University of Virginia Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, facility staff failed to follow facility policy when using restraints in two (2) of four (4) patients whose medical records were included in the survey sample. The findings include: On 6/11/24 at 1:10 p.m., a review of four (4) patient medical records was conducted. Patient #3 was placed in restraints on 5/15/24. There was no documentation in Patient’s #3 medical record that the Registered Nurse notified or educated the patient, the patient’s care partner and/or family on the reason Patient #3 was placed in restraints. Patient #4 was placed in restraints on 5/25/24. There was no documentation in Patient’s #4 medical record that the Registered Nurse notified or educated the patient, the patient’s care partner and/or family on the reason Patient #4 was placed in restraints. A review of the facility’s policy “Restraint and Seclusion of Patients”, revised 11/1/22 stated in part: “...e. The registered nurse shall made reasonable efforts to educate the patient or surrogate decision maker, care partner, and/or family on the reason for restraint, anticipated length of time the restraint will be used, alternatives attempted prior to applying the restraint, and conditions necessary for the restraints to be removed...7. Documentation...b. A registered nurse shall document the following using the Restraint Flowsheet...c) Education of the patient and/or care partner, family or surrogate decision maker concerning the use of restraints/seclusion...”. The findings were discussed with Staff Members #1, #2 and #5 at the exit conference at 5:00 p.m. on 6/11/24.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 46466 Based on interviews and facility document review, the facility staff failed to provide written notice of its grievance decision to one (1) of three (3) patients included in the survey sample. The findings include: On 2/28/24 at 2:20 p.m., an interview was conducted with Staff Members #16 (SM16) and #17 (SM17). SM16 confirmed they received an emailed complaint related to Patient #1 on 11/26/23 and confirmed receipt the following day. SM16 stated they “dropped the ball” and never followed up with the spouse after replying to the email. SM16 explained that the typical process to handle any grievance is to input the information into the grievance tracking database and follow-up with a the complainant within 24 hours or the next business day from the receipt of a grievance. The resolution could take forty-eight (48) hours or up to 30 days. Typically, a letter is sent to the complainant within seven (7) days advising the person that the grievance is open. SM17 stated that Patient Relations became aware of issues with this complaint when the surveyor came onsite. SM17 stated that they met with the Patient Relations team, discussed what happened and how to avoid this from happening again. SM17 further explained that all Patient Relations staff had since the discovery reviewed all their emails and correspondence to ensure that all grievances/complaints are listed in the tracking system and are being handled. SM17 added that the facility’s Grievance Policy is in the process of being revised to add specific timeframes for follow-ups and a new checklist was implemented on 1/16/24 to ensure that all grievances were handled according to policy. On 2/28/24, a review of facility documentation found an email with complaint related to Patient #1, dated 11/26/23 at 7:05 p.m. sent to SM16. It documented “Hello (SM16). Can you confirm that you received my email from November 16? It is copied below in case you didn’t. I thought I would have heard something from you by now. Thank you...”. SM16’s email reply dated 11/27/23 at 10:57 a.m. stated in part, “Hello, (complainant’s name). I apologize. I did not receive your email on November 16th. However, I am confirming the receipt of it now...”. SM17 provided an email from Staff Member #23 sent on 11/14/23 at 4:15 p.m. to the Patient Relations Department, including a submission form for complaint related to Patient #1 who was at that time an inpatient at the facility. The Summary of Concern read, “Patient’s (spouse) would like to speak to patient relations concerning (Patient #1’s) care on 4 West ICU. There has been a series of issues that haven’t been resolved, and (complainant) feels that there has been clear lack of communications. A meeting was set up by the case manager but (complainant) called the floor today and the case manager wasn’t aware of any family meeting. (Complainant) is very concerned and would like to speak to patient rep asap...”