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Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each patient received care in a safe setting for two (2) of seventeen (17) sampled patients, Patient #5 and Patient #6.

Patient #5 received an unordered Computed Tomography (CT) scan of the head, in error, due to a mix-up with Patient #6, who had the last name as Patient #5. Then, when a subdural hematoma was discovered from the scan, Patient #5 did not receive follow-up in a timely manner because of the mix-up. In addition, Patient #6 received unnecessary blood products and tests because of the error. Further, there was no documented staff education provided to prevent potential future incidents, following the error in patient identification.

The findings include:

Review of the facility's policy titled, "Patient Rights and Patient Responsibilities", last revised 12/2019, revealed it was a patient right for the facility to provide patients with safe and appropriate medical care.

Review of the facility's policy titled, "Patient Identification", last revised 10/2020, revealed, before a patient received treatment or service, staff must reliably identify the patient as the person for whom the treatment or service is intended through the use of two (2) patient identifiers, which must be directly associated with the patient.

Review of the facility's policy titled, "Code Stroke Protocol", last revised 12/2021, revealed the facility would assure rapid, consistent assessment and initiation of definitive treatment for patients presenting with acute symptoms of stroke.

Review of Resident #5's medical record revealed the facility admitted the patient to the Emergency Department (ED), on 01/01/2022 at 6:27 PM, with diagnoses including Depression and Suicidal Ideation. Resident #5 was discharged from the ED, on 01/03/2022 at 5:57 PM, to a local psychiatric hospital. Per the record, Patient #5 was given a CT scan of the head, on 01/03/2022 at 3:01 PM, and was found to have a subdural hematoma. However, Patient #5's record did not reveal a physician's order for the CT scan. Per the record, Patient #5 was transferred to a local psychiatric hospital, on 01/03/2022 at 5:57 PM. Further review revealed the psychiatric hospital was notified, on 01/04/20022 at 5:07 PM by RN #1, of the CT scan findings.

Review of Resident #5's medical record from the psychiatric hospital revealed the psychiatric hospital received a report from this facility, on 01/04/2022, that Patient #5 had some concerns for a subarachnoid hemorrhage. The record from the psychiatric hospital revealed that facility sent Patient #5 to another acute care hospital for medical clearance and a neurology consult. Patient #5 was discharged from the psychiatric facility on 01/11/2022.

Review of Resident #6's medical record revealed the patient presented to the ED, on 01/03/2022 at 12:42 PM, via Emergency Medical Services (EMS) with symptoms of weakness and altered mental status. Review of the Physician's Orders, dated 01/03/2022 at 1:55 PM, revealed a stat (required to be done immediately) order was written for Patient #6 to have a CT scan of the head without contrast. The reason for the exam was his/her altered mental status and stroke-like symptoms. In addition, the record revealed Patient #6 tested positive for COVID, on 01/03/2022 at 1:14 PM.

Continued review of Patient #6's medical record revealed a progress note, dated 01/03/2022 at 7:06 PM, which stated Patient #6 was treated with a platelet transfusion related to a subdural hematoma (was actually Patient #5's CT scan result).

Continued review of Patient #6's medical record revealed another stat CT scan of the head was ordered, on 01/04/2022 at 8:48 AM, for altered mental status and subdural hematoma. Results of this CT scan, read on 01/04/2022 at 9:12 AM, revealed right subdural hematoma was not appreciated which could be secondary to motion artifact.

Continued review of Patient #6's medical record revealed a Neurology consult was ordered because of the subdural hematoma. Per the record, Neurosurgery ordered a third CT scan of the head on 01/04/2022. The scan was completed on 01/04/2022 at 4:20 PM. In addition, a Magnetic Resonance Imaging (MRI) scan was ordered because the initial CT scan suggested a subdural hematoma, which was not confirmed on subsequent CT scans. The MRI was completed on 01/05/2022 at 2:52 PM, and the impression of the scan was atrophy and white matter changes without an acute process.

Review of the facility's investigation report concerning Patient #6, dated 01/05/2022, revealed the CT scan of the head, ordered for Patient #6, on 01/03/2022 at 1:55 PM, was instead performed in error on Patient #5. Patient #6 and Patient #5 had the same last name. The report did not include a root cause analysis, staff education given, or any interventions that were immediately done to address the error.

