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Based on record review, policy review, and interviews, the hospital failed to ensure the safety of 1 (Patient #1) of 4 patients sampled. The standard of practice for managing critical radiology findings for dissections was not properly implemented for emergent and life-threatening conditions, contributing to the death of Patient #1.

Refer to A0144 Patient Rights: Care in a Safe Setting, CFR 482.13.

The facility provided an Immediate Jeopardy removal plan on 09/11/2025. The immediacy was determined to be removed 2:30 PM on 09/11/2025.
The actions included:
Review of physician Quality of Care, Medical Staff Peer Review Process Completed Completion Date: 7/15/25
The physician will complete the education modules in Emergency Medicine minefield navigator focusing on management of life-threatening emergencies and effective inter physician communication. The physician must submit proof of completion to Medical Staff Office within 60 days. Completion Date: 9/1/25
Review of policy and procedure for diagnostic imagining related to CVA (Cerebrovascular Accident, which is another name for a stroke) vs TIA (transient ischemic attack, is a "mini-stroke") to include CTA (Computed Tomographic Angiography, a medical imaging technique) evaluation. Completion Date: 7/15/25
Review of Communication of Critical Results Policy and Procedure Meeting conducted on 8/7/2025 including MEC Chair and Radiology Chair. Meeting conducted on 8/13/2025 including MEC (Medical Executive Committee) Chair, and Radiology Chair, and CMO (Chief Medical Officer). Completion Date: 8/13/2025
Creation of Standardized Pathway for Type A (Type A dissecting aortic aneurysm is a medical emergency where the inner layer of the aorta tears in the ascending aorta, the part that curves up from the heart) & B (Type B aortic dissection is a tear in the inner layer of the aorta, specifically in the descending aorta (the lower part of the aorta))Aortic Dissections. Completion Date: 9/9/2025
Creation of Standardized Pathway for Carotid Dissections (a condition where the inner lining of the carotid artery, which carries blood to the brain, tears or separates). Completion Date: 9/9/25
Process for Communication of Critical Radiology Results. Completion Date: 9/11/25, and ongoing
Audits of communication and outcome of critical radiology results will be conducted by Medical Staff and Quality Improvement on a daily basis for 4 weeks, and then monthly for 3 months, then quarterly thereafter. Results will be reported to: Medical Staff Peer Review Committee meeting monthly x 6 months, Board Clinical Excellence Committee meetings x 3 meetings (or ongoing if issues arise).

Based on record review, interviews, policy review, and facility corrective action review, the hospital failed to ensure appropriate communication mechanisms were implemented for delivering critical imaging results to appropriate Medical Staff during a medical emergency, and that an appropriate corrective action plan was implemented after identification of a serious adverse event that resulted in the cardiac arrest and death of Patient #1.

Refer to A0286 Patient Safety, CFR 482.21.

Based on record review, policy review, corrective action plan review and interviews, the hospital failed to ensure continuity of communication between physicians regarding critical radiological (imaging) results, implement an emergent consult to a cardiothoracic surgeon, and transfer to a higher level of care, resulting in the discharge and death of 1 (Patient #1) of 4 patients sampled. Failure to communicate, treat and transfer resulted in the death of Patient #1.

Refer to A0347 Medical Staff Organization and Accountability, CFR 482.22


Review of physician Quality of Care, Medical Staff Peer Review Process Completed Completion Date: 7/15/25
The physician will complete the education modules in Emergency Medicine minefield navigator focusing on management of life-threatening emergencies and effective inter physician communication. The physician must submit proof of completion to Medical Staff Office within 60 days. Completion Date: 9/1/25
Review of policy and procedure for diagnostic imagining related to CVA (Cerebrovascular Accident, which is another name for a stroke) vs TIA (transient ischemic attack, is a "mini-stroke") to include CTA (Computed Tomographic Angiography, a medical imaging technique) evaluation. Completion Date: 7/15/25
Review of Communication of Critical Results Policy and Procedure Meeting conducted on 8/7/2025 including MEC Chair and Radiology Chair. Meeting conducted on 8/13/2025 including MEC (Medical Executive Committee) Chair, and Radiology Chair, and CMO (Chief Medical Officer). Completion Date: 8/13/2025
Creation of Standardized Pathway for Type A (Type A dissecting aortic aneurysm is a medical emergency where the inner layer of the aorta tears in the ascending aorta, the part that curves up from the heart) & B (Type B aortic dissection is a tear in the inner layer of the aorta, specifically in the descending aorta (the lower part of the aorta))Aortic Dissections. Completion Date: 9/9/2025
Creation of Standardized Pathway for Carotid Dissections (a condition where the inner lining of the carotid artery, which carries blood to the brain, tears or separates). Completion Date: 9/9/25
Process for Communication of Critical Radiology Results. Completion Date: 9/11/25, and ongoing
Audits of communication and outcome of critical radiology results will be conducted by Medical Staff and Quality Improvement on a daily basis for 4 weeks, and then monthly for 3 months, then quarterly thereafter. Results will be reported to: Medical Staff Peer Review Committee meeting monthly x 6 months, Board Clinical Excellence Committee meetings x 3 meetings (or ongoing if issues arise).

