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Based on interview and record review, the facility failed to ensure nursing staff adhered to the policies and procedures of the hospital for 1 (P-1) of 20 patients reviewed for neurologic examinations following an unwitnessed fall with head injury, resulting in P-1's death. Findings include:

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A-0398 - Failure to follow hospital policies and procedures of the hospital.

Based on interview and record review, the facility failed to ensure nursing staff adhered to the policies and procedures of the hospital for 1 (P-1) of 20 patients reviewed for neurologic examinations following an unwitnessed fall, resulting in P-1's death. Findings include:

Record review of P-1's medical record revealed P-1 had an unwitnessed fall on 09/27/2024 at 1145. P-1 told staff she hit her head. At 1607 the patient was found with a change in neuro status including non-reactive pupils and not responsive to commands. At 1709 a "code stroke" was called after the head CT scan was completed at 1636. The only nursing flowsheet documentation between the fall and change of status was as follows:

1145 - GCS 14, alert confused (TIME OF FALL)
1150 - CT scan head ordered STAT
1317 - Changed PureWik, IV flushed
1607 - VS - BP 224/98, HR 80, 96%, GCS 6, Neuro exam (unable to assess), pupils non-reactive (right and left)
1624 - Glucose 130
1636 - CT-Scan head completed STAT
1709 - Code Stroke

Chart review revealed there was no documentation of neuro checks or increased monitoring after the unwitnessed fall until 1607.

During an interview with the nurse (Staff HH) on 10/17/2024 at 1011 it was revealed she was assigned to care for P-1 on the day of P-1's fall. When queried if she tried to call anyone from management to help facilitate getting the CT-scan done sooner, Staff HH revealed, "I don't have time to run around looking for phone numbers." When queried if she was monitoring P-1 closely for her neurological status after the fall, Staff HH revealed "yes, but I forgot to chart" and "she seemed at her baseline until she was found unresponsive in her room."

On 10/16/2024 at 1500 an interview with the Director of Patient Safety and Clinical Risk (Staff U) was conducted and revealed she was "familiar with this case" regarding P-1. Staff U stated a Root Cause Analysis (RCA) investigation is scheduled for 10/31/2024 (over a month post incident). Staff U revealed that the Radiology Technician that delayed the CT-scan was terminated. When queried if any changes have been made by the facility to ensure this type of incident does not occur again, Staff U revealed "you would have to ask the leaders" of the Units.

On 10/16/2024 at 1552 an interview with the Nurse Manager (Staff P) for 9-South, (the unit where P-1 fell) occurred. Staff P explained she spoke with Staff HH again the following Monday about the fall and reviewed the Post Fall Checklist with her and found that neurological checks were not completed every two hours. When queried if this was a concern that the neurological assessments had not been completed by Staff HH every 2 hours after the unwitnessed fall, Staff P responded, "well the physician did not order additional neuro checks". When queried what changes have been implemented since the fall, Staff P explained she has been discussing in the daily staff huddles "how to escalate a delay in a STAT order and to let management know in real time". When queried if she could provide a list of employees that received this education and a copy of the education provided, Staff P revealed she did not have anything in writing, it was all done verbally at huddles. There was no evidence of education regarding interventions, including neurological monitoring post fall, how to escalate CT department concerns, or the delay in identification of a "code stroke".

On 10/17/2024 at 1500 review of Policy #PC-116, titled "Fall Prevention and Management" review date 4/19, Section 5, Post Fall Management, 5.32. "Complete the Post Fall Huddle Form and notify Manager/Nursing Supervisor". Review of the Post Fall Huddle form, which is included in the Policy #PC-116, page 7, reveals a checklist titled "Complete items listed below for all falls:", "Implement neuro checks and document in the 24-hour nursing daily focused assessment (every 2 hours x 48 hours if fall is not witnessed or per physician order)."

Based on interview and record review, the facility failed to ensure CT (computed tomography)-scan technicians adhered to the policies and procedures of the hospital for 1 (P-1) of 20 patients reviewed for timeliness of STAT (immediate/urgent) inpatient CT-scans, resulting in the delay of diagnosing a life-threatening brain injury, which resulted in P-1's death. Findings include:

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A-0529 - Failure to maintain available radiologic services according to the needs of the patients.

Based on interview and record review, the facility failed to ensure CT (computed tomography)-scan technicians adhered to the policies and procedures of the hospital for 1 (P-1) of 20 patients reviewed for timeliness of STAT (immediate/urgent) inpatient CT-scans, resulting in patient death. Findings include:

On 10/16/2024 at 1345 record review revealed P-1 fell on 9/27/2024 at 1145, a STAT CT-scan was ordered at 1150 and was not completed until 1636. CT scan results showed a large subdural hematoma with complications and the patient expired at 1830.

During an interview with the nurse (Staff HH) on 10/17/2024 at 1011 it was revealed she was assigned to care for P-1 the day of the fall. Staff HH revealed after the fall she called CT-scan and spoke with the CT-tech (Staff FF) and told him about the order for STAT CT for P-1 "after a fall". Staff HH explained after about an hour P-1 was still not taken for CT-scan, so she called and spoke with Staff FF again who explained he was doing the scans for priority outpatient biopsies.

On 10/16/2024 at 1500 an interview with the Director of Patient Safety and Clinical Risk (Staff U) was conducted and revealed she was "familiar with this case" regarding P-1 and the delay in P-1's STAT CT scan. Staff U revealed a Root Cause Analysis (RCA) investigation regarding the delay is scheduled for 10/31/2024 (over a month post incident). Staff U revealed that the Radiology Technician that delayed the CT-scan was terminated. When queried if any changes have been made by the facility to ensure this type of incident does not occur again, Staff U stated "you would have to ask the leaders" of the Units.

On 10/16/2024 at 1523 an interview was conducted with the Manager of Radiology (Staff L), Radiology Supervisor (Staff K) and a Radiology Supervisor (Staff K). Staff L explained she was notified of P-1's delayed CT at 1830 on 09/27/2024 from the Director of Radiology (Staff GG). Staff L revealed she called and spoke with the CT-techs around 1845-1900 and asked Staff K to speak with the staff about the incident. Staff K revealed he spoke with Staff FF and Staff Z (the CT techs who were working at the time of P-1's STAT CT orders) and Staff FF told him "I had outpatients to do, they were timed exams, and I had to get them done." Staff K confirmed, STAT exams always come first so he was unclear why Staff FF would have done the outpatients first. When queried what changes have been implemented since the incident to prevent this type of delay from happening again, Staff L revealed she spoke with each technician and "reviewed how to prioritize workflow" and she will be including education about prioritization at their next employee meeting on 10/23/2024 (almost 1 month after P-1's delayed CT scan and death). When queried if she could provide evidence of corrective actions such as a list of people she had spoken with inlcuding, the time, date and the information reviewed, Staff L revealed "no, they were just verbal 1:1 conversations, I do not have anything in writing."

Review of facility policy "Diagnostic Imaging Order Priority and Completion" effective 07/2015 revealed under Procedures "1. STAT orders for imaging studies are prioritized ahead of all timed and routine inpatient and outpatient studies. It is the goal of Diagnostic Imaging to respond to all STAT orders within 60 minutes of order entry..."