. A review of the facility’s policy “Patient Complaints and Grievances”, last revision 2/1/21 stated in part: “...4. Grievance: A patient grievance (“Grievance”) is: a. Any written Complaint, including email...expressed by a patient and/or the patient’s legally authorized representative on behalf of the patient. b. a written or verbal Complaint expressed by a patient and/or the patient’s legally authorized representative on behalf of the patient, regarding i. the patient’s care...3. Grievance Process...d. Respective of their scope of responsibilities, the Patient Relations Department...shall facilitate investigations and coordinate and review the Medical Center’s response(s) to the patient and/or the patient’s legally authorized representative. e. The substance of every Grievance must be fully investigated. If the substance of the Grievance is validated, the involved service(s) or department(s) must provide written notification of any corrective action taken to the Patient Relations Department...f. The Medical Center shall provide written notification to the patient and/or the patient’s legally authorized representative of the results of its investigation. g. The Patient Relations Department and/or any other departments involved in the Grievance resolution shall provide the Medical Center Patient Grievance Committee with sufficient information to ensure resolution. 4. Documentation: a. Patient Complaints and Grievances shall be documented in the patient feedback system...b. The Medical Center shall maintain documentation of all Grievances, copies of its investigations, and responses to patients...6. Responsibility of the Patient Grievance Committee: a. The Patient Grievance Committee is responsible for the review, resolution, tracking, auditing, and reporting of Medical Center patient Grievances...”. The findings were discussed with Staff Members #1, #2 and #14 at the exit conference on 2/28/24 at 3:45 p.m.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 46466 Based on interviews, medical record and facility document review, the facility’s medical staff failed to communicate changes in patient’s medical status to providers involved in care and prevent patient’s decline in health. The findings included: Patient #1’s (P1) Neurological Surgery Consult History and Physical dated 10/17/23 at 12:03 p.m. documented “...(P1) with past medical history of prior cavernous malformation of the midbrain that presented in 2015...(P1) developed obstructive hydrocephalus, requiring placement of a Codman Hakin valve set to 80. (P1) is not required revisions, but has had multiple shunt adjustments. Apparently, (P1) is rather sensitive to shunt adjustments and developed hydrocephalus multiple times after adjustments at (another hospital)...Recent MRI August demonstrates recurrence in growth of (P1’s) cavernous malformation...Assessment...CT head demonstrates no diffuse cerebral edema and no hydrocephalus concerning for shunt failure...neurosurgery to follow peripherally while workup continues...”. On 10/17/23 at 10:13 a.m., P1 had a VP (ventriculoperitoneal) shunt series with valve shot x-ray. The results documented in part, “Narrative & Impression: Additional Clinical Data: AMS (altered mental status)...FINDINGS:...Shunt setting of Codman Hakim at 90...IMPRESSION: Right approach ventricular shunt catheter with distal tubing terminating in the right lower quadrant. No evidence of shallow discontinuity or kinking. Shunt setting at 90...”. On 10/18/23, P1 had an MRI completed. On 10/19/23 at 1:20 a.m., P1 underwent another VP (ventriculoperitoneal) shunt series with valve shot x-ray. The results documented in part, “...Indication: needed post MRI...Comparison: CT Head 10/17/2023; CT Head Chest 10/17/2023...Shunt setting at 100...IMPRESSION: 1. Right parietal ventriculoperitoneal shunt in place, with no evidence of complicating feature. 2. No acute cardiopulmonary disease. 3. No acute abdominal or pelvic process...”