Based on record review, policy review and interviews, the hospital failed to ensure the standard of care was followed for reporting critical imaging results prior to discharge for 1 (Patient #1) of 4 patients sampled. Failure to follow the standard of care resulted in the death of Patient #1.

Findings included:

A review of the medical record for Patient #1 reflected Patient #1 came to the hospital ED (Emergency Department) by ambulance on 6/26/2025 for stroke-like symptoms, that resolved in the ambulance on the way to the hospital. A Doppler ultrasound of the neck and carotid arteries was completed in the ED and showed findings of an abnormality concerning for dissection of the right carotid artery. Patient #1 was admitted for further observation and testing. On 6/27/2025 a CT (computed tomography) angiogram of the neck and carotid arteries was completed. During the imaging study, Staff D, CT Coordinator, communicated findings of right carotid artery dissection along with Type A thoracic aorta dissection. This was also communicated to Staff A, Hospitalist by Staff F, RN (Registered Nurse), who had been informed by Staff B, Radiologist, after he interpreted the imaging. Staff A, Hospitalist indicated in his Discharge Summary, that this was communicated with and discussed with Neurologist, Staff C, who recommended anticoagulation therapy (blood thinners) and follow-up outpatient with neurology. The patient was discharged home with a diagnosis of TIA-transient ischemic attack (pre-stroke symptoms), and instructions to take aspirin and Plavix, and follow up with a neurologist in 3 weeks. Upon review of the imaging results the next day, 6/28/25, the Neurologist, Staff C, discovered the Type A thoracic dissection. She attempted to contact Patient #1 and was unable to reach her directly but did speak to the patient's family member and told him of the emergent nature of the findings and advised him Patient #1 needed to return to the ED immediately. Patient #1 did not return. However, the next day, 6/29/25 at 6:15 PM she was brought in by ambulance in cardiac arrest. Patient #1 was unable to be revived, and the time of death was called in the ED at 6:28 PM.

Review of the policy, Communication of Stroke, Critical Results, and Stat/Wet Read, January 2024, revealed the following:
Critical Results Communication (Excluding Storke Alerts) or Exams made Stat/wet Read by Radiologist
Any critical finding, as identified by the reading radiologist, will be communicated to the appropriate healthcare provider as outlined below:
Reading Radiologist communicates critical results to Ordering Physician and/or ISR/ISOA (Imaging Services Representative/Imaging Services Operations Specialist).
ISR/ISOA confirms critical communication result between Radiologist and Ordering Physician (or Hospitalist that has assumed care for the patient if shift change occurs), as follows:
Scenario A
If the Radiologist confirmed contact with the ordering physician, ISR/IOA will document protocol in RIS (Radiologist Information System) to include date, time, and name of physician spoken to.
Scenario B:
If the Radiologist is unable to confirm contact with the Ordering Physician, ISR/IOA will contact the Ordering Physician, relay the results, and ask if they wish to be connected with the Radiologist.

During an interview on 09/09/2025 at 10:10 AM, Staff G, Radiologist, stated he calls the referring physician or ordering physician, but if he cannot reach them then he calls the floor nurse. If he cannot get the floor nurse, then he would call the supervisor. An urgent finding requires a call. Often the ordering physician is either not available, or he cannot find the number to call him in the system. Sometimes the ordering physician will call back.

During an interview on 09/09/2025 at 10:13 AM, Staff D, CT coordinator, stated she called the attending Staff A, hospitalist, to ask if he wanted more scans. He said it is not in his scope; it was neurology and that he was just the ordering physician. Staff A, Hospitalist, suggested a stat neurology consult. "We were in the process of still doing the study. It hadn't been sent yet." The radiologist cannot do anything until the images are in the computer. Staff D, CT Coordinator, said she called Staff B, Radiologist, for a stat read. She called the nurse after she spoke to Staff A, hospitalist. The patient's nurse was busy, so she called the charge nurse. There has been no change to communication that she is aware of.

