HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure for 1 of 10 (Pt. #1) records reviewed, the Hospital failed to ensure complete and accurate documentation.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 2/8/17. Pt. #1 was a 49 year old female admitted on 2/2/17, with a diagnosis of opiate withdrawal. The admission orders dated 2/2/17 indicated: inpatient services for medical detoxification on the 2 Northwest unit, which included every 4 hour vital signs and PRN as necessary; and to follow opiate withdrawal protocols. Nursing progress notes on 2/4/17 at 9:46 and 10:19 AM indicated no signs of opiate withdrawal or discomfort. The next progress note dated 2/4/17 at 8:00 PM indicated that Pt. #1 was taking a shower and a female sitter in the room. There was no documentation by 2NW staff between the two entries at 10:19 AM and at 8:00 PM, lacking documentation of the allegations made by Pt #1 of being sexually assaulted by a nurse. In addition there were no Attending Physician notes documenting the allegation of sexual assault.

Pt. #1's Emergency Department (ED) record was reviewed on 2/8/17. The ED record indicated that Pt. #1 was sent from 2 Northwest (NW) to the Hospital's ED at 4:24 PM, with a complaint of sexual assault by a nurse in the Medical Detox (2NW) unit. ED nursing documentation indicated Pt. #1 complained of penile and oral penetration. ED documentation indicated that a full evaluation and examination was conducted including a sexual assault kit; offers and refusals of HIV medications, antibiotics and contraceptives; education on sexually transmitted disease and pamphlets for sexual assault survivors was provided.

2. The Facility policy titled "Charting Focus"(rev. 12/09) required, "The Nursing Progress notes...One line entries may be made in the progress notes when necessary to document a special event occurring with the patient; including but not limited to change in patient condition..."

3. The Hospital's Medical Staff Bylaws and Rules and Regulations required, "Medical Records: 1. the attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. 2. Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care...."

4. The above findings were discussed with the Vice President of Nursing Services (E #2) on 2/8/17, who stated the allegations made by Pt. #1 should have been documented. E #2 stated that she could not find any documentation of the allegations by the 2 NW unit staff.