. On 10/25/23, P1 had an MRI completed. On 10/28/23 at 11:52 a.m., P1 received a VP (ventriculoperitoneal) shunt series with valve shot x-ray. The results documented in part, “...Indication: check shunt setting. Comparison: CT Head Chest 10/19/2023...Codman Hakim programmable valve setting most closely approximates 100-110 mmH2O... IMPRESSION: 1. Right parietal approach ventriculoperitoneal shunt in place, with no evidence of complicating feature. 2. Codman Hakim programmable valve setting most closely approximates 100-110 mmH20. 3. No acute cardiopulmonary disease. 1. (sic) No acute abdominal or pelvic process...”. An Internal Medicine Physician Progress Noted dated 10/28/23 at 7:28 a.m., with a revision at 10/28/23 at 9:00 p.m., documented in part, “...4 episodes of vomiting overnight, family at bedside also note seems more confused this morning, less interactive and with worsened extremity movements...Imaging: XR shunt 10/28/23...Codman Hakim programmable vale setting most closely approximates 100-110 mm H20...Assessment and Plan: ...No evidence of hydrocephalus on VP shunt series. Both neurosurgery and neurology have been consulted and deemed it unlikely that cavernoma was the primary driver of (P1’s) encephalopathy and AMS. More likely is a toxic/metabolic encephalopathy, in the setting of hypernatremia and urinary tract infection, MRI with unchanged appearance of cavernous malformation...no change in ventricle size on CT head 10/28. Notably, family under the impression shunt valve should be set at 80 but was 100-110. However, given stable appearance of ventricles neurosurgery would not recommend adjustment.... Vomiting: Unclear cause of new vomiting 10/28....” On 11/3/23 at 3:13 p.m. a Critical Care Physician documented “...Prior 24-Hour Events: Unwitnessed fall: patient claimed (P1) did not hit (P1’s) head...Imaging: Pertinent 24H Imaging Results: (11/3) CT Head Interval development of hydrocephalus with increase in ventricular size....Non-Obstructive Hydrocephalus ISO Hakim VP Shunt Hx. Brainstem Cavernoma S/P Resection (2016): S/P unwitnessed fall on evening (11/02). (P1) states that (P1) did not hit (P1’s) head, so no f/u imaging was pursued. Was obtunded this AM...CTH demonstrated finding of nonobstructive hydrocephalus ISO Hakim VP shunt, Consult NSGY (neurosurgery)....APP Critical Care Services...At the time I saw the patient there was a high probability of imminent or life threatening deterioration, and the patient’s diagnosis acutely impairs one or more vital organ system...”. On 11/3/23 at 6:07 p.m., a Neurological Surgery Consult H&P documented “...Of note, patient has had to (sic) MRIs since being admitted with 2 shunt series which demonstrated that the valve was at 110. NSGY was never contacted regarding a shunt setting change. Of note, (P1’s spouse) states that a pre/post XR after MRI at (outside facility) in August noted that the Hakim was at 90 pre and then 100 post, but the shunt was never changed back to its original shunt setting...Assessment...(P1’s) recent CTH today demonstrated concern for acute hydrocephalus with a recent valve shot at 110. Given (P1’s) image and clinical findings, there was concern for acute hydrocephalus warranting further investigation with a shunt tap to determine if this is a result of shunt malfunction or due to an incorrect shunt settings...”. P1’s shunt reprogramming was conducted by neurosurgery on 11/3/23 at 7:09 p.m. and note documented in part, “...Codman Hakim Right Ventriculo-Peritoneal shunt Shunt Valve New Setting: 80, Previous setting: 110...”. On 2/28/24 at 1:30 a.m., an interview was conducted with Staff Member #12 (SM12) who stated that brain shunts could only be changed because of exposure to a magnetic field, such as an MRI. On 2/28/24 at 3:30 p.m., an interview was conducted with SM1 who provided a printed timeline showing the chronology of events regarding P1’s radiology scans and decline in health. SM1 explained that according to P1’s medical records, P1 was admitted on 10/17/23 with an altered mental status, probably due to an infection since P1’s 10/17/23 CT head scan didn’t show an acute hydrocephalus on admission. P1’s x-ray on admission documented VP shunt setting at 90. P1’s notes indicated that prior to admission, P1’s shunt was set at 80. Neurosurgery was consulted upon admission due to the shunt, but signed