NYU Langone Hospitals

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 37527 Based on medical record review, document review, and interview, in one (1) of five (5) medical records (MRs), the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program tracked, trended, and analyzed radiological misreads to identify opportunities for improvement. Findings: Review of Patient #4’s MR identified that this patient walked into the Emergency Department (ED) on 12/16/2024 at 4:49 PM with a chief complaint of fall. X-rays of the right hand and right wrist, resulted at 7:51 PM, revealed no evidence of acute fractures in the right hand or wrist. A CT (Computed Tomography - medical imaging technique used to obtain internal images of the body) scan of the spine, resulted at 8:25 PM, revealed no acute fracture or traumatic malalignment of the spine. The patient was discharged at 10:00 PM. Review of the Complaints and Grievances List, dated from 09/01/2024 to 02/23/2025, revealed that Patient #4’s spouse submitted a grievance to the facility on 01/22/2025. The grievance alleged that Patient #4 received a MRI (Magnetic Resonance Image) at another facility which revealed a fracture of the spine and right wrist, and that a rigid neck collar had been ordered for the patient. During interview of Staff J-1 (Radiologist) on 02/25/2025 at 1:56 PM, Staff J-1 shared images of Patient #4’s radiological studies. Staff J-1 confirmed that the CT scan of Patient #4’s spine had been misread, and that the image revealed a hairline fracture that was not initially identified. During interview of Staff K-1 (Radiologist) on 02/25/2025 at 2:15PM, Staff K-1 acknowledged that they had misread Patient #4’s right hand and wrist X-ray. Review of the facility’s Radiology Policy titled, “Reportable Events Reporting,” last reviewed 02/2023, revealed that the policy does not address radiology misreads. During interview of Staff L-1 (Administrator) on 02/26/2025 at 11:01 AM, Staff L-1 confirmed that Patient #4’s radiological images had been misread, and that they had conversations with the involved radiologists about the misinterpretations. Review of the ED QAPI Meeting Minutes, dated from 01/2025 to 02/2025, identified no documented evidence that the hospital tracked, trended, nor analyzed radiology misreads to identify opportunities for improvement. On 02/27/2025 at 1:49PM, a request was made for the ED Radiology Department Meeting Minutes. A second request was made on 03/04/2025. Electronic mail from Staff P-1 (Director) dated 03/04/2027 at 10:48 AM revealed, “ ...radiology does not keep minutes for case review meetings/QA meetings based on advice of counsel.” During re-interview of Staff L-1 on 02/27/2025 at 2:13 PM, Staff L-1 confirmed the facility did not have a process of tracking, trending, and analyzing radiology misreads. These findings were shared with Staff Z-1 (Administrator), Staff A-2 (Administrator), and Staff B2 (Administrator) during the Exit Conference on 03/04/2025 at 3:45 PM.”

“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: 35161 . Based on medical record review, document review, and interview, in one (1) of twelve (12) medical records reviewed, the facility failed to ensure that the incident of a patient who was identified to have sustained a fracture during hospitalization was investigated and the patient protected from further injury. Findings: A review of the medical record for Patient #1 identified that the patient was admitted on 08/20/2024 with diagnoses of Pneumonia and Urinary Tract Infection. On 09/02/2024 at 2:14 PM, the patient had an abdominal computerized tomography (C.T.) scan [computerized x-ray imaging procedure] to rule out “Aortic Aneurism or Dissection” (a tear in a main artery). The scan revealed no evidence of abdominal aortic aneurism or dissection but a new finding of an “Angular Impacted Fracture of the Right Neck of Femur” (a fracture within the capsule of the hip joint) compared to the C.T. scan on 08/21/2024. On 09/03/2024 at 10:25 AM, an Orthopedic Consultant (Staff L) documented, “Right femoral neck fracture incidentally found on C.T. abdomen and pelvis. New since previous C.T. on August 21st. Traumatic event unknown.” The patient has bilateral lower extremity contracture and is not alert and oriented to place, persons, and time. There is no plan for operative intervention, but orthopedic services will continue to follow the patient’s clinical progression and reevaluate for surgery. During an interview on 10/25/2024 at 12:33 PM with Staff C (Unit Nurse Manager, 11E), they stated the patient had contractions and required frequent repositioning in bed. Staff C reported that the patient had no fall incident and that they did not know the cause of the fracture. Staff C confirmed the facility did not investigate the incident. On 10/29/2024 at 12:01 PM, during an interview with Staff H (Registered Nurse, 11E), they stated the patient had a history of osteomyelitis and deep pressure sores; they were bedbound and needed frequent repositioning. Staff H acknowledged that the patient sustained a fracture, but the fracture was not investigated because it was not a reportable incident. A review of the facility’s policy titled “Reporting of Adverse Events (Incident Reporting)” reviewed and reissued 01/2024) stated, “Adverse Event” means untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided during the course of a patient’s hospitalization, during outpatient care or while a person is a visitor at the facility (e.g. IV infiltrate, allergic drug reaction, burns, fall with injury, unexpected death, air embolism, unexpected postoperative complication, etc.)