Observation, on 07/21/2022 at 1:55 PM, of the computer screen in the ED with two patients with the same name, revealed the names were italicized.

Interview with Registered Nurse (RN) #1, on 07/21/2022 at 2:00 PM, revealed when two (2) patients were in the ED with the same last name, staff identified the patients by asking the name and date of birth prior to any procedure. Also, she stated the same name patients were italicized in the computer, and the facility had been italicizing same name patients, as an alert, since 2013.

Interview with the Chief of Radiology, on 07/19/2022 at 2:29 PM, revealed the computer system presented to him the images of the CT scan. He stated he then read the images and determined the diagnoses. He stated he did not enter orders into the computer. He stated, if the results were on the wrong patient, it would be up to the Director of Radiology to determine what to do next.

Interview with the Director of Radiology, on 07/19/2022 at 2:41 PM, revealed when a physician wrote an order for a CT scan, the requisition printed off on the printer in the CT department. The CT Technician, then, looked on the ED room log to see where the patient was located. She stated the technician got the patient and took the patient to the CT department. The Director stated the technologist was to verify the name and the date of birth of the patient. She stated CT Technician #1 was the person who took Patient #5 to the CT room on 01/03/2022.

Interview with CT Technician #1, on 07/20/2022 at 11:00 AM, revealed on 01/03/2022 at about 3:00 PM, she went to the Emergency Department (ED) and took Patient #5 to the CT Room. She stated she asked the patient his/her name, date of birth, and looked at the arm band. She stated she did not scan the arm band because the patient was not receiving contrast. She stated she did not remember if this matched the order. She stated she performed the scan and then returned Patient #5 to the ED. CT Technician #1 stated the process was after she completed the exam, she went to the computer, where there was an order on the worklist. She stated she entered that the CT scan was completed. She explained. at that point, the scan was sent to the radiologist to be read. She also revealed she had not received any training on patient identification since the incident.

Interview with the Director of Radiology, on 07/20/2022 at 4:07 PM, revealed the patient's arm band was only scanned for CT scans when contrast was given.

Interview with the Neurology Physician's Assistant (PA), on 07/20/2022 at 4:50 PM, revealed he looked at the CT scan of the head, completed on 01/04/2022 at 8:45 AM, and knew it could not be the same patient that had the scan performed, on 01/03/2022 at 3:01 PM. The Neurology PA reported there was a septal deviation and dental fillings seen on the 01/04/2022 scan that were not on the 01/03/2022 scan. He stated he left a message on the Radiology Director's phone, the morning of 01/04/2022. He stated he, along with the Director of Radiology, started investigating the error about 12:00 PM on 01/04/2022. He stated, about 4:00 PM on 01/04/2022, they discovered that Patient #5 was the patient who had the CT scan of the head on 01/03/2022 at 3:01 PM. He stated the decision was made to inform the psychiatric hospital of the CT findings and advise them to watch for signs and symptoms of seizures, acute mental status changes, and severe headache.

Interview with the Radiology Manager, on 07/21/2022 at 4:38 PM, revealed it was not necessary to have Patient Identification listed in the Radiology Policy as it was mentioned in the hospital policy. The Manager also stated CT Technician #1 did not properly check the identity of the patient who received the CT scan of the head in error.

Based on interview and record review, it was determined the facility failed to ensure verbal orders were infrequent and not used for the convenience of the ordering practitioner. Review of verbal orders for thirteen (13) of fifteen (15) sampled patients revealed verbal orders were used frequently with no indication it was impossible or impractical for the ordering practitioner to enter the order. The thirteen patients were Patient #1, #2, #3, #4, #6, #7, #9, #10, #11, #12, #13, #14, and #15.

The findings include:

Review of the facility's policy titled, ""Medical Orders-Written, Verbal, and Telephone", dated 03/2019, stated the purpose of the policy was to eliminate potential medication or treatment errors due to communication issues when giving or receiving orders. The policy further stated, "Verbal/telephone orders are to be used infrequently and should be limited to situations where immediate written or electronic communication is not feasible".

Review of a report of verbal order entries, dated 07/21/2022, revealed:

1. Four (4) verbal orders were placed for Patient #1 from 02/14/2022 through 02/17/2022.

2. Forty-six (46) verbal orders were placed for Patient #2 from 12/18/2021 through 01/26/2022.

3. Twenty-four (24) verbal orders were placed for Patient #3 from 04/09/2022 through 04/28/2022.

4. Nineteen (19) verbal orders were placed for Patient #4 from 06/29/2022 through 06/30/2022.

5. Two (2) verbal orders were placed for Patient #6 from 01/05/2022 through 01/06/2022.

6. Thirty-eight (38) verbal orders were placed for Patient #7 from 07/14/2022 through 07/20/2022.

7. Sixteen (16) verbal orders were placed for Patient #9 from 06/17/2022 through 07/17/2022.

8. Two hundred fifteen (215) verbal orders were placed for Patient #10 from 02/16/2022 through 07/20/2022.

9. Thirty-six (36) verbal orders were placed for Patient #11 from 07/01/2022 through 07/18/2022.

10. Fourteen (14) verbal orders were placed for Patient #12 from 07/02/2022 through 07/12/2022.

11. Sixty-five (65) verbal orders were placed for Patient #13 from 07/06/2022 through 07/20/2022.

12. Twenty-eight (28) verbal orders were placed for Patient #14 from 06/08/2022 through 07/11/2022.

13. Eight (8) verbal orders were placed for Patient #15 from 07/07/2022 through 07/17/2022.

Interview with Registered Nurse (RN) #2, on 07/19/2022 at 3:28 PM, revealed physicians in the South Intensive Care Unit (ICU) asked her to put in routine physician's orders frequently, including an order for a Fentanyl (an opioid narcotic) intravenous infusion on the morning of 07/19/2022. She stated if she asked the physicians to enter orders, they typically would not do so in a timely fashion, resulting in delays in patient care.

Interview with RN #17, on 07/21/2022 at 2:43 PM, revealed physicians gave her verbal orders all the time, particularly the intensive care specialists. RN #17 stated that if she asked the intensivists to put in the orders while they were present at the bedside during a non-emergent situation, they routinely asked her to do it instead.

Interview with RN #18, on 07/21/2022 at 2:51 PM, revealed physicians asked her to enter verbal orders in the computer frequently, including routine orders. RN #18 recalled entering verbal orders in the computer for Patient #13 for routine home medications on the evening of 07/07/2022. She stated this was not an emergency situation.

Interview with RN #8, the ICU Manager, on 07/20/2022 at 11:49 AM, revealed the nurses she supervised had expressed concerns to her over the frequency that physicians asked them to enter verbal and telephone orders in the computer. She stated this practice was especially common when a patient was being transferred from the ICU to the floor; but the patient could not be moved until a physician discontinued medications that could only be given in the ICU.

Interview with Physician (MD) #2, on 07/21/2022 at 5:56 PM, revealed he issued verbal orders because the electronic health record made order entry a time-consuming process. He stated having the nurse enter orders for one (1) patient allowed him to see other patients more quickly.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure safe radiology procedures were performed for two (2) of seventeen (17) sampled patients, Patient #5 and #6.

Patient #5 received an unordered Computed Tomography (CT) scan of the head, in error, due to a mix-up with Patient #6, who had the last name as Patient #5. Then, when a subdural hematoma was discovered from the scan, Patient #5 did not receive follow-up in a timely manner because of the mix-up. In addition, Patient #6 received unnecessary blood products and tests because of the error. Further, there was no documented staff education provided to prevent potential future incidents, following the error in patient identification.

The findings include:

Review of the facility's policy titled, "Radiology", last revised 03/2020, revealed the facility's radiology department would maintain personnel and patient safety when performing procedures. The policy also stated the department would provide the highest quality patient care and would assure proper services were provided.

Review of the facility's policy titled, "Code Stroke Protocol", last revised 12/2021, revealed the facility would have an order by a physician, radiology protocol, or a physician's verbal order for any radiological procedure to be performed on a patient.

Review of the facility's policy titled, "Patient Identification", last revised 10/2020, revealed staff must reliably identify the patient as the person for whom the treatment or service was intended through the use of two (2) patient identifiers which must be directly associated with the patient.