off concluding P1’s symptoms were probably not due to the shunt setting, however, Neurology continued to follow P1. On 10/18/23, P1 received a second MRI and on 10/19/23 X-ray series were completed, documenting the shunt setting was at 100. SM1’s opinion was that the MRI on 10/18/23 probably reset the shunt setting from 90 to 100, but the shunt setting change was not communicated to Neurosurgery. On 10/25/23, a third MRI was performed, but the shunt series x-ray order was canceled for an unknown reason. On 10/28/23, the shunt series x-ray was performed with documentation that the shunt setting was now at 100-110. This was not communicated to Neurosurgery. On the evening of 11/2/23, P1 fell out of bed, was evaluated by the RN and the Hospitalist and found to have no injuries or to have hit (his/her) head. On the morning of 11/3/23, P1 was found hypothermic and subsequently transferred to ICU where a CT scan of the head was performed and acute hydrocephaly was diagnosed. At that point, Neurosurgery was called in and P1’s shunt was reprogrammed from 110 to 80. Another CT scan was completed on 11/4/23 and documented improving hydrocephaly. SM1 stated that P1’s health continued to improve after that. SM1 stated that Neurology primarily focuses on the cause for the altered mental status and Neurosurgery primarily focuses on shunt settings. A review of an adverse event documented on 11/3/23. The description of the event documented “...MET (medical emergency team) called for AMS (altered mental status), hypothermia and bradycardia while on 5S under Hospitalist service...CT head obtained for further investigation of acute AMS which revealed new hydrocephalus. NSGY consulted. VP shunt series revealed a change in her VP shunt from 80-110 likely result in new acute hydrocephalus. Upon chart review, patient had an MRI on 10/25; there was no VP shunt series performed following MRI and NSGY was not notified. Per NSGY this is standard procedure for a patient with this specific VP shunt. The patient required escalation of care to the IC (intensive care), removal of 20cc of CSF (cerebral spinal fluid), close neuro monitoring due to this oversight and ongoing setback in neuro status p/t event”. The Investigation Findings/Corrective Actions documented by Staff Member #11 read “...To this end, I have made specific queries to Hospitalist about knowledge to obtain a shunt series after every MRI for risk that the shunt can migrate/move w/ MRI. This is a clear knowledge deficit for myself as well as every Hospitalist team member I have discussed this case with (5 in total). A couple courses of action I might propose for consideration: -- (1) create an EHR (electronic health record) hard stop when ordering any MRI that requires addition of a shunt series, -- (2) create an EHR hard stop or policy restriction in management of patients/primary team to only those providers with such knowledge -- neurosurgery vs neurology (defer to most knowledgeable)”. An additional response was documented by a Radiology team member and read “...Our MRI staff is responsible for paging neurosurgery after each such MRI to check the status of the shunt...However I would like to amend the narrative of this particular case. After the MRI on 10/25, there were shunt series radiographs that were performed on 10/28 which showed NO change in the shunt setting compared to the prior shunt series on 10/19. That would indicate that the subsequently discovered change in the shunt setting on 11/3 was NOT a result of the 10/25 MRI...There is a process in place that when a patient with a programmable shunt has an MRI, a visit with a LIP (licensed provider) in neurosurgery is needed (outpatient) or a consultation for assessment of shunt (inpatient) is needed. In this case, it seems that the MRI was not responsible for the shunt alteration. Would suggest retraining for any MRI techs who are not aware of this arrangement...”. A review of the facility’s policy “Ventricular Shunts Policy”, effective date 3/14/17 stated in part “...(3) If it is a programmable shunt, the MRI technologist contacts the neurosurgery clinic to arrange for a post-MRI shunt check as a scheduled appointment. (4) If this is accomplished, the patient undergoes the MRI and is instructed to go to the neurosurgery clinic after the MRI. (5) If the MRI occurs after hours or on weekend, or if a neurosurgery clinic appointment has not be arranged in advance, the Neurosurgery on-call resident is paged, and it is arranged for the neurosurgery resident to meet the patient at the Medical Center to check the shunt...