During an interview on 09/09/2025 at 1:20 PM, the Manager of Imaging stated most of the time a critical report goes from the radiologist to the ordering physician. It goes from the report to the nurse to the doctor. The doctor can call the radiologist with questions. Staff D, CT Coordinator called the physician because she saw the abnormality and wanted to know if he wanted to expand the scan, because it is easier to do it while we're there. Otherwise, if they sent the patient back, they would have to insert another IV (intravenous), get another big order block set. It is a courtesy so we can do it while we're there. They cannot ask the radiologist to order an expanded test, they have to call the ordering physician. Staff D, CT Coordinator wasn't calling to report the result, she was asking how far up (arteries) he wanted her to look. The radiologist is the only one who can read results. The physician can request a technologist to read a report, but the results are only provided by the radiologist. She was letting him know there was a finding and asking if he wanted to expand the scan.

During a group interview on 09/10/2025 at 10:40 AM with the Quality Director and the Risk Manager (RM), the Quality Director said radiology called the nurse. The nurse used the patient safe phone and texted Staff A, Hospitalist, the results. We have a high level of confidence that the hospitalist knew what the radiologist saw so he called Staff C, Tele-Neurology. Now, it is he said, she said. Staff A, Hospitalist said he told Staff C, Neurologist, there was a Type A dissection. Staff C, Neurologist, said if she knew it was Type A aortic dissection, she would not have discharged the patient. Staff A should have called cardiothoracic surgery. Then, Risk Manager disclosed that there were two things going on at the same time. Staff D, CT Coordinator, noticed it (the dissection) was extending and called Staff A, Hospitalist. She asked if he wanted further scans. He said no. He stated he wanted a stat consult with neurology. At the same time, the radiologist received the images and called the nurse with the results. The nurse texted Staff A, Hospitalist, with the results. He said to do a stat neurology consult. He talked to the Neurologist, Staff A, and the plan was for anticoagulation, to discharge home and follow-up outpatient because it was a carotid dissection. Staff A, Hospitalist, knew about it. He did not understand what he had. The report was not available when he was making those decisions. He did not understand what he was looking at. Staff C, Neurologist, said she was doing an audit. She said she looks at all her charts and does an audit, and because she did not see the scan report yet. When she tried to call Patient #1, she did not answer. When the voice mail came on there wasn't enough identifying information for her to leave a voice mail. She called the family member who was on the Face Sheet and was in the room on the day of discharge. The family member said she was out shopping and wouldn't answer her phone. Staff C, Neurologist, communicated that Patient #1 needed to be brought back to the hospital. Patient #1 never came back. She refused the CTA initially in the ED. It would have been caught in the ED, and she would have been transferred. The hospitalists never see these. The patients are transferred out. Staff A, Hospitalist, said he never sees these. He did not know what to do. Since the neurologist ordered the test, he called her. The neurologist said she was under the impression they were still discussing the carotid dissection, and that's why she told him to continue the current treatment plan. It was almost 25 hours after they found the dissection that she came back through the ED. The only reason we knew about it was that the CT technologist was working in the ED CT and recognized the name.

During a telephone interview on 09/10/2025 at 10:43 AM, Staff A, Hospitalist, said Patient #1 came with neurologic symptoms. The Neurologist ordered a CT scan. The study was obtained and the technologist called about the abnormality. Staff A, Hospitalist said he discussed it with Staff C, Neurologist, and she thought it was carotid dissection, not aortic. She based the treatment on the ultrasound report, which was an ambiguous element of abnormality. She ordered a CT angiogram the next morning routine, but he changed it to stat because the patient wanted to go home. Staff A, Hospitalist said he communicated the discharge plan with the patient and she was in agreement. The neurologist said it was ok for carotid and thoracic dissection. The patient was hemodynamically stable (describes a patient whose vital signs, including heart rate, blood pressure, and oxygen saturation, are within normal ranges, indicating that their circulatory system is functioning adequately without immediate risk of life-threatening complications) and was discharged.

Based on record review, policy review, facility corrective action plan review, and interviews, the hospital failed to ensure corrective measures were implemented, including a plan to monitor, track, trend, and analyze, after a serious adverse event was identified that resulted in the death of Patient #1, for 1 of 1 QAPI (Quality Assurance Performance Improvement) plan.

