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Based on review of medical records, Medical Staff Bylaws Rules and Regulations, policies and procedures, Nurse Practice Practitioner Schedule, ED waiting room video footage, credential and personnel files, staff interviews, and observations during a facility tour, it was determined that the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical conditions existed, when a request was made on the patient's behalf by his/her mother, for an examination for trauma from an alleged sexual assault for 1 (#21- a child) of 21 sampled patients.

Cross refer to A-2406, as it relates to the facility's failure to provide an appropriate medical screening examination to Patient #21 on 11/3/2018 when the patient presented to the facility's ED with an emergency medical condition.

Based on review of the hospital's policy and procedure, emergency department waiting room video footage, and the Emergency Department Intake Log, it was determined the facility failed to maintain a central log of each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (#21) of 21 sampled patients whose mother came to the emergency department requesting/seeking medical assistance for an alleged sexual abuse.


Findings were:

1. Video Footage

A review of a three (three) minute and 30 (thirty) second-long surveillance video footage captioned ED 11/03/2018 revealed a female carrying a small child with another child who looked about 4-5 years old, dressed in a hooded coat, walking behind the female. They enter the ED and stop to talk to someone off-camera at 1:55 (one minute and fifty-five) seconds into the video. The female appears to be talking to someone off-camera for about a minute and is then seen leaving with both children at 3:19 (three minutes and nineteen seconds) into the video. The ED waiting room footage validated that Patient #21 presented to the hospital's ED on 11/03/2018.


2. Emergency Department Central Log

A review of the facility's ED (Emergency Department) intake log revealed that Patient #21's visit was not documented in the ED log. Review of the facility's ED log for the month of November until the date of the survey failed to reveal evidence that Patient #21 was logged in the ED log, and his/her name is unknown.


3. Policy and Procedure

EMTALA- Central Log Policy, revised 01/2016, revealed that the policy's purpose is to establish guidelines for tracking the care provided to each individual seeking care in a DED for a medical condition or seeking care in areas on hospital property other than a DED for an EMC, as required of any hospital with an emergency department by EMTALA. The policy further revealed that the hospital will maintain a Central Log and must be made by the appropriate individual, containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before an MSE could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. All hospitals must maintain the Central Log in an electronic format and must contain at a minimum, the name of the individual and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired.

The facility failed to ensure that their EMTALA Central Log policy was followed as evidenced by failing to maintain a central log for Patient #21 when his/her mother presented to the hospital's ED, and requested medical assistance for a medical condition of alleged sexual abuse on 11/3/2018.

Based on review of medical records, Medical Staff Bylaws Rules and Regulations, policies and procedures, Nurse Practice Practitioner Schedule, ED waiting room video footage, credential and personnel files, staff interviews, and observations during a facility tour, it was determined that the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical conditions existed, when a request was made on the patient's behalf by his/her mother, for an examination for trauma from an alleged sexual assault for 1 (#21- a child) of 21 sampled patients.


Findings were:


1. Observational Tours:

A tour of the facility was conducted on 11/14/18 at 11:44 a.m. with the facility's ED Manager (RN #7), the facility's Chief Nursing Officer (CNO), The Quality Review Manager (QRM, Staff #8), and the ED educator. EMTALA signage in two (2) languages was observed to be at the registration desk and waiting room area. There was a kiosk with a greeter at the ED entry for rapid registration into the facility system. The ED had a pediatric ED and an adult ED.


2. Emergency Department Waiting Room Video Footage

A review of a three (three) minute and 30 (thirty) second-long surveillance video footage captioned ED 11/03/2018 revealed a female carrying a small child with another child who looked about 4-5 years old, dressed in a hooded coat, walking behind the female. They enter the ED and stop to talk to someone off-camera at 1:55 (one minute and fifty-five) seconds into the video. The female appears to be talking to someone off-camera for about a minute and is then seen leaving with both children at 3:19 (three minutes and nineteen seconds) into the video. The ED waiting room footage validated that Patient #21 presented to the hospital's ED on 11/03/2018.


3. INTERVIEWS

1. An interview with MD #3 (Pediatric MD) on 11/14/18 at 9:45 a.m. in the conference room revealed that MD # did not know of any incidents that occurred in the ED on 11/03/18. MD #3 stated that if a pediatric patient was suspected to be sexually abused, the patient would be brought to the pediatric bay. An MSE (including vital signs, physical/examination) would be performed. MD #3 stated that the staff would contact the local authorities and the local crisis center in which a child abuse specialist (MD) would be consulted to address the jurisdiction and acuity regarding the next steps for the patient.

