRI would be performed at the sister hospitals. The list of the patients who received MRI orders was requested. Random patients were selected to be reviewed.

On 4/17/25, the medical records of Patients 3, 5, and 7 was reviewed.

1. Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 1/19/25 and discharged on 1/29/25.

Review of the physician's order dated 1/19/25 at 1107 hours, showed to perform MRI brain without contrast STAT.

Review of the Radiology Report dated 1/22/25 at 1358 hours, showed the MRI was completed (three days later).

2. Patient 5's medical record showed Patient 5 was admitted to the hospital on 4/10/25.

Review of the physician's order dated 4/11/25 at 1047 and 1702 hours, showed to perform routine MRI of T Spine with and without contrast and MRI of L Spine with and without contrast respectively.

Review of the Radiology Report dated 4/16/25 at 0809 hours, showed the MRI was completed (five days later).

3. Patient 7's closed medical record showed Patient 7 was admitted on 1/28/25 and discharged on 2/2/25.

Review of the physician's order dated 1/28/25 at 1507 hours, showed to perform STAT MRI of brain without contrast.

Review of the physician's order dated 1/29/25 at 2238 hours, showed the perform routine MRI of brain without contrast. However, the order was canceled on 1/30/25 at 0835 hours, due to duplicate order.

Review of the physician's order dated 1/31/25 at 0831 hours, showed the STAT MRI of brain without contrast originally ordered on 1/28/25 was canceled (three days later).

On 4/17/25 at 0919 hours, the Director of Imaging Services was interviewed. When asked, the Director of Imaging Services stated the written guidelines were developed for the patients who transported to the sister hospitals for the MRI examination.

Review of the documents for transporting the patients to the sister hospitals (undated) failed to show the expected turnaround time for the STAT or routine MRI orders.

On 4/17/25 at 0919 hours,, the Director of Imaging Services verified the above findings.

Based on interview and record review, the hospital failed to ensure the system for the alternative MRI process was tracked and reviewed for the turnaround time of the MRI orders which were performed at their other hospitals. This failure had the risk of not identifying the concerns and missing the opportunity to improve performance.

Findings:

Review of the hospital's Radiology Subsection Rules and Regulations (undated) showed the radiology section will participate in the identification of important aspects of care, indicators used to monitor the quality of the important aspects of care, and evaluation of the indicators. Evaluation of care will be to note trends and patterns of performance to determine if problems or opportunities to improve care exist. When problems or opportunities to improve care are identified, actions will be taken and assessed for effectiveness in accordance with the performance improvement plan. The radiology section shall meet on an Ad-Hoc basis and may schedule regular meetings.

On 4/16/25 at 1000 hours, the Director of Imaging Services was interviewed. When asked, Director of Imaging Services stated the MRI in house was broken since 1/17/25. The Director of Imaging Services stated the MRI would be performed at the sister hospitals.

When requested, the hospital provided the list of patients with MRI orders. Review of the list showed there were 139 MRI orders from 1/17/25 to 4/16/25.

During an interview and record review with the Director of Imaging Service on 4/16 and 4/17/25, the Director of Imaging Services verified the hospital's written guideline related to transporting patients to other hospital for the MRI examination did not include the expected turnaround time for the STAT and routine MRIs orders. Cross reference to A529.

On 4/17/25 at 1430 hours, the Director of Quality was interviewed. When asked, the Director of Quality stated the Radiation Safety Committee meet every three months.

Review of the Radiation Safety Committee Meeting dated 10/10/24 and 1/28/25, failed to show documented evidence of reviewing the turnaround time for MRI orders, which performed in hospital's sister hospitals.

On 4/17/25 at 0919 hours, the Director of Imaging Services verified the above findings.

Based on interview and record review, the hospital failed to ensure the identified issues from the physicist's annual inspections for the MRI, fluoroscopy, and x-ray machines were properly followed up, creating the increased risk of radiation safety hazards.

Findings:

Review of the hospital's Radiology Subsection Rules and Regulations (undated) showed the radiology section will participate in the identification of important aspects of care, indicators used to monitor the quality of the important aspects of care, and evaluation of the indicators. Evaluation of care will be to note trends and patterns of performance to determine if problems or opportunities to improve care exist. When problems or opportunities to improve care are identified, actions will be taken and assessed for effectiveness in accordance with the performance improvement plan. The radiology section shall meet on an Ad-Hoc basis and may schedule regular meetings.

1. Review of the MRI Annual System Performance Evaluation dated 7/15/24, showed "during the survey it was noticed that the foot/ankle coil is falling apart. There is a tear in the cord, the base is cracked, pieces are falling off. This is a hazard to the patient and should no longer be used until it can be replaced."

On 4/18/25 at 1020 hours, the Director of Quality was interviewed in the presence of the CNO. When asked, the Director of Quality stated the foot/ankle coil was not used. The radiology department was able to use other coils. When asked, if the resolution was followed up on the recommendations, the Director of Quality was not providing the answer.

2. Review of the Medical Physicist's Annual Survey for Fluoroscopy machine used in Angiography suite dated 7/9/24, showed the test for Disp. Air Kerma was failed.

Review of the Medical Physicist's Annual Survey for C- Arm Fluoroscopy used in Cath Lab A dated 7/9/24, showed the test for exposure rate was failed.

Review of the Medical Physicist's Annual Survey for Fluoroscopy machine used in Cath Lab A dated 7/9/24, showed the test for exposure rate and Disp. Air Kerma were failed.

Review of the Medical Physicist's Annual Survey for Fluoroscopy machine used in Cath Lab B dated 7/9/24, showed the test for the Disp. Air Kerma were failed.

Review of the Medical Physicist's Annual Survey for X-ray Machine used in dated 7/9/24, showed the test for the Disp. Air Kerma were failed.

Review of the Radiation Safety Committee Meeting dated 10/10/24 and 1/28/25, failed to show documented evidence the above physicist's reports had been reviewed.

On 4/18/25 at 1105 hours, the CNO and the Director of Quality verified the above findings.