Findings included:

A review of the medical record revealed Patient #1 came to the hospital ED (Emergency Department) by ambulance on 6/26/2025 for stroke-like symptoms, the symptoms resolved in the ambulance on the way to the hospital. An ultrasound of the neck and carotid arteries was completed in the ED and findings showed an abnormality concerning dissection of the right carotid artery. Patient #1 was admitted for further observation and testing. On 6/27/2025 a CT (computed tomography) angiogram (a medical imaging technique that uses X-rays to create detailed images of blood vessels) of the neck and carotid arteries was completed. During the imaging study, Staff D, CT Coordinator, communicated findings of right carotid artery dissection along with Type A thoracic aorta dissection (a life-threatening condition where the inner layer of the aorta (the main artery that carries blood from the heart to the body) tears and separates, creating a new channel (false lumen) within the aortic wall) to Staff A, Hospitalists. This was also communicated to Staff A, Hospitalist by Staff F, RN (Registered Nurse), who had been informed by Staff B, Radiologist, after he interpreted the imaging. Staff A, Hospitalist indicated in his Discharge Summary, that this was communicated and discussed with Staff C, Neurologist who recommended anticoagulation therapy (blood thinners) and follow-up outpatient with neurology. The patient was discharged home with a diagnosis of TIA-transient ischemic attack (pre-stroke symptoms) with instructions to take aspirin and Plavix and follow up with a neurologist in 3 weeks. Upon review of the imaging results the next day, 6/28/2025, the Staff C, Neurologist, discovered the Type A thoracic dissection. She attempted to contact Patient #1 and was unable to reach her but did speak to the patient's family member. Staff C, Neurologists informed the family member the emergent nature of the findings and advised Patient #1 needed to return to the ED immediately. Patient #1 did not return. The next day, 6/29/2025 at 6:15 PM, Patient #1 was brought in by ambulance in cardiac arrest. Patient #1 was unable to be revived, and the time of death was called in the ED at 6:28 PM.

Review of the policy, Communication of Stroke, Critical Results, and Stat/Wet Read, January 24, revealed the following:
Critical Results Communication (Excluding Storke Alerts) or Exams made Stat/wet Read by Radiologist
Any critical finding, as identified by the reading radiologist, will be communicated to the appropriate healthcare provider as outlined below:
Reading Radiologist communicates critical results to Ordering Physician and/or ISR/ISOA (Imaging Services Representative/Imaging Services Operations Specialist).
ISR/ISOA confirms critical communication result between Radiologist and Ordering Physician (or Hospitalist that has assumed care for the patient if shift change occurs), as follows:
Scenario A
If the Radiologist confirmed contact with the ordering physician, ISR/IOA will document protocol in RIS (Radiologist Information System) to include date, time, and name of physician spoken to.
Scenario B:
If theRradiologist is unable to confirm contact with the Ordering Physician, ISR/IOA will contact the ordering physician, relay the results, and ask if they wish to be connected with the radiologist.

Review of facility corrective action dated 7/14/2025 reflected the following actions:
1. Collaboration with Radiology concerning the communication of life threatening
critical results between physicians. Review policy NCL 0039 (Critical Results, Communication of) for clarification of acceptable recipients of critical values. Discuss the expansion of diagnostic imaging pathways when life threatening and critical results are identified.
2. Development of pathways and algorithms for inpatient treatment of all types of dissections to include placement, transfers, consultations, and additional
diagnostic testing.

Review of electronic communication from the CMO to the department heads of the hospitalist groups, dated 9/2/2025 reflected a Subject: Radiology Communication:
See attached meeting minutes regarding communication of radiology results. I have highlighted a phone number just in case the provider wants to connect with radiology to verify/discuss the radiology results. Attached was meeting minutes from August 13, 2025 regarding no change to the policy, but included the direct line with extension for providers to contact the Radiologist.

Review of electronic communication sent to all hospitalists on 9/9/25 at 9:24 PM reflected the development of Pathways for Carotid Dissection-Symptomatic Patients, Type A Aortic Dissection, and Type B Aortic Dissection.
Additional corrective action review reflected electronic communication from the Quality Director, dated 9/10/2025, addressed to the Manager of Imaging and the Supervisor of Imaging: Educate and implement new process and train team members, due date 10/1/2025. Distribute AOD (Administrator on Duty) and the hospital phone directory, hospitalist phone list, and ED physician list to other team members for communication after business hours and on weekends. Due date 10/1/25.

A review of the 2025 QAPI Plan reflected the following:
Scope:
Quality Improvement and Patient Safety activities are conducted with an interdisciplinary approach between hospital and medical staff and include inpatient and outpatient services provided at the hospital.
Sentinel Events
Risk Management department tracks, trends, collects data, and reports events
WINTER HAVEN HOSPITAL CLINICAL EXCELLENCE COMMITTEE (CEC) OF THE BOARD
The Clinical Excellence Committee of the Board (Board CEC) derives its authority from the Board of Trustees. The Committee has been delegated the responsibility for oversight of the continuous improvement of the organization's processes. Board CEC shall be responsible for oversight of the quality philosophy and process. Implementation of improvement actions is the responsibility of hospital administration and medical staff leadership.
MEDICAL EXECUTIVE COMMITTEE
Inform the Medical Staff on quality and safety issues. Review quality, safety and patient satisfaction performance measures related to the medical staff. o Implement quality improvement and patient safety in medical staff processes.

During an interview on 09/09/2025 at 10:10 AM, Staff G, Radiologist said he calls the referring physician or ordering physician. They are rarely on the floor, so if he cannot reach them then he calls the floor nurse. If he cannot get the nurse, then he would call the supervisor. An urgent finding requires a call. Often times the ordering physician is not available, or he cannot find them in the system. Sometimes the ordering physician calls back.

During a interview on 09/09/2025 at 10:13 AM, Staff D, CT coordinator stated she called the attending hospitalist to ask if he wanted more scans. He said it's not in his scope; it was neurology. He was the ordering physician. He suggested a stat neurology consult. "We were in the process of doing the study. It hadn't been sent yet." The radiologist cannot do anything until the images are in the computer. Staff D, CT coordinator, said she called him for a stat read. She called the nurse after she spoke to the physician. The patient's nurse was busy, so she called the charge nurse. There has been no change to communication that she is aware of.

During a telephone interview on 09/09/2025 at 10:44 AM, the Medical Director of Radiology said he has had several meetings with the CMO and Medical Quality Staff. He has spoken to the physician and the radiologists. They need to read the report and see if it says what we mean it to say. There wasn't documentation that the radiologist contacted the physician. It should be physician to care team. If the doctor is not available, then licensed clinical staff. The Medical Director of Radiology said he doesn't know if the final document was put out by the CMO and Medical Quality Staff. It was verbal from himself to the group. The radiologist was new to the group. There were mentors who spoke to him directly. There wouldn't be a paper trail. "If you're asking if we're auditing something, I cannot answer that." That would be the Medical Quality Staff.

During an interview on 09/09/2025 at 12:02 PM, the CMO stated that several elements came out of the analysis. Communicating with hospital medicine and radiology department and bringing them together to see if there was any opportunity to streamline the communication. They reviewed the policy that governs the communication for radiology for emergent imaging studies. They met with the radiology department, the chair of the Medical Executive Committee and himself to see if there were opportunities. They reviewed the process and the policy. The process was determined to be intact. A change in the process would probably confuse people. Once the hospitalist receives the critical result, the hospitalist should communicate that back to the radiologist. It is on the agenda for a hospitalist collaborative that is scheduled 9/17/2025. We will discuss consultative referral patterns. It hasn't happened yet. The hospitalists will communicate in their monthly meeting if any similar occurrence happens. There hasn't been one. We have not taken this to Medical Quality. This is the hospitalist general meeting.

During an interview on 09/09/2025 at 12:36 PM, the Quality Manger confirmed the hospitalist collaborative meeting was scheduled for 9/17/2025 (over 2 and half months after Patient #1 died).

During an interview on 09/09/2025 at 1:15 PM, the Quality Manager said they rely on the Incident Reporting System to track any future occurrences. Quality looks at all those event reports. We are in the system looking at mortalities and errors. We should be tracking critical values and the physicians calling the criticals back. There are actions that don't require follow-up and there are those that need auditing. "In this particular case, I cannot show you any audits." We cannot pull critical result reports for radiology.

During an interview on 09/09/2025 at 3:48 PM, the Quality Director stated a cardiothoracic surgeon should have been consulted for a course of action. There isn't a protocol or standard of care for dissection. The second item on the corrective action is the one the CMO is going to talk about at the hospitalist collaborative meeting on September 17th.

During a group interview on 09/10/2025 at 10:40 AM with the Quality Director and the Risk Manager, the Quality Director said radiology called the nurse. The nurse used the patient safe phone and texted the hospitalist the results. We have a high level of confidence that the hospitalist knew what the radiologist saw. He called tele-neurology. Now it's he said, she said. Staff A, Hospitalist said he told the Neurologist, Staff C there was a Type A dissection. Staff C, Neurologist, said if she knew it was Type A aortic, she would not have discharged the patient. Staff A should have called cardiothoracic surgery. The Risk Manager said there were two things going on at the same time. Staff D, CT Coordinator, noticed it was extending and called Staff A, Hospitalist. She asked if he wanted further scans and he stated he wanted a stat consult with neurology. At the same time, the radiologist received the images and called the nurse with the results. The nurse texted Staff A, Hospitalist with the results. He said to do a stat neurology consult. He talked to the neurologist, and the plan was for anticoagulation and to discharge home and follow-up outpatient because it was a carotid dissection. Staff A, Hospitalist knew about it. He did not understand what he had. The report was not available when he was making those decisions. He did not understand what he was looking at. Staff C, Neurologist said she was doing an audit. She said she looks at all her charts and does an audit, and since she did not see the scan report yet. When she tried to call Patient #1, she did not answer. When the voice mail came on there wasn't enough identifying information for her to leave a voice mail. She called the family who was on the Face sheet and was in the room on the day of discharge. The family member said she was out shopping and wouldn't answer her phone. Staff C, Neurologist communicated that Patient #1 needed to be brought back to the hospital. Patient #1 never came back. She refused the CTA initially in the ED. It would have been caught in the ED and she would have been transferred. The hospitalists never see these. The patients are transferred out. Staff A, Hospitalist said he never sees these. He did not know what to do. Since the neurologist ordered the test, he called her. It was almost 25 hours after they found the dissection that she came back through the ED. The only reason we knew about it was that the CT technologist was working in the ED CT and recognized the name. The policy was followed. The results were reported to the nurse which the policy says can be done. The gap was the physician did not know what to do, and the CT was ordered routine. Auditing the critical results is something we should do, but that was not the issue. When they were addressing the policy, they wanted the radiologist to call the physician directly, but there were a lot of physician leaders in that meeting and they decided that wasn't reasonable, and did not make that policy change. The neurologist's direct supervisor is now not answering any of my texts or calls. RM said she interviewed the neurologist, who said she was under the impression they were still discussing the carotid dissection, and that's why she told him to continue the current treatment plan (confirmed by documented interview from RM investigation). Auditing the critical results is something we should do, but that was not the issue. When they were addressing the policy, they wanted the radiologist to call the physician directly, but there were a lot of physician leaders in that meeting and they decided that wasn't reasonable, and did not make that policy change. The neurologist's direct supervisor is now not answering any of my texts or calls. RM said she interviewed the neurologist, who said she was under the impression they were still discussing the carotid dissection, and that's why she told him to continue the current treatment plan (confirmed by documented interview from RM investigation).

During a telephone interview on 09/10/2025 at 10:43 AM, Staff A, Hospitalist said Patient #1 came with neurologic symptoms. The Neurologist ordered a CT scan. The study was obtained and the technologist called about the abnormality. Staff A, Hospitalist said he discussed it with Staff C, Neurologist, and she thought it was carotid dissection, not aortic. She based the treatment on the ultrasound report, which was an ambiguous element of abnormality. She ordered a CT angiogram the next morning routine, but he changed it to stat because the patient wanted to go home. Staff A, Hospitalist said he communicated the discharge plan with the patient and she was in agreement. The neurologist said it was ok for carotid and thoracic dissection. The patient was hemodynamically stable(describes a patient whose vital signs, including heart rate, blood pressure, and oxygen saturation, are within normal ranges, indicating that their circulatory system is functioning adequately without immediate risk of life-threatening complications) and was discharged.

Based on record review, policy review, corrective action plan, and interviews conducted, the hospital failed to ensure critical imaging results were communicated appropriately by the radiologist to the physician, and that critical results were acted upon appropriately in order to prevent the death of 1 (Patient #1) of 4 patients sampled.

Findings included:

