Community Medical Center

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 46468 Based on staff interview, review of facility documents and six of ten medical records [Patient (P)1, P4, P7, P8, P9, and P10], it was determined the facility failed to ensure there is an expected timeframe for the reading and interpretation of routine radiology exams. Findings include: On 01/14/26 at 10:48 AM, P1’s medical record was reviewed in the presence of Staff (S)1 and S2 and revealed the following: On 11/25/25 at 3:00 PM, P1 was admitted to the 2D Telemetry nursing unit with a diagnosis of COPD (chronic obstructive pulmonary disease) exacerbation. On 11/28/25 at 12:53 PM, S13 ordered a CT Abdomen Pelvis Without IV (intravenous) contrast. P1’s CT was performed on 11/28/25 at 5:31 PM. The results were read and interpreted by S12 on 11/30/25 at 2:56 PM. This was 45 hours and 25 minutes after the CT was performed. During an interview on 1/14/26 at 1:04 PM, S12 was interviewed regarding the process for reading and resulting radiology tests. S12 stated, “it depends on where the results are coming from, we triage by most important. ER (emergency room) STATs are first, next, in-patient STATs are read, and then routine in-patient tests.” S12 also stated, “our turn around goal is around 24-hours.” S12 was asked about possible delays in the reading and interpretation of routine in-patient radiology tests. S12 stated, “there is a severe staffing issue, nationally, not just in the hospital, it is all over. Our primary goal is to keep the ER read as quickly as possible. Once the results are read, they go right into EPIC [the facility’s electronic medical record (EMR) platform]. There are times when the tech doesn’t complete all their checkboxes on their end, and the results won’t show up on my worklist to be read, which can cause a delay. The techs are aware of this issue, sometimes things happen. If there is a delay, and a clinician is concerned, they will reach out to me, and I will read the test immediately. We [radiologists] are always available. We have 550-600 cases sent to us a day; my worklist is always at 100. We’re always a day and a half behind.” S12 further explained that the hospital does not physically have a radiologist in the facility 24 hours a day, seven days a week. However, S12 stated that someone is always available to read and interpret exams through a contracted radiology coverage service. S12 stated, “We have a significant staffing issue.” When S12 was asked to review the order time and result time for P1’s routine CT abdomen pelvis without IV contrast, S12 stated, “less than 48 hours, not that bad for weekend turnaround time.” During an interview on 1/14/26 at 1:48 PM, S13 stated he/she does not track the amount of time it takes for a radiology test to be read and interpreted. S13 stated, “If we’re not seeing results, we call to follow-up. When I called about the patient [P1’s] results, on the first and second day, I was told the radiologist is not readily available to read. After the second day, I put a surgery consult in so that surgery can look at the results and determine if we can feed the patient.” During an interview on 1/14/26 at 2:28 PM, S17 was asked about the process for completion of a CT (computed tomography; cat scan). S17 stated that once the test is performed the results go into the electronic medical record, then to the doctor. S17 stated, “We highlight images in PACs [radiology imaging computer system] and end the study in PACs. Once the study is ended this triggers for the radiologist to see [the results].” S17 once the images are sent from the scanner [CT machine] the radiologist can read it, even if the boxes [from the CT tech] were not checked off.” On 01/15/26 at 10:52 AM, a review of P4, P7, P8, P9 and P10’s medical records was conducted in the presence of S1 and revealed the following: On 11/16/2025, P4 was admitted to the ICU (intensive care unit) with complaints of (c/o) dyspnea (shortness of breath), chest discomfort, and black stools. On 11/17/25 at 6:37 PM, a nuclear medicine Cardiac Amyloid scan (a