2. An interview with Armed Police Officer (APO #4) on 11/14/18 at 9:47 a.m. in the conference room revealed that APO #4 worked on 11/3/18 to 11/4/18 from 11:00 p.m. to 6:00 a.m. APO #4 stated he/she was standing three (3) feet away from Paramedic #1 and RN #2 at the registration/greet desk. APO #4 stated that a person came into the ED with two (2) children and was asked by Paramedic #1 if he/she needed to see a Doctor; APO #4 recalled the person saying "no, my child does." APO #4 stated that the person revealed that he/she believed that his/her child (Patient #21) had been molested. The APO #4 stated that Paramedic #1 stated: "we don't have a rape kit here." Paramedic #1 named another facility that could carry out the procedures they needed. APO #4 stated that RN #2 backed up what Paramedic #1 stated. APO #4 revealed that the person stood at the desk for a moment and stated, "I should go to the other facility." The APO #4 indicated that no physician saw Patient #21. The APO #4 did not recall Patient #21 looking distressed, and Patient #21 appeared to be about seven (7) or eight (8) years of age. APO #4 stated that after the individual left with the children, APO #4 asked Paramedic #1 and RN #2 if there was really nothing that could be done to help Patient #21. APO #4 stated that he/she did not know anything about EMTALA nor had any training.

3. An interview with the ED Manager (RN #7) on 11/14/18 at 10:55 a.m., in the Conference Room revealed that he/she has been employed at the facility corporation system for 18 (eighteen) years and had been the ED Manager for three (3) months at the current facility. The ED manager stated that he/she was unaware of a child sexual assault case presenting in the ED on or around 11/3/18 or 11/4/18. The ED Manager stated that upon orientation and annually, every ED employee received the Emergency Medical Treatment and Labor Act (EMTALA) training and that he/she would expect the ED staff to understand the EMTALA regulations. The ED Manager stated that usually a greeter (a Paramedic) welcomes the walk-in patients and completes a quick registration which generates the patient's name onto the ED log. The Registrar then completes the registration at the patient's bedside. The ED Manager further stated that additional functions of the Paramedic/Greeter are maintaining communication with the Triage Nurse and facilitating decrease wait times for patients.

4. A telephone interview with RN #2 on 11/14/18 at 11:07 a.m. revealed that he/she had been working at the facility for approximately three (3) years. RN #2 stated that he/she was working triage (the assignment of degrees of urgency to patients presenting to the ED to decide the order of treatment) the night of 11/3/18 with Paramedic #1 when a parent with his/her two (2) children presented to the ED and stated that he/she believed that his/her child (Patient #21) had been sexually assaulted. RN #2 stated that the parent wanted to confirm whether the child had been sexually assaulted. RN #2 stated he/she explained to the parent what would happen; that the child would be taken to the back, the police would be contacted, and the crisis health facility would be called. RN #2 stated that the parent then stated he/she did not want to go through with it that night. RN #2 stated that he/she encouraged the parent to call the police and to sign in. RN #2 further stated that he/she informed the parent of Patient #21 that the facility would not be able to do an exam on Patient #21. RN #2 stated that Patient #21 did not look in distress and that Patient #21 looked to be four (4) or (5) years of age. RN #2 stated he/she had received EMTALA training through the facility and had been an ED RN for 10 years. RN #2 stated that Paramedic #1 was the first person with whom the parent of Patient #21 had contact. RN #2 reiterated what Paramedic #1 had told the parent of Patient #21; that the facility did not have rape kits, and that the patient needed to go to another facility that could deal with a rape crisis. The facility failed to provide documented evidence that Patient #21 was triaged on 11/3/2018, when he/she presented to the ED when a request was made on his/her behalf for an examination of a an alleged sexual assault.

5. A telephone interview with Paramedic #1 on 11/14/18 at 1:40 p.m. in the conference room revealed that Paramedic #1 had worked at the facility for four (4) years. Paramedic #1 stated he/she was a medic/greeter who sits at the front desk to assess if a patient was in distress. Paramedic #1 further stated that he/she would enter the chief complaint and pass it on to the triage nurse. Paramedic #1 recalled that a parent came in with two (2) children, a baby about 1(one) year of age and a child (Patient #21), four (4)-five (5) years of age. Paramedic #1 stated that the parent explained that he/she had had a house fire and was staying with an individual and was not sure if the individual sexually assaulted his/her child (Patient #21). Paramedic #1 stated that he/she told the parent they had to get him/her checked in. Paramedic #1 explained that the parent said he/she wanted someone to look and see if something happened to his/her child. Paramedic #1 stated he/she told the parent of Patient #21 that no physical examination would be done at the current facility's ED. That the facility would do everything else but will not do a pelvic exam on a pediatric patient. Paramedic #1 explained that the crisis center would be informed and that RN #2 backed up his/her comments. Paramedic #1 stated that the parent asked if there was somewhere else he/she could go, and the paramedic replied, that no one else, no other ED will do a pelvic exam. Paramedic #1 stated that the parent said he/she would rather go the crisis center to do it, that he/she would just wait, and then the parent left. Paramedic #1 explained that the children looked well-kempt and in no distress. Paramedic #1 stated that he/she believed this occurred around 1:00 a.m. 11/4/18, with APO #4 in the area. Paramedic #1 stated that the parent of Patient #21 understood that the facility was unable to provide an examination for a pediatric rape victim, although it was repeated more than once. