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Based on review of two (2) of ten (10) medical records (Patient (P) 1 and P7), and staff interviews it was determined the facility failed to integrate and coordinate services provided by other departments of the hospital to ensure that diagnostic tests ordered STAT are completed in a timely manner.

Findings include:

On 7/26/23, a review of P1's medical record showed that P1 was brought into the facilities Emergency Department (ED) by EMS on 3/16/23 at 9:18 AM with complaints of generalized weakness, left hip and shoulder pain and right knee pain. P1 was seen by the ED physician at 9:44 AM and at 9:54 AM an order for a STAT CT of the head without contrast was placed. The order for the STAT CT of head without contrast stated, ".. Order: HEAD W/O CONTRAST [CT] Stat ... Order: 03/16/23 09:54 ...Complete: 03/16/23 14:11 ..." A review of the order indicated that the STAT CT of the head without contrast was completed over 4 hours after the test was ordered. P7 presented to the facilities ED on 4/9/23 at 2:07 PM with a chief complaint of left arm/left leg weakness that started 5 days prior. P7 reported that on 4/9/23 his/her left leg gave out and he/she fell. P7 was triaged with an ESI level 3. A CTA head and neck and CT of the head without contrast were ordered STAT at 2:34 PM and was completed at 4:53 PM, over 2 hours after it was ordered by a provider.

On 7/26/23 at 11:30 AM, during an interview with S1 (Interim Quality Director) and S4 (Patient Care Director), they explained that the goal for STAT orders was to get the patient to CT within 45 minutes. S1 explained that the facility does not have any policies that define the timeframe in which a STAT order has to be completed. At 2:27 PM, an interview was conducted with S9 (Registered Nurse) who explained that STAT orders were to be done within an hour. At 2:35 PM, during an interview with S2 (Chief Hospital Executive) and S6 (ED Physician Director), they explained that all imaging orders (CT, MRI, X-ray) placed in the ED are ordered STAT. S2 and S6 explained that Non-Code Stroke STAT orders should ideally be done within an hour and that STAT indicates "1st available."

Based on review of P1 and P7's medical records and the interviews listed above the facility failed to ensure that STAT orders are performed within 45 minutes to 1 hour.

Based on review of one of one medical record (Patient (P)1) and staff interview it was determined the facility failed to ensure that a policy and procedure for vital signs in the Emergency Department was developed and implemented.

Findings include:

A review of P1's medical record revealed that P1 was brought into Emergency Department (ED) by EMS on 3/16/23 at 9:18 AM with complaints of generalized weakness, left hip and shoulder pain and right knee pain. P1 was triaged and was assigned an ESI (Emergency Severity Index) level 2. P1 also had vital signs taken at 9:18 AM during the triage, P1's blood pressure (BP) was 187/67, pulse 117, temperature 98.2 (Fahrenheit), pulse ox 98% on room air, and respiratory rate of 20. Review of the Vital Signs documentation indicated that P1 had vital signs taken at 9:18 AM, 1:11 PM, 2:45 PM, and 3:01 PM.

On 7/26/23 at 2:20 PM, during an interview with S8 (ED Registered Nurse) he/she explained that he/she performs vital signs on ED patients every 2 hours unless they are an ICU level patient then vital signs are done hourly. At 2:27 PM, during an interview with S9 (ED Registered Nurse), he/she explained that vital signs are taken every 2 hours on patients in the ED and that the physician will place an order for vital signs to be done at other intervals. At 2:35 PM, during an interview with S6 (ED Physician Director) and S7 (ED Nursing Director), confirmed that there was no set interval for vital signs to be done in the ED, but that the physician will discuss with the nurse how often vital signs should be taken. Upon request, the facility was unable to provide a policy and procedure detailing how often vital signs need to be done in the ED.