HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 3 (Pt #2, 10 and 11) patients with Emergency Department (ED) orders for CT (Computed Tomography-diagnostic test used to show images of blood vessels) Scans, the Hospital failed to ensure the scans were completed as required.

Findings include:

1. On 2/14/19 at approximately 2:45 PM, the Hospital presented a portion of the Electronic Medical Record (last edit date 8/10/17) program that included all Emergency Department orders default to STAT (without delay, immediate).

2. The clinical record of Pt #2 was reviewed on 2/13/19. Pt #2 was a 76 year old female who presented to the ED on 11/7/2018 at 6:08 AM, via ambulance with the complaint of generalized weakness. Pt #2's clinical record contained a physician's order dated 11/7/18 at 6:52 AM, that required a CT of the head witout contrast, Stat (medical abbreviattion for immediate). A Nursing Note dated 11/7/18 at 11:24 AM, included, "PT (patient-Pt #2) returned from CT-completed ...Hooked back to Cardiac Monitor; VSS (vital signs stable) ...CT was completed at 11:07 AM...( with 4 hours and 15 mintues delay)..."

3. The clinical record of Pt #10 was reviewed on 2/14/19 at approximately 10:40 AM. Pt #10 was a 73 year old male who presented to the ED on 12/22/18 with complaints of abdominal pain, head pain, and a need for a well being check. Pt #10's clinical record contained a physician's order dated 12/22/18 at 6:24 PM, that required a CT of the head without contrast, result of the CT indicated "Acute to subacute infarcts of the right caudate nucleus."CT was completed at 8:25 PM( with 1 hour and 59 minutes delay). Nursing documentation dated 12/22/18 at 8:38 PM included, "Pt returned from CT via wheelchair..."

4. The Radiology Departments CT log dated 12/22/18 included, on 12/22/18 at 8:35 PM, Pt #10's CT was completed ( with 2 hours and 14 minutes delay).

5. The clinical record of Pt #11 was reviewed on 2/14/19 at approximately 11:00 AM. Pt #11 was a 48 year old female who presented to the ED on 12/30/18 with complaints of headache. Pt #11's clinical record contained a physician's order dated 12/30/18 at 10:44 PM for a CT of the head without contrast. Nursing documentation dated 12/31/18 at 2:40 AM included, "...patient transferred to radiology for CT without contrast...CT scan was completed at 2:34 AM..( with 3 hours and 50 minutes delay)."

6. On 2/15/19 at approximately 10:30 AM, an interview was conducted with the Interim Director of Quality and Regulatory Services (E #8). E #8 stated, "All orders are considered STAT from the ED and should be completed within 30 to 60 minutes. The 2 to 3 hours wait time is too long."

7. On 2/15/19 at approximately 11:00 AM, an interview was conducted with the Director of Radiology (E #18). E #18 stated, "We monitor the turn around time of the report during the day only. We do not monitor the time the order was received or the time of completion."