(7) Radiologist will add in the “IMPRESSION” section for radiology readings of such cases a state as “Patient has a ventricular shunt. It may need to be reprogrammed by Neurosurgery”. The findings were discussed with Staff Members #1, #2 and #14 at the exit conference on 2/28/24 at 3:45 p.m.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46466 Based on interviews, medical record and facility document review, the staff failed to adhere to facility policies and procedures when documenting patient’s fall event. The findings include: On 2/27/24 at 12:47 p.m., a review of Patient #1’s (P1) medical record was completed with assistance of Staff Member #8 (SM8). P1’s medical record revealed that P1 experienced a fall on 11/2/23 at 6:08 p.m. SM8 navigated through all of the Registered Nurse (RN) notes for 11/2/23, however, there was no RN Event Note that documented P1’s fall or injuries. SM8 navigated to the RN flowsheet and found a notation within the flowsheet documenting that P1 fell out of bed and the physician was paged. Vital signs were documented at 6:08 p.m.. There was no head-to-toe assessment documented by the RN or the Hospitalist and/or evidence of documentation by a Hospitalist evaluating P1 after the fall. On 2/28/24 at 10:00 a.m. an interview was conducted with Staff Member #9 (SM9) who stated that Staff Member #10 (SM10), RN was assigned to care for P1 on 11/2/23 when P1’s fall occurred. SM10 was still in orientation and was being precepted by a travel nurse who is no longer working at the facility. On the day of the fall, SM9 stated that per SM10 recollection , P1’s bed alarm was activated,. SM10 went into P1’s room and found P1 face down on the floor mat. The Charge Nurse and team were paged to P1’s room. P1 was lifted off the floor into the bed with a hover jack. Vital signs were taken, and the attending physician felt that P1 was stable, without injuries and not needing further workup. SM9 stated that at some point Staff Member #11 spoke with P1’s spouse about their complaint related to not being told about P1’s fall. SM9 was asked for the typical procedure that staff should follow after a patient fall. SM9 responded that the person who found the patient would page the team to include the charge nurse, MET (medical emergency team) and attending physician. After assessment of the patient, the patient would be transferred to the bed, vital signs would be taken, and a conversation should occur between the physician and the assigned nurse as to who will contact the patient’s family member. The nurse would document a “Be Safe” event where the fall information would be reviewed by the nurse supervisor and manager, so the unit could discuss any learning opportunities. SM9 added that the patient’s medical record should document the vital signs, physical assessment and fall in an event note. A review of the facility’s policy “Fall Prevention for Adult and Pediatric Patients Guideline”, last revised 1/5/24, stated in part: “...Fall Management...3. RN or LIP obtains VS and performs head-to-toe assessment...b. If the patient does not have evidence of major injury, place the patient in a safe place using minimal lift equipment if the patient requires assistance...5. LIP assess the patient, determines if any diagnostics are needed, and notifies the patient’s emergency contact as appropriate...7. Once the patient is stabilized and received appropriate treatment, place an event note in the EHR, notify the RN Manager, and place a Be Safe Event...”. The findings were discussed with Staff Members #1, #2 and #14 at the exit conference on 2/28/24 at 3:45 p.m.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 46466 Based on interviews, medical record and facility document review, radiology staff failed to follow policies and procedures to ensure patient safety. The findings include: Patient #1’s (P1) Neurological Surgery Consult History and Physical dated 10/17/23 at 12:03 p.m. documented “...(P1) with past medical history of prior cavernous malformation of the midbrain that presented in 2015...