Encompass Health Rehab Hospital of Huntington

“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: 43434 Based on policy review, medical record review and staff interview, the facility failed to follow their radiology policy on two (2) out of twelve (12) patients reviewed (patient 1 and patient 8). This failure has the potential to effect all patients needing radiology services. Findings: A review was conducted of the policy titled “Radiology”, last reviewed 08/14/25. The policy states in part, “ ...Radiology services sufficient to meet the needs of the patient population are available 24 [twenty-four] hours per day, which may include transfer to an acute care facility for testing ...All radiology requests need to be addressed within 4 [four] hours of order ...” A review of a document titled “AMENDED AND RESTATED ANCILLARY SERVICES AGREEMENT”, Encompass Health Rehabilitation Hospital of Huntington (“Encompass Health”), and Cardiovascular Imaging Services, Inc. was conducted. The document states in part, “ ...Scope of Services. At the request of the Hospital, Provider shall provide cardiovascular imaging services for the Hospital in accordance with all applicable federal and state laws and regulations and protocols set forth by Hospital. Hospital shall provide a written, signed order from a Hospital physician specifying the type of cardiovascular imaging service to be performed and medical necessity. The cardiovascular imaging services to be performed shall include, but not be limited to, the following: ...4. Provider shall provide the cardiovascular imaging services on an as needed basis during normal business hours. 5. Provider shall provide Hospital and the ordering physician with results of the cardiovascular imaging service in a timely manner either by telephone, messenger, U.S. mail, fax or electronic reporting. STAT reports shall be reported within 2-4 hours of the cardiovascular imaging procedure.”... A medical record review was conducted for Patient 1. Patient 1 was admitted to the facility on 11/20/25. The patient has a diagnosis of Parkinson Disease, Chronic Kidney Disease, Diabetes, Basal cell carcinoma, and Ataxia with multiple falls. Patient 1 has recently suffered falls at home that has severely limited (his/her) mobility and the ability to complete activities of daily living (ADL’s). Patient was placed on high-risk safety precautions for falls. Patient 1 was given a yellow wrist band and admitted to Room 116 with fall precautions in place: Fall Risk Level-High, Fall Precautions-Bathroom Supervision-in BR, Bed Alarm-Fall level, Seatbelts-self releasing with alarm. Referrals were made to receive services for rehabilitative nursing, physical therapy, occupational therapy, speech language pathology, and case management, to assist with activities of daily living (ADL’s) and ambulation and continue with treatment for pressure ulcers. On 11/30/25 at 6:00 p.m. the medical record reflects that patient 1 fell in the bathroom while being assisted to the commode. Staff 1 ordered x-rays of the patients left forearm on 11/30/25 at 7:19 p.m. At 7:07 a.m. on 12/01/25, staff 1 again ordered stat x-rays of the patient’s left forearm. At 10:36 a.m. on 12/01/25, the contracted imaging service completed the requested order. The results were read at 1:34 p.m. and staff 1 received the results at 2:03 p.m. The nursing staff attempted to notify the family at 3:34 p.m. with the results. Patient 1 suffered a humeral head and neck fracture; a sling was placed on (his/her) arm. On 12/01/25 at 3:34 p.m. patient 1 was sent out to the emergency room for further evaluation per the family’s request. Patient 1 was discharged from the emergency room with the recommendation of continuing to wear the sling and outpatient follow-up. Patient returned to the facility on 12/01/25. On 12/02/25, patient 1 was discharged as medically stable. A medical record review was completed on patient 8. Patient 8 was admitted to the facility on 12/29/25, due to worsening back and leg pain after a recent fall. The fall caused the patient to have a T12 (thoracic vertebra twelve) fracture. On 12/17/25 the patient underwent a T11-12 and T12-L1 (first lumbar vertrbra) total laminectomy central canal and the lateral recess decompression. On 12/22/25, it was reported that the patient was having radiating pain in (his/her) RLE from the hip down (his/her) leg which prohibited ambulation. The patient was admitted to the facility. Referrals were made to receive services for rehabilitative nursing, physical therapy, occupational therapy, respiratory therapy, speech language pathology, and case management, to assist with activities of daily living (ADL’s), safety and ambulation. On 1/2/26 at 10:43 a.m., the record reflects a physician order was submitted for XR Chest two (2) views with super STAT status to rule out pneumonia. The order was completed on 1/2/26 at 5:51 p.m. The results were read at 9:52 p.m. An interview was conducted on 01/06/26 at 3:00 p.m. with staff 11. Staff 11 stated, “Cardiovascular Imaging Services, Inc. does all the x-rays for the facility. Cardiovascular Imaging Services has a technician that comes in each day around 10:00 a.m. and then leaves around 5:00 p.m. If the service is needed after those hours, you can call Cardiovascular Imaging Services and they will come back out and if they can’t come back, then we send the patient to the hospital”. Staff 11 confirmed that the “Radiology Policy” does state that radiology services are to be available to patients 24 hours per day and may include transferring to an acute care facility for testing if for any reason the service can’t be performed. It was also confirmed that a radiology request is to be addressed within four (4) hours of order per the policy. Staff 11 stated, [he/she] had requested clarification on addressing an order within four [4] hours and even though the statement is vague, it is believed to mean that the service would be initiated within four [4] hours”. Staff 11 confirmed that the policy wasn’t followed and patient 1 and patient 8 did have delays in radiology services.”