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 [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."

A. Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, #5, and #6) clinical records reviewed for ESI (Emergency Severity Index) rating, the Hospital failed to ensure appropriate ESI assessment as required by policy. Findings include: 1. On 7/5/17 at approximately 10:00 AM, the Hospital's policy titled "Triage Protocol" (reviewed 4/17) was reviewed and required, "...Triage... using the ESI (Emergency Severity Index) levels 1 thru 5. Acuity is based on the patient's presentation to the Emergency Department... Procedure:... 4. Classify an ESI level... b. Level 2: Emergent/Immediate: Patients are high-risk, their condition can easily deteriorate or the condition requires time-sensitive treatment. Patients require immediate attention and are to be sent directly to the treatment area. Examples:... Suicidal or homicidal patients... c. Level 3: Urgent: Patients have conditions, which require many resources for treatment and may have abnormal vital signs..." 2. On 7/5/17 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male who was brought to the Hospital's emergency room (ER) on 5/22/17 due to psychiatric complaint. On the RN (registered nurse) triage assessment, the stated complaint indicated, "(Pt. #1) said he wants to die, suicidal ideation..." However, the RN triage assessment was completed with an ESI score of 3 (rather than 2). 3. On 7/5/17 at approximately 1:00 PM, findings were discussed with E # 2 (ER Manager). E #2 stated that the ESI score should have been 2. 4. The clinical record of Pt #5 was reviewed on 7/6/17 at approximately 9:15 AM. Pt #5 was a [AGE] year old male who (MDS) dated [DATE] with complaints of "Wanting to harm self after argument with father." Pt #5 was triaged at 4:45 PM was a category 3 and with documented vital signs of: temperature (T) 98.4; pulse (P) 63; respirations (R) 18; and blood pressure (B/P) 101/86. 5. The clinical record of Pt #6 was reviewed on 7/6/17 at approximately 9:30 AM. Pt #6 was a [AGE] year old male who (MDS) dated [DATE] with complaints of "My voice told me to do it... desire to do self-harm." Pt #6 was triaged at 10:28 AM as a category 3 and with documented vital signs of: T 97.2; P 64; R 16; and B/P 141/64. 6. E #2 stated, during an interview on 7/6/17 at approximately 9:55 AM, that no psychiatric patient should be triaged as a level 5 and according to the policy the suicide ideation patients should have been categorized as a level 2. B. Based on document review and interview, it was determined that for 3 of 7 (Pt. #1, #5, and #6) clinical records reviewed for ED nursing assessment, the Hospital failed to ensure assessment was conducted as required by policy. Findings include: 1. On 7/5/17 at approximately 10:00 AM, the Hospital's policy titled "Assessment, Emergency Nursing" (reviewed 10/16) was reviewed and required, "... Procedure: A. Nursing assessment... 2. General Survey... c. Vital Signs... Frequency of Assessments:... 2. All patients will be assessed no less than evey 2 hours..." 2. On 7/5/17 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male who was brought to the Hospital's emergency room (ER) on 5/22/17 due to a psychiatric complaint. The clinical record indicated that vital signs were not assessed on 5/22/17 between 4:10 PM and 8:01 PM (3 hours and 51 minutes). 3. The clinical record of Pt #5 was reviewed on 7/6/17 at approximately 9:15 AM. Pt #5 was a [AGE] year old male who (MDS) dated [DATE] with complaints of "Wanting to harm self after argument with father." Pt #5 was triaged at 4:45 PM and as reassessed at 7:30 PM, 11:09 PM (3:39 minutes) and again on 6/12/17 at 10:45 AM (11 hours 36 minutes). 4. The clinical record of Pt #6 was reviewed on 7/6/17 at approximately 9:30 AM. Pt #6 was a [AGE] year old male who (MDS) dated [DATE] with complaints of "My voice told me to do it... desire to do self-harm." Pt #6 was triaged at 10:28 AM and was reassessed at 12:10 PM, 4:10 PM (4 hours later), and at 5:53 PM. 5. On 7/5/17 at approximately 1:00 PM and 7/6/17 at approximately 11:00 AM, findings were discussed with E #2 (ER Manager). E #2 agreed that vital signs were not assessed every 2 hours. E #2 stated, "Patients are reassessed at least every 2 hours."