... The Patient Safety Risk Management Department shall review, investigate, and monitor all reported incidents and untoward occurrences, as appropriate and necessary.” There was no documentation of an investigation of the patient’s fracture, and no measures were implemented to protect the patient from further injury. During an interview on 10/29/2024 at 2:39 PM, Staff J (Senior Director of Patient Safety and Risk Management) acknowledged the findings and stated that the patient’s fracture, although of unknown origin, should have been reported as an incident, investigated to determine the cause of the fracture, and, if problems are identified, implement corrective actions. On 10/29/24, at 4:00 PM, during an interview with Staff L, they reported that they could not determine how the patient sustained the fracture. Staff L stated that the patient was bedbound, and the decision was not to perform a surgical repair. These findings were brought to the attention of Staff J (Chief Regulatory Officer) during the exit conference on 10/29/2024 at approximately 5:00 PM.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 48939 Based on document review, staff interview, and in one (1) of eight (8) medical records reviewed, the facility failed to ensure that staff reported hospital acquired pressure injuries as incidents per policy, and the facility failed to identify this and develop corrective action. (Patient #2). Findings include: Review of the facility’s policy and procedure (P&P) “Reporting of Adverse Events,” last revised January 2024, states: “any stage 3 or 4 or unstageable pressure ulcer acquired after admission/ presentation to the health care facility is classified as a Never Event.” The policy also states, as part of the adverse event procedure, “staff must also enter the event in the Patient Safety Intelligence (PSI) database ...The Patient Safety Risk Management staff read all reported PSI events and ensure that they are processed appropriately or reported to the appropriate State or Federal agency in accordance with New York State occurrence and incident reporting laws and Joint Commission Sentinel Event Standards.” Review of the facility’s Incident Reports, from November 2023 to 1/11/2024 revealed that an incident was not reported for the development of two hospital acquired pressure injuries in Patient #2. Review of Medical record for Patient #2 identified: patient was admitted to medical step-down unit on 11/03/2023 with a diagnosis of hypoxic respiratory failure, sepsis, and pneumonia. The registered nurse’s (RN’s) initial assessment revealed that the patient had a Stage 2 pressure injury on the mid-upper sacrum present on admission. On 11/07/2023, Patient #2 was transferred to a general medical-surgical unit. On 11/14/2023, Staff G, Wound Care Nurse Practitioner (NP), documented, Patient #2 developed a deep tissue pressure injury (DTPI) of her left ischium. On 11/21/2023, documentation by Staff G, stated that Patient #2 developed an additional DTPI of her right iliac crest, and that the sacral and left ischium DTPIs had advanced to unstageable by 11/21/2023. Review of the facility’s Incident Reports revealed that an incident was not entered for the pressure injuries developed on 11/14/2023 or 11/21/2023. Per interview on 1/12/2024 at 10:15AM, Staff E, RN, stated that they sometimes report hospital acquired pressure injuries as a PSI. Per interview on 1/16/20204 at 11:00AM with Staff U, Nurse Manager of Unit 5600, stated, staff have daily huddles where they discuss patients at risk for pressure injury. Staff U also stated, they have a monthly staff meeting, and provided the document, “Unit 5600-5700 Staff Meeting Agenda/Minutes,” dated 12/14/2023. The document stated: “Last month (November 2023) a patient had a worsening of a community-acquired pressure injury.” However, the hospital acquired pressure injuries developed on 11/14/2023 and 11/21/2023 were not discussed. Staff U confirmed that this was not addressed during the staff meeting. Staff U stated that she became aware of Patient #2’s pressure injury on 11/21/2023, one week after the first hospital acquired pressure injury was identified. When asked why an incident was not entered for this patient, Staff U stated there may have been some confusion because the patient was also admitted with an existing pressure injury, which they do not typically report. Per interview on 1/16/2024 at 11:35AM, Staff B, Nurse Manager of Nursing Quality, confirmed that an incident report should have been completed for Patient #2’s hospital acquired pressure injury. Staff B provided documentation of an email sent by Staff G, wound care NP on 11/14/2023, stating that Patient #2 had a hospital acquired pressure injury. Staff B also stated that incidents regarding nursing care issues will be referred to the nursing quality team for an Apparent Cause Analysis (ACA) investigation. Staff B provided documentation of an ACA report for Patient #2, dated 1/11/2024. When asked why Patient #2’s ACA was not conducted until two months later when the surveyors were on site, Staff B stated they did not have an answer.”