Review of Patient #6's medical record revealed the patient presented to the Emergency Department (ED), on 01/03/2022 at 12:42 PM via Emergency Medical Services (EMS) with weakness and altered mental status. Review of Physician Orders, dated 01/03/2022 at 1:55 PM, revealed a stat order (order to be carried out immediately) was written for Patient #6 to have a CT (Computed Tomography) scan of the head without contrast. The reason for the exam was altered mental status and stroke like symptoms. Patient #6 did not receive this CT scan. Further review revealed Patient #6 tested positive for COVID on 01/03/2022 at 1:14 PM.

Review of Patient #5's ED record revealed the patient presented to the ED, on 01/01/2022 at 6:27 PM, with diagnoses including Depression and Suicidal Ideation. Further review revealed there was no physician's order for a CT scan of the head. However, on 01/03/2022 at 3:01 PM, Patient #5 received a CT scan of the head without contrast, which revealed a subdural hematoma. In addition, the record revealed no immediate follow-up to the results of the CT scan for this patient because the facility thought the results were for Patient #6. Per the record, Patient #5 was transferred to a local psychiatric hospital, on 01/03/2022 at 5:57 PM. Further review revealed the psychiatric hospital was notified, on 01/04/20022 at 5:07 PM by RN #1, of the CT scan findings.

Review of Patient #6's ED note, dated 01/03/2022 at 7:06 PM, revealed Patient #6 was treated with a platelet transfusion related to the CT scan result of subdural hematoma.

Continued review of Patient #6's medical record revealed another stat CT scan of the head was ordered, on 01/04/2022 at 8:48 AM, for altered mental status and subdural hematoma. The results of this CT scan, on 01/04/2022 at 9:12 AM, revealed the right subdural hematoma was not appreciated, which could be secondary to motion artifact.

Continued review of Patient #6's medical record revealed a third CT scan of the head was ordered by Neurosurgery, on 01/04/2022 at 10:32 AM, and completed on 01/04/2022 at 4:20 PM. Further review Neurology was consulted for the abnormal CT scan, and a Magnetic Resonance Imaging (MRI) scan of the head was ordered due to the initial CT scan, which suggested a subdural hematoma, but was not confirmed on subsequent CT scans. The MRI was completed on 01/05/2022 at 2:52 PM. The impression was atrophy and white matter changes without an acute process.

Review of the facility's investigation report concerning Patient #6, dated 01/05/2022, revealed the CT scan of the head, ordered for Patient #6, on 01/03/2022 at 1:55 PM, was instead performed in error on Patient #5. Patient #6 and Patient #5 had the same last name. The report did not include a root cause analysis, staff education given, or any interventions that were immediately done to address the error.

Interview with the Neurology Physician's Assistant (PA), on 07/20/2022 at 4:50 PM, revealed he looked at the CT scan of the head, completed on 01/04/2022 at 8:45 AM, and knew it could not be the same patient that had the scan performed, on 01/03/2022 at 3:01 PM. The Neurology PA reported there was a septal deviation and dental fillings seen on the 01/04/2022 scan that were not on the 01/03/2022 scan. He stated he left a message on the Radiology Director's phone, the morning of 01/04/2022. He stated he, along with the Director of Radiology, started investigating the error about 12:00 PM on 01/04/2022. He stated, about 4:00 PM on 01/04/2022, they discovered that Patient #5 was the patient who had the CT scan of the head on 01/03/2022 at 3:01 PM.

Observation, on 07/21/2022 at 1:55 PM, of the computer screen in the ED was done on two (2) patients with the same last name. The names were italicized.

Interview with Registered Nurse (RN) #1, on 07/21/2022 at 2:00 PM, revealed when two (2) patients were in the ED with the same last name, staff identified the patients by asking the name and date of birth prior to any procedure. Also, she stated the names were italicized in the computer.

Interview with CT Technician #1, on 07/20/2022 at 11:00 AM, revealed on 01/03/2022 at about 3:00 PM, she went to the Emergency Department (ED) and took Patient #5 to the CT Room. She stated she asked the patient his/her name, date of birth, and looked at the arm band. She stated she did not scan the arm band because the patient was not receiving contrast. She stated she did not remember if this matched the order. She stated she performed the scan and then returned Patient #5 to the ED. CT Technician #1 stated the process was after she completed the exam, she went to the computer, where there was an order on the worklist. She stated she entered that the CT scan was completed. She explained. at that point, the scan was sent to the radiologist to be read. She also revealed she had not received any training on patient identification since the incident.