A review of the medical record revealed Patient #1 came to the hospital ED (Emergency Department) by ambulance on 6/26/2025 for stroke-like symptoms, the symptoms resolved in the ambulance on the way to the hospital. An ultrasound of the neck and carotid arteries was completed in the ED and findings showed an abnormality concerning dissection of the right carotid artery. Patient #1 was admitted for further observation and testing. On 6/27/2025 a CT (computed tomography) angiogram (a medical imaging technique that uses X-rays to create detailed images of blood vessels) of the neck and carotid arteries was completed. During the imaging study, Staff D, CT Coordinator, communicated findings of right carotid artery dissection along with Type A thoracic aorta dissection (a life-threatening condition where the inner layer of the aorta (the main artery that carries blood from the heart to the body) tears and separates, creating a new channel (false lumen) within the aortic wall) to Staff A, Hospitalists. This was also communicated to Staff A, Hospitalist by Staff F, RN (Registered Nurse), who had been informed by Staff B, Radiologist, after he interpreted the imaging. Staff A, Hospitalist indicated in his Discharge Summary, that this was communicated and discussed with Staff C, Neurologist who recommended anticoagulation therapy (blood thinners) and follow-up outpatient with neurology. The patient was discharged home with a diagnosis of TIA-transient ischemic attack (pre-stroke symptoms) with instructions to take aspirin and Plavix and follow up with a neurologist in 3 weeks. Upon review of the imaging results the next day, 6/28/2025, the Staff C, Neurologist, discovered the Type A thoracic dissection. She attempted to contact Patient #1 and was unable to reach her but did speak to the patient's family member. Staff C, Neurologists informed the family member the emergent nature of the findings and advised Patient #1 needed to return to the ED immediately. Patient #1 did not return. The next day, 6/29/2025 at 6:15 PM, Patient #1 was brought in by ambulance in cardiac arrest. Patient #1 was unable to be revived, and the time of death was called in the ED at 6:28 PM.

Review of the policy, Communication of Stroke, Critical Results, and Stat/Wet Read, January 2024, revealed the following:
Critical Results Communication (Excluding Storke Alerts) or Exams made Stat/wet Read by Radiologist
Any critical finding, as identified by the reading radiologist, will be communicated to the appropriate healthcare provider as outlined below:
Reading Radiologist communicates critical results to Ordering Physician and/or ISR/ISOA (Imaging Services Representative/Imaging Services Operations Specialist).
ISR/ISOA confirms critical communication result between Radiologist and Ordering Physician (or Hospitalist that has assumed care for the patient if shift change occurs), as follows:
Scenario A
If the Radiologist confirmed contact with the ordering physician, ISR/IOA will document protocol in RIS (Radiologist Information System) to include date, time, and name of physician spoken to.
Scenario B:
If the Radiologist is unable to confirm contact with the Ordering Physician, ISR/IOA will contact the ordering physician, relay the results, and ask if they wish to be connected with the radiologist.

Review of facility corrective action dated 7/14/2025 reflected the following actions:
1. Collaboration with Radiology concerning the communication of life threatening critical results between physicians. Review policy NCL 0039 (Critical Results, Communication of) for clarification of acceptable recipients of critical values. Discuss the expansion of diagnostic imaging pathways when life threatening and critical results are identified.
2. Development of pathways and algorithms for inpatient treatment of all types of dissections to include placement, transfers, consultations, and additional diagnostic testing.

Review of electronic communication from the CMO to the department heads of the hospitalist groups, dated 9/2/2025 reflected a Subject: Radiology Communication:
See attached meeting minutes regarding communication of radiology results. I have highlighted a phone number just in case the provider wants to connect with radiology to verify/discuss the radiology results. Attached was meeting minutes from August 13, 2025 regarding no change to the policy, but included the direct line with extension for providers to contact the Radiologist.

Review of electronic communication sent to all hospitalists on 09/09/2025 at 9:24 PM reflected the development of Pathways for Carotid Dissection-Symptomatic Patients, Type A Aortic Dissection, and Type B Aortic Dissection.
Additional corrective action review reflected electronic communication from the Quality Director, dated 09/10/2025, addressed to the Manager of Imaging and the Supervisor of Imaging: Educate and implement new process and train team members, due date 10/1/2025. Distribute AOD (Administrator on Duty) and the hospital phone directory, hospitalist phone list, and ED physician list to other team members for communication after business hours and on weekends. Due date 10/1/25.

During an interview on 09/09/2025 at 10:10 AM, Staff G, Radiologist said he calls the referring physician or ordering physician. They are rarely on the floor, so if he cannot reach them then he calls the floor nurse. If he cannot get the nurse, then he would call the supervisor. An urgent finding requires a call. Often the ordering physician is not available, or he cannot find them in the system. Sometimes the ordering physician calls back.

During an interview on 09/09/2025 at 10:13 AM, Staff D, CT coordinator said she called the attending hospitalist (Staff A) to ask if he wanted more scans. He said it's not in his scope, it was neurology. He was the ordering physician. He suggested a stat neurology consult. "We were in the process of doing the study. It hadn't been sent yet." The radiologist cannot do anything until the images are in the computer. Staff D, CT Coordinator, said she called the radiologist (Staff B) for a stat read. She called the nurse after she spoke to the physician (Staff A). The patient's nurse was busy, so she called the charge nurse.