(P1) developed obstructive hydrocephalus, requiring placement of a Codman Hakin valve set to 80. (P1) is not required revisions, but has had multiple shunt adjustments. Apparently, (P1) is rather sensitive to shunt adjustments and developed hydrocephalus multiple times after adjustments at (another hospital)...Recent MRI August demonstrates recurrence in growth of (P1’s) cavernous malformation to include the left thalamus...Assessment...CT head demonstrates no diffuse cerebral edema and no hydrocephalus concerning for shunt failure...neurosurgery to follow peripherally while workup continues...”. On 10/17/23 at 10:13 a.m., a VP (ventriculoperitoneal) shunt series with valve shot x-ray was completed on P1. The results documented “Narrative & Impression: Additional Clinical Data: AMS (altered mental status)...FINDINGS:...Shunt setting of Codman Hakim at 90...IMPRESSION: Right approach ventricular shunt catheter with distal tubing terminating in the right lower quadrant. No evidence of shallow discontinuity or kinking. Shunt setting at 90...”. On 10/18/23, P1 had an MRI completed. On 10/19/23 at 1:20 a.m., a VP (ventriculoperitoneal) shunt series with valve shot x-ray was completed on P1. The results documented “...Indication: needed post MRI...Comparison: CT Head 10/17/2023; CR Head Chest 10/17/2023...Shunt setting at 100...IMPRESSION: 1. Right parietal ventriculoperitoneal shunt in place, with no evidence of complicating feature. 2. No acute cardiopulmonary disease. 3. No acute abdominal or pelvic process...”. On 10/25/23, P1 had an MRI completed. On 10/28/23, a VP (ventriculoperitoneal) shunt series with valve shot x-ray was completed on P1. The results documented “...Indication: check shunt setting. Comparison: CR Head Chest 10/19/2023...Codman Hakim programmable valve setting most closely approximates 100-110 mmH2O...IMPRESSION: 1. Right parietal approach ventriculoperitoneal shunt in place, with no evidence of complicating feature. 2. Codman Hakim programmable valve setting most closely approximates 100-110 mmH20. 3. No acute cardiopulmonary disease. 1. (sic) No acute abdominal or pelvic process...”. On 11/3/23 at 6:07 p.m., a Neurological Surgery Consult H&P documented “...Of note, patient has had to (sic) MRIs since being admitted with 2 shunt series which demonstrated that the valve was at 110. NSGY was never contacted regarding a shunt setting change. Of note, (P1’s spouse) states that a pre/post XR after MRI at (outside facility) in August noted that the Hakim was at 90 pre and then 100 post, but the shunt was never changed back to its original shunt setting...Assessment...(P1’s) recent CTH today demonstrated concern for acute hydrocephalus with a recent valve shot at 110. Given (P1’s) image and clinical findings, there was concern for acute hydrocephalus warranting further investigation with a shunt tap to determine if this is a result of shunt malfunction or due to an incorrect shunt settings...”. A Neurosurgery Shunt Reprogramming was conducted on P1 on 11/3/23 at 7:09 p.m. It was documented “...Codman Hakim Right Ventriculo-Peritoneal shunt Shunt Valve New Setting: 80, Previous setting: 110...”. On 2/28/24 at 3:30 p.m., an interview was conducted with SM1. SM1 provided a printed timeline showing the chronology of events regarding P1’s radiology scans and decline in health. SM1 explained that according to P1’s medical records, P1 was admitted on 10/17/23 with an altered mental status.SM1 stated that the P1’s altered mental status was probably due to an infection since P1’s 10/17/23 CT head head revealed that P1 did not have acute hydrocephalus on admission. P1 received an x-ray on admission which documented that P1’s VP shunt setting was at 90. P1’s notes indicated that previously, P1’s shunt was set at 80 prior to P1’s admission to the facility. Neurosurgery was consulted upon admission due to the shunt, but neurosurgery signed off since P1’s symptoms were probably not due to the shunt setting. On 10/18/23, P1 received an MRI and X-ray series on 10/19/23, immediately after the MRI that documented the shunt setting was 100. SM1’s opinion was that the 10/18/23 MRI reset the shunt setting from 90 to 100 but these results were not communicated to Neurosurgery. On 10/25/23, another MRI was performed, but the shunt