Interview with the Director of Radiology, on 07/20/2022 at 4:07 PM, revealed the patient's arm band was only scanned for CT scans when contrast was given.

Interview with the Chief of Radiology, on 07/19/2022 at 2:29 PM, revealed he was presented with the images of the CT scans from the computer system. He stated he then read the images and determined the diagnoses. He stated he did not enter the orders into the computer. He stated, if the results were on the wrong patient, it would be up to the Director of Radiology to determine what to do next.

Additional interview with the Director of Radiology, on 07/19/2022 at 2:41 PM, revealed when a physician wrote an order for a CT scan, the requisition printed off on the printer in the CT department. The CT Technician, then, looked on the ED room log to see where the patient was located. She stated the technician got the patient and took the patient to the CT department. The Director stated the technologist was to verify the name and the date of birth of the patient. She stated CT Technician #1 was the person who took Patient #5 to the CT room on 01/03/2022.

Interview with the Radiology Manager, on 07/21/2022 at 4:38 PM, revealed it was not necessary to have Patient Identification listed in the Radiology Policy as it was mentioned in the hospital policy. The Manager also stated CT Technician #1 did not properly check the identity of the patient who received the CT scan of the head in error.

Interviews with CT Technician #2, on 07/21/2022 at 10:50 AM; Radiology Lead Technician, on 07/21/2022 at 1:11 PM; Radiology Technician #1, on 07/21/2022 at 1:14 PM; and Radiology Technician #2, on 07/21/2022 at 1:25 PM, revealed that no education on patient identification had been done since the 01/03/2022 incident.

Additional interview with the Director of Radiology, on 07/21/2022 at 10:24 AM, revealed she did not do patient identification education with CT Technician #1 with a posttest to validate understanding.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to have an order for a Computed Tomography (CT) scan for one (1) of seventeen (17) sampled patients, Patient #5. Patient #5 did not have a physician's order for the CT scan of the head performed on 01/03/2022 at 3:01 PM.

The findings include:

Review of the facility's policy titled, "Radiology", policystat ID:7736297, last revised 03/2020, revealed the facility would provide the highest quality patient care. The policy also stated the facility would assure proper services were provided and remain in compliance with regulations.

Review of the facility's policy titled, "Code Stroke Protocol", last revised 12/2021, revealed the facility would have an order by a physician, radiology protocol, or a physician's verbal order for any radiological procedure to be performed on a patient.

Review of the facility's policy titled, "Patient Identification", last revised 10/2020, revealed staff must reliably identify the patient as the person for whom the treatment or service was intended through the use of two (2) patient identifiers which must be directly associated with the patient.

Review of Patient #5's medical record revealed the Emergency Department (ED) admitted the patient, on 01/01/2022 at 6:27 PM, with diagnoses including Depression and Suicidal Ideation. The facility performed a Computed Tomography (CT) scan of the head without contrast on Patient #5, on 01/03/2022 at 3:01 PM. Further review revealed there was no physician's order to do the CT scan.

Interview with CT Technician #1, on 07/20/2022 at 9:58 AM, revealed on 01/03/2022 at about 3:00 PM, she went to the Emergency Department (ED) and transported Patient #5 to the CT department, instead of Patient #6 for whom the scan was ordered and who had the same last name as Patient #5.

Additional interview with CT Technician #1, on 07/20/2022 at 11:00 AM, revealed she asked the patient she brought to the CT department, his/her name and date of birth. However, she did not remember if the response matched the order. She stated she performed the scan and then returned Patient #5 to the ED. She stated after she completed the exam, she went to the computer and entered that the CT scan had been completed on the order found in the worklist.

Interview with the Director of Radiology, on 07/20/2022 at 4:07 PM, revealed the patient's arm band was only scanned for a CT scan when contrast was given.

Interview with the Radiology Manager, on 07/21/2022 at 4:38 PM, revealed it was not necessary to have Patient Identification listed in the Radiology Policy as it was mentioned in the hospital policy. The Manager also stated CT Technician #1 did not properly check the identity of the patient who received the CT scan of the head in error.

Interview with the Chief Medical Officer, on 07/21/2022 at 4:54 PM, revealed he assured the providers who ordered radiological studies had the qualifications by credentialing the providers, which ensured they were qualified to order the studies.