During a telephone interview on 9/9/25 at 10:44 AM, the Medical Director of Radiology said he has had several meetings with the CMO and Medical Quality Staff. He has spoken to the physician and the radiologists. They need to read the report and see if it says what we mean it to say. There wasn't documentation that the physician contacted the physician. It should be physician to care team. If the doctor is not available, then licensed clinical staff.
During an interview on 09/09/2025 at 3:48 PM, the Quality Director, Quality Manager, and the Risk Manager, the Quality Director said a cardiothoracic surgeon should have been consulted for a course of action. There isn't a protocol or standard of care for dissection. (#2) on the corrective action is the one he is going to talk about at the hospitalist collab on September 17th.

During a group interview on 09/10/2025 at 10:40 AM with the Quality Director and the Risk Manager (RM), the Quality Director said radiology called the nurse. The nurse used the patient safe phone and texted the hospitalist (Staff A) the results. We have a high level of confidence that the hospitalist knew what the radiologist saw. He called tele-neurology (Staff C). Now, it's he said, she said. Staff A, Hospitalist said he told the Neurologist, Staff C there was a Type A dissection. Staff C, Neurologist, said if she knew it was Type A aortic, she would not have discharged the patient. Staff A should have called cardiothoracic surgery. During the interview, The Risk Manager disclosed that there were two things going on at the same time. Staff D, CT Coordinator, noticed it (the dissection) was extending and called Staff A, Hospitalist. She asked if he wanted further scans. He said no. He stated he wanted a stat consult with neurology. At the same time, the radiologist received the images and called the nurse with the results. The nurse texted Staff A, Hospitalist with the results. He said to do a stat neurology consult. He talked to the Neurologist, Staff A, and the plan was for anticoagulation, to discharge home and follow-up outpatient because it was a carotid dissection. Staff A, Hospitalist knew about it. He did not understand what he had. The report was not available when he was making those decisions. He did not understand what he was looking at. Staff C, Neurologist said she was doing an audit. She said she looks at all her charts and does an audit, and because she did not see the scan report yet. When she tried to call Patient #1, she did not answer. When the voice mail came on there wasn't enough identifying information for her to leave a voice mail. She called the family member who was on the Face Sheet and was in the room on the day of discharge. The family member said she was out shopping and wouldn't answer her phone. Staff C, Neurologist communicated that Patient #1 needed to be brought back to the hospital. Patient #1 never came back. She refused the CTA initially in the ED. It would have been caught in the ED, and she would have been transferred. The hospitalists never see these. The patients are transferred out. Staff A, Hospitalist said he never sees these. He did not know what to do. Since the neurologist ordered the test, he called her. The neurologist said she was under the impression they were still discussing the carotid dissection, and that's why she told him to continue the current treatment plan. It was almost 25 hours after they found the dissection that she came back through the ED. The only reason we knew about it was that the CT technologist was working in the ED CT and recognized the name.
During a telephone interview on 09/10/2025 at 10:43 AM, Staff A, Hospitalist said Patient #1 came with neurologic symptoms. The Neurologist ordered a CT scan. The study was obtained and the technologist called about the abnormality. Staff A, Hospitalist said he discussed it with Staff C, Neurologist, and she thought it was carotid dissection, not aortic. She based the treatment on the ultrasound report, which was an ambiguous element of abnormality. She ordered a CT angiogram the next morning routine, but he changed it to stat because the patient wanted to go home. Staff A, Hospitalist said he communicated the discharge plan with the patient, and she was in agreement. The neurologist said it was ok for carotid and thoracic dissection. The patient was hemodynamically stable and was discharged.

During an interview on 09/10/2025 at 1:20 PM, the Manager of Imaging said most of the time a critical report goes from the radiologist to the ordering physician. It goes from the report to the nurse to the doctor. The doctor can call the radiologist with questions. Staff D, CT Coordinator called the physician because she saw the abnormality and wanted to know if he wanted to expand the scan, because it's easier to do it while we're there. Otherwise, if they sent the patient back, they would have to insert another IV (intravenous), get another big order block set. It's a courtesy so we can do it while we're there. They cannot ask the radiologist to order an expanded test; they have to call the ordering physician. Staff D, CT Coordinator wasn't calling to report the result, she was asking how far up (arteries) he wanted her to look. The radiologist is the only one who can read results. The physician can request a technologist to read a report, but the results are only provided by the radiologist. She was letting him know there was a finding and asking if he wanted to expand the scan.