HospitalInspections.org

Based on document review and interview, the facility failed to ensure staff followed facility policy related to STAT physician orders for 1 of 10 medical records (MR) reviewed. (Patient #2)

Findings include:

1. Facility policy titled "Results Reporting" last reviewed/revised on 1/2021 indicated the following: "PURPOSE: The purpose of this policy is to define the procedure for report creation and distribution of finalized results on procedures performed by the Imaging Department. 4. STAT interpretations. 4.1 Those procedures requiring immediate interpretation or ordered as STAT are entered into Meditech with a priority of S (STAT)."

2. Review of Patient #2's medical record indicated the following:
(a.) The patient arrived to the emergency department on 1/25/23 at 12:43 a.m. with complaints of abdominal pain, post gallbladder removal on 1/24/23.
(b.) Patient #2 was seen by MD2 (Doctor of Medicine/Emergency Services) on 1/25/23 at 12:56 a.m.
(c.) A physician order for computed tomography (CT) of abdomen/pelvis without contrast was ordered STAT on 1/25/23 at 1:04 a.m. by MD2.
(d.) A physician order for computed tomography angiography (CTA) of chest pulmonary embolism protocol ordered STAT on 1/25/23 at 1:04 a.m. by MD2.
(e.) A review of Patient #2's Audit Trail indicated that the patient was ready for radiology technician on 1/25/23 at 1:11 a.m. and was in radiology for CT of abdomen/pelvis and CTA of chest on 1/25/23 at 2:57 a.m. Approximately two hours after the CT of abdomen/pelvis and CTA of chest were ordered STAT.
(f.) A review of Patient #2's CT of abdomen/pelvis without contrast dated 1/25/23 at 3:30 a.m. indicated a subcapsular hematoma of the liver and intraperitoneal hemorrhage estimated volume of 500-1000 (milliliters).

3. During an interview with A3 (Director of Emergency Services) on 3/7/23 at 5:20 p.m., he/she verified the medical record information for Patients #2.