test to rule out heart dysfunction) was ordered. The scan was completed on 11/19/25 at 12:03 PM. The scan was read by the radiologist on 11/23/25 at 11:44 PM. That was 83-hours after the Cardiac Amyloid scan was performed. P4 was discharged on 11/19/25, prior to the scan results being read by a radiologist. On 12/27/25, P4 came to the facility, status post a fall, and at 4:43 PM, a Pelvis x-ray was ordered. The x-ray was completed on 12/27/25 at 6:08 PM, and read by the radiologist on 12/29/25 at 11:23 AM. That was 41 hours and 15-minutes after the x-ray was performed. The delay in both radiological study readings (Cardiac Amyloid scan Pelvis x-ray) by a radiologist and lack of preliminary report for P4 was confirmed with S2 on 1/15/26 at 12:05 PM. A review of P7’s medical record was conducted with S1 and revealed the following: On 11/23/25 P7 was admitted to the ICU with c/o jaundice. On 11/26/25 at 4:32 PM, a CT of the abdomen and pelvis was ordered. On 11/27/25 at 10:28 AM, the CT was completed and read by the radiologist on 11/28/25 at 3:08 PM. That was 28-hours and 48-minutes after the CT was performed. The delay in radiological exam readings by a radiologist and lack of preliminary report for P7 was confirmed with S2 on 1/15/26 at 10:48 AM. On 11/25/25, P8 was admitted to 3E Orthopedics with c/o back pain. On 11/25/25 at 7:31 PM, a CT of the Lumbar and Thoracic Spine was ordered. The CT was completed on 11/28/25 at 9:09 AM and read by a radiologist on 12/2/25 at 8:10 AM. That was 95-hours and 1-minute after CT was performed. The delay in radiological exam readings by a radiologist and lack of preliminary report for P8 was confirmed with S2 on 1/15/26 at 11:39 AM. On 11/25/25 P9 was admitted to 4F [medical-surgical unit] with c/o acute respiratory failure. On 11/25/25 at 9:33 PM, an MRI of the head was ordered. The MRI was completed on 11/27/25 at 2:57 PM and read by the radiologist on 12/1/25 at 11:03 AM. This was 92-hours and 54-minutes after the MRI was performed. The delay in radiological exam readings by a radiologist and lack of preliminary report for P9 was confirmed with S2 on 1/15/26 at 11:39 AM. On 11/20/25 P10 was admitted to ICU with c/o pulmonary embolism (blood clot in the lungs). On 11/25/25 at 2:15 PM, an MRI of the abdomen was ordered. The MRI was completed on 11/28/25 at 9:54 AM and read by the radiologist on 11/30/25 at 2:26 PM. That was 52-hours and 32-minutes after the MRI was performed. The delay in radiologic exam readings by a radiologist and lack of preliminary report for P10 was confirmed with S2 on 1/15/26 at 12:05 PM. During an interview on 1/14/26 at 10:06 AM, S6 stated that radiology tests are usually reviewed by the radiologist in “one to two days, usually within 24 hours though.” During an interview on 1/14/26 at 10:19 AM, S7 explained that radiology results can sometimes be delayed. S7 stated that results take “lately, a few days. If we ask the director, [he/she] will nudge them, and we can get the results faster. I’ve had a patient recently leave before because the MRI (Magnetic Resonance Imaging) results took days.” S7 indicated that STAT [immediate] results are not delayed. However, routine radiology testing, “especially on the weekend, will not get read until Monday.” During an interview on 1/14/26 at 10:33 AM, S10 stated radiology test result reading times “have gotten a lot better. It was taking a long time but recently, in the last few weeks, it has been much faster.” The “Bylaws of the Medical Staff” dated 06/25, were reviewed, and lacked evidence of expected timeframe’s for the reading and interpretation of routine radiology exams. Facility policy titled, “Critical Test Result Reporting” dated 07/19, was reviewed, and lacked evidence of expected timeframe’s for the reading and interpretation of routine radiology exams. On 01/15/26 at 12:15 PM, a policy referencing expected timeframe’s for the reading and interpretation of routine radiology exam results was requested. S1 stated the facility does not have a policy that reflects the expected timeframe that routine radiology exam results are read and interpreted.