HospitalInspections.org

Based on staff interviews and review of facility document review, it was determined the facility failed to ensure CT (computed tomography) services are available for patients with signs and symptoms of stroke, in accordance with facility policy.

Findings include:

Reference #1: Facility policy titled "Stroke/TIA (Transient Ischemic Attack) Management Protocol" (Revised 03/27/23) states, " ... Policy: ... 2. Managing a patient presenting to the Emergency Room with signs and symptoms of Stroke must follow the established patient care protocol. ... Procedure: ... 5 ... e. CT of the Brain shall be performed within 25 minutes following patient arrival. ... ED Stroke Patient Arrival Flowchart: Patient arrives to ED (Emergency Department) with signs and symptoms of Stroke/TIA ... Patient is triaged within 3 minutes of arrival ... Patient is seen by ED Physician within 5 minutes of arrival ... ED Physician places Code Stroke Order set within 10 minutes of arrival ... Patient is transported to Radiology for CT and/or CTA (Computed Tomographic Angiography) with ED RN (Registered Nurse) and monitor ... CT and/or CTA results are communicated to ED Physician within 25 minutes of arrival ... ."

Reference #2: NJ (New Jersey) Administrative Code 8:43G states, " ... 7A.2 Definitions ... 'Primary stroke center' means a licensed general hospital designated to evaluate, stabilize, and provide emergency care to patients with acute stroke symptoms, and to admit such patients for inpatient services as appropriate to the needs of the patient, but which has limited capacity to provide inpatient care to patients with a complex stroke. ... 7A.3 ... (a) To be designated as a primary stroke center, a hospital shall, at a minimum provide ... 3. Neuro-imaging services capability that is available 24 hours a day, seven days a week, such that imaging shall be performed within 25 minutes following order entry. ... i. Neuro-imaging services shall, at a minimum, include computerized tomography (CT) scanning ... ." A CT scan is an imaging test that takes detailed images of the inside of the body, including bones, muscles, fat, organs, and blood vessels.

During the entrance conference conducted on 12/27/23 at 10:15 AM, in the presence of Staff (S) 1, (Director of Quality), S2 (ED Director of Nursing), S3 (Director of Critical Care), S4 (Director of Emergency Preparedness), and S5 (Chief Operating Officer), S1 confirmed that CT services had been on divert to another campus "several times this month," due to staffing issues.

During an interview on 12/27/23 at 10:30 AM, S6 (Director of Radiology) stated, "The CT department is extremely short-staffed right now. We've offered premium pay, bonus pay for extra shifts, and have started using 'travelers' (agency staff), but still cannot get all the shifts covered on the schedule. We have a few CT techs (technicians) that can 'float' between campuses to try and cover the schedule, but we've still had to divert CT services numerous times due to lack of staffing. When the CT department is on divert, patients are transported to [name of another facility in hospital system] via EMS. We cannot operate the CT department without staff, and we do not have enough staff to cover the schedule, so we have to divert CT services."

Upon interview on 12/28/23 at 11:20 AM, S16 (Chief Nursing Officer) confirmed the facility is a primary stroke center.

Review of the facility's Divert Logs on 12/27/23, revealed that CT services at the facility were on divert one time in October 2023, 13 times in November 2023, and 18 times in December 2023, as follows:

Review of the CT technician staff schedule for October, November, and December 2023, confirmed that no CT technicians were scheduled during the dates and times CT services were on divert. The CT staff roster indicated there are nine CT technicians in the department - eight CT technicians are facility employees and one is an agency CT technician.

Upon interview with S15 (EMS Director) on 12/28/23 at 10:15 AM, S15 stated, "If CT is on divert, the hospital is also considered to be on 'Stroke Divert.' If dispatch receives a call (from the community) that the person is exhibiting symptoms of a stroke, the patient is taken directly to [name of facility in hospital system] or the nearest hospital. EMS would not bring the patient here when we're on CT divert."

Upon interview with S16 on 12/28/23 at 11:20 AM, it was confirmed that CT services at the facility were diverted thirty-two (32) times from 10/29/23 until 12/27/23, and the facility failed to provide CT services despite being a primary stroke center.