The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ROSELAND COMMUNITY HOSPITAL||45 W 111TH STREET CHICAGO, IL 60628||Feb. 14, 2019|
|VIOLATION: INTEGRATION OF EMERGENCY SERVICES||Tag No: A1103|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
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.
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 [AGE] year old female who (MDS) dated [DATE] 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 [AGE] year old male who (MDS) dated [DATE] 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 [AGE] year old female who (MDS) dated [DATE] 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."