HospitalInspections.org

Based on medical record review (MR) and staff interviews (EMP), it was determined that the facility staff failed to maintain records of the results of all examinations, test and services provided to one of nine sexual assault victims. (MR1)

Findings include:

Review of policy and procedure, "Sexual Assault" Emergency Department S-4.0, dated November 2010 revealed, "UPMC Passavant will accept all alleged sexually abused victims/case. Treatment will be for the total well being of the person. To ensure immediate attention to all sexual assault/rape victims/cases with the accurate assessment and commitment to the holistic care by meeting their physical, psychological, emotional, social and spiritual needs...Documentation and Evidence Collection...All injuries, even minimal ones of no medical significance, should be documented. Photographs should be taken of any visible injuries... Once all specimens are collected, the rape kit is sealed, label filled out, and given to officer in charge..."

1. During an interview on February 7, 2012, at approximately 1:00 PM, EMP2 indicated, "Once the rape kit is completed, one copy [evidence collection forms] is put in the rape kit, and then the papers are copied for the patient's medical record."

2. During an interview on February 7, 2012, at approximately 2:30 PM, EMP2 indicated, "No, there are no copies of the forms [evidence collection forms], in the medical record [MR1]." EMP2 further confirmed that MR1 did not include any other specific documentation of the evidence collection, which included, "Head hair combings, head hair standards, oral swabs and smear, nail clippings (scrapings) pubic hair combings, vaginal swabs and smears, rectal swabs and smears, miscellaneous collections..."

Based on review of facility documents, medical records and staff interview, it was determined that the facility does not ensure that every patient seeking medical care from the emergency service who is not in need of emergency services are provided with information on how to obtain appropriate medical care.

Findings include the following:

Review of policy and procedure, "Sexual Assault" Emergency department S-4.0, dated November 2010, on February 6, 2012, at approximately 10:00 AM revealed, "UPMC Passavant will accept all alleged sexually abused victims/case. Treatment will be for the total well being of the person. To ensure immediate attention to all sexual assault/rape victims/cases with the accurate assessment and commitment to the holistic care by meeting their physical, psychological, emotional, social and spiritual needs...Documentation and Evidence Collection...If the victim suspects that she may have been drugged by the suspect, samples must be collected in order to test for the presence of drugs."

1. Review of MR1 on February 7, 2012, at approximately 2:00 PM, revealed a physician note dated October 6, 2011, at 12:16, that indicated, "...Pt returned today for PCP testing..." The discharge instructions final report, dated October 6, 2011, at 12:47 PM indicated, "You had requested PCP testing after... exam yesterday. There was no indication of PCP ingestion yesterday during your exam or any indication by history. PCP testing is not part of the regular...exam, it was not considered necessary for this exam, therefore we will not be testing you for PCP."

Continued review of MR 1 on February 7, 2012, at approximately 2:00 PM, revealed an ED Nurse's Note dated October 6, 2011, at 5:44 PM, which indicated, "Pt presented again to ED requesting UDS (urine drug screen), had script in hand...Explained I am unable to obtain legal UDS unless ordered by an MD as medically necessary and otherwise requires specially trained personnel to adequately collect legal UDS..."

Further review of MR1 on February 7, 2012, at approximately 2:00 PM revealed there was no documentation related to any specific direction given to the patient regarding police accompaniment for a legal urine drug screen collection.

2. During an interview on February 7, 2012, at 9:30 AM, EMP7 indicated that the lab has drawn criminal drug tests in the past, but the police officer brought the drug testing kit to the hospital. EMP7 further stated, "...So a patient could have criminal drug testing if they are accompanied by the police..."

3. During an interview on February 7, 2012, at 11:30 AM, EMP8 indicated, "I would just tell them to go to Quest...the test requires a special container, so the lab would not do a criminal drug test unless a police officer accompanied the patient. EMP8 further stated, "The specimen would have to be sent to Quest to be processed anyway, because we only do screens...even if she came with a prescription."