HospitalInspections.org

Based on staff interviews and review of facility documents it was determined the facility failed to meet the emergent needs of patients in accordance with acceptable standards of practice, consistent with the designation as a primary stroke center by failing to adequately integrate emergency services with radiology services as evidenced by documented gaps in staffing coverage and the inability to ensure the availability of radiology services and personnel (1103) and failed to establish and implement a policy and procedure for diverting when services are unavailable (1104).

Based on staff interviews and review of facility documents, it was determined that the facility failed to integrate emergency services with radiology services, as evidenced by documented staffing coverage gaps, thus the facility is unable to assure the immediate availability of radiology services and personnel consistent with acceptable standards of practice for a facility designated as a primary stroke center.

Findings include:

Reference #1: Facility website accessed on 3/12/24 at https://carewellhealth.org/emergency-department/ states " ...We are staffed 24 hours a day, 365 days a year by a highly trained team of emergency medicine physicians, who are board certified and assisted by other emergency medicine professionals. CareWell Health is a Primary Stroke Center and recognizes that time is essential in an emergency. Our entire staff is dedicated to treating patients as quickly as possible and our experienced team of medical professionals is focused solely on your health, with the facilities and technology necessary to treat you best. ..."

Reference #2: The State of New Jersey, Department of Health, Acute Stroke Service, Complete List of Designated Stroke Center Hospitals in New Jersey [pdf] accessed on 3/12/24 at Designated_Stroke_Centers_2024.pdf (nj.gov) lists Carewell Health Medical Center as a Primary Stroke Center.

Reference #3: 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).

Reference #4: NJ Administrative Code 8:43G states, " ... 12.7 (w) Radiology services for emergency needs shall be available to the emergency department 24 hours a day. ... ."

During the entrance conference conducted on 1/30/24 at 9:40 AM, in the presence of Staff (S)1 (Senior Director of Nursing), S2 (Quality Nurse Coordinator), and S3 (Medical Director), S3 stated there have been "gaps" in CT services due to staffing shortages. S3 stated the previous Radiology Director left the organization at the end of December (2023) and would "cover gaps in the schedule" prior to his/her departure.

During an interview on 1/30/24 at 10:00 AM, S2 stated, "Honestly, we are not sure if we are a primary stroke center. We used to be." On 2/1/24, the facility was identified as a Primary Stroke Center on the New Jersey Department of Health website.

During an interview on 1/30/24 at 10:45 AM, S4 (Radiology Director) stated the Radiology Department currently has three open positions for x-ray technicians and three open positions for CT technicians. The facility has a contract with an agency to fill staffing gaps with contracted x-ray technicians. The facility does not have any contracted CT technicians. When asked if he/she covers gaps in radiology services, S4 stated that he/she is not "CT certified."

Upon review of the CT and x-ray staffing schedule on 1/30/23 at 2:15 PM, in the presence of S1, it was revealed that CT services were unavailable 11 times and x-ray services were unavailable 4 times from 12/17/23 until 1/30/24.

During an interview conducted on 1/31/24 at 10:27 AM, S19 (ED Medical Director) stated, "I have made multiple requests in December alone to place the hospital on divert due to the CT scan not being available. If a patient develops stroke-like symptoms while in our facility, they will get transferred out."

On 1/30/24 at 2:30 PM, S3 confirmed that CT and x-ray services were not available at the facility for patients 24 hours a day, seven days a week, for patients exhibiting signs and symptoms of a stroke.

On 2/1/24 at 2:47 PM the on-call schedule for the Radiology Department was requested and reviewed. Due to the facility having staffing shortages in the CT and x-ray departments, the Radiology on-call list for November 2023 through February 2024 was requested and reviewed. Review of the "[Name of Radiology Group] Month by Assignment," Radiology on call schedule, revealed there were no physician or group name listed for on-call coverage on the following dates: every Saturday and Sunday; Thursday, November 23, 2023; Friday, November 24, 2023; Monday, December 25, 2025; and Monday, January 1, 2024. The last page of the call schedule is an addendum that states "*[Name of Contracted Radiology group] Radiology extends coverage beyond regulare [sic] hours*".

On 2/1/24 at 2:50 PM, during interview with S6 (Director of Informatics), he/she explained that the radiology service is provided by contract through [name of Radiology group]. S6 stated [name of Radiology group] has a contract with [name of contracted Radiology group] to take call for them and do their readings after hours. Both contracts were requested for review. S6 was able to provide the facility's contract with [name of Radiology group], but after multiple requests, was unable to provide the contract between [name of Radiology group] and [name of contracted Radiology group].

Based on staff interviews and review of facility documents, it was determined the facility failed to establish a policy and procedure to implement when CT (computerized tomography) and x-ray services are unavailable, and the department diverts radiology services to another facility.

Findings include:

During the entrance conference conducted 1/30/24 at 9:40 AM, in the presence of S1, S2, and S3, it was confirmed the facility has experienced gaps in CT and x-ray services due to staffing shortages.

On 1/30/24, review of the CT staff roster determined that six CT technicians are currently employed at the facility. The facility does not currently have any agency CT technicians. Review of the x-ray staff roster determined that eight x-ray technicians are currently employed at the facility and cover the radiology and ED departments.

On 1/30/24 at 2:15 PM, during review of the CT and x-ray staffing schedules in the presence of S1, he/she confirmed that no technicians were identified on the CT and x-ray staffing schedules from 12/17/23 until 1/30/24 for the following shifts:

CT: 12/25/23 (4PM-12AM); 12/30/23 (8PM-12AM); 1/5/24 (12PM-4PM); 1/6/24 (5PM-12AM); 1/8/24 (12AM-8AM); 1/9/24 (4PM-8PM); 1/14/24 (8PM-12AM); 1/16/24 (4PM-12AM); 1/20/24 (4PM-12AM); 1/21/24 (8PM-12AM); 1/28/24 (4PM-8PM).

X-ray: 1/1/24 (8AM-3PM); 1/9/24 (12AM-8AM); 1/16/24 (4PM-6PM); 1/20/24 (4PM-8PM).

The radiology department experienced lapses in CT services 11 times and lapses in x-ray services four times, from 12/17/23 until 1/30/24, due to lack of staffing.

Upon interview on 1/31/24 at 10:30 AM, S3 stated, "We never went on divert for CT services. We do not have equipment issues so there was no reason to put the services on divert." Upon request of the facility's "Divert Policy," S1 stated, "We do not have any divert policy when CT services are not available here."

On 1/31/24 at 11:00 AM, S6 (Director of Informatics) confirmed the facility does not have a policy to follow when radiology services are unavailable and CT and x-ray services are diverted to another facility.