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49828 Based on observation, staff interview, review of four of six medical records (Patient [P] 3, P4, P5, and P6) for patients identified as a fall risk, and a review of facility documents, it was determined that the facility failed to implement their “Falls Prevention Program” policy and procedure. Findings include: On 09/10/24 at 10:30 AM, during a tour of the 4 Pavilion (4P) unit, in the presence of Staff (S) 1, Manager of Standards, Licensure and Accreditation, and Quality Resource Services, the following was revealed: At 10:31 AM, Room 4523 had door signage indicating that P3 was a fall risk. S2, Assistant Director of 4P, explained that any patient identified as a fall risk will have a yellow wristband applied, yellow non-slip socks on, bed alarms in place, and fall risk signage outside of the patient room. At 10:32 AM, S2 the entered Room 4523 and confirmed that P3 was not wearing a yellow wristband and stated that the wristband should have been applied on admission. A review P3’s medical record indicated that the patient was admitted on 09/05/24 at 05:26 AM to the Intensive Care Unit (ICU) for septic shock. The Johns Hopkins Fall Risk Calculator indicated that the patient was deemed a “high” fall risk per the automatic high fall risk protocol. P3 was transferred to 4P on 09/08/24 at 11:12 AM and remained a high fall risk. At 10:43 AM, P4 in Room 4530B and P5 in Room 4530A, had door signage indicating they both were a fall risk. At 10:45 AM, S4, a Registered Nurse (RN), entered Room 4530 and confirmed that P4 and P5 were not wearing yellow wristbands and stated that the wristbands should have been applied on admission. A review of P4’s medical record indicated the patient was admitted on 09/08/24 at 03:49 PM from the Emergency Department (ED) and arrived to 4P on 09/08/24 at 5:19 PM for dizziness, nausea, and vomiting. Initial Fall Risk Score of five (5) was recorded in the ED on 09/07/24 at 12:55 PM, which deemed the patient a “low” fall risk. On 09/8/24 at 6:53 PM, upon initial assessment on 4P, the fall risk score was 7, which deemed the patient a “moderate” fall risk. The patient remained a “moderate” fall risk during his/her admission. A review of P5’s medical record indicated the patient was admitted on 09/08/24 at 10:54 PM from the ED and arrived at 4P on 09/09/24 at 12:18 AM for the diagnoses of cystitis, generalized weakness, and altered mental status. Initial Fall Risk Score of 14 was recorded in the ED on 09/08/24 at 7:55 PM, which deemed the patient a “high” fall risk. The patient remained a high fall risk during the admission. On 09/10/24 at 11:00 AM, a tour of the 4A unit was conducted in the presence of S1. During the tour, Room 4103A, had door signage indicating that P6 was a fall risk. At 11:05 AM, S6, a RN, stated that P6 was at high risk for falls due to seizures and that if patients are identified as a fall risk, they will wear a yellow wristband and yellow non-slip socks as fall precautions. S2 confirmed P6 was not wearing a yellow wristband and stated that it should have been applied on admission to the unit. A review of P6’s medical record indicated the patient was a direct admission to 4A on 09/09/24 at 07:24 AM for symptoms of syncope (fainting). The Johns Hopkins Fall Risk Calculator indicated that the patient was deemed a “high” fall risk and remained a “high” fall risk during his/her admission. A review of facility policy and procedure titled, “Policy: Falls Prevention Program,” Effective date 12/05/22, stated, “... Policy: ... Fall risk is assessed upon initial assessment and is re-assessed following any change in status, upon intra-facility transfer to another level of care ... A yellow sign will be placed on doorframe outside the patient room, yellow slip resistant socks and yellow wristband, indicating that the patient is a moderate risk for falls. A red sign will be placed on the doorframe outside the patient room ... slip resistant socks and yellow wristband, indicating that the patient is a high risk for falls ... .””