series x-ray order was canceled for an unknown reason. On 10/28/23, the shunt series x-ray was performed with documentation that the shunt setting was 100-110. On the evening of 11/2/23, P1 fell of bed, was evaluated by the RN and the Hospitalist and found to have no injuries or to have hit (his/her) head. On the morning of 11/3/23, P1 was found hypothermic and subsequently transferred to ICU where a CT scan of the head was performed and acute hydrocephaly was diagnosed. At that point, Neurosurgery was called in and P1’s shunt was reprogrammed from 110 to 80. Another CT scan was completed on 11/4/23 and documented improving hydrocephaly. SM1 stated that P1’s health continued to improve after that. SM1 stated that Neurology primarily focuses on the cause for the altered mental status and Neurosurgery primarily focuses on shunt settings. A review of another adverse event entered regarding P1 was documented on 11/3/23. The description of the event documented “...(P1) was MET called for AMS, hypothermia and bradycardia while on 5S under hospitalist service...CT head obtained for further investigation of acute AMS which revealed new hydrocephalus. NSGY consulted. VP shunt series revealed a change in her VP shunt from 80-110 likely result in new acute hydrocephalus. Upon chart review, patient had an MRI on 10/25; there was no VP shunt series performed following MRI and NSGY was not notified. Per NSGY this is standard procedure for a patient with this specific VP shunt. The patient required escalation of care to the IC, removal of 20cc of CSF (cerebral spinal fluid), clos neuro monitoring due to this oversight and ongoing setback in neuro status p/t event”. The Investigation Findings/Corrective Actions documented by Staff Member #11 read “...To this end, I have made specfific queiries to hosptialists about knowledge to obtain a shunt series after every MRI for risk that the shunt can migrate/move w/ MRI. This is a clear knowledge deficit for myself as well as every hosptalist team member I have discussed this case with (5 in total). A couple courses of action I might propose for consideration: -- (1) create an EHR had stop when ordering any MRI that requires addition of a shunt series, -- (2) create an EHR hard sstop or policy restriction in managment of patients/primary team to only those providers with such knowledge -- neurosurgery vs neurology (defer to most knowledgeable)”. An additional response was documented by a Radiology team member and read “...Our MRI staff is responsible for paging neurosurgery after each such MRI to check the status of the shunt...However I would like to amend the narrative of this particular case. Ater the MRI on 10/25, there were shunt series radiographs that were performed on 10/28 which showed NO change in the shunt setting compared to the prior shunt series on 10/19. That would indicate that the subsequently discovered change in the shunt setting on 11/3 was NOT a result of the 10/25 MRI...There is a process in place that when a patient with a programmable shunt has an MRI, a visit with a LIP (licensed provider) in neurosurgery is needed (outpatient) or a consultation for assessment of shunt (inpatient) is needed. In this case, it seems that the mri was not responsible for the shunt alteration. Would suggest retraining for any MRI techs who are not aware of this arrangement...”. A review of the facility’s policy “Ventricular Shunts Policy”, effective date 3/14/17 stated in part “...(3) If it is a programmable shunt, the MRI technologist contacts the neurosurgery clinic to arrange for a post-MRI shunt check as a scheduled appointment. (4) If this is accomplished, the patient undergoes the MRI and is instructed to go to the neurosurgery clinic after the MRI. (5) If the MRI occurs after hours or on weekend, or if a neurosurgery clinic appointment has not be arranged in advance, the Neurosurgery on-call resident is paged, and it is arranged for the neurosurgery resident to meet the patient at the Medical Center to check the shunt...(7) Radiologist will add in the “IMPRESSION” section for radiology readings of such cases a state as “Patient has a ventricular shunt. It may need to be reprogrammed by Neurosurgery”. The findings were discussed with Staff Members #1, #2 and #14 at the exit conference on 2/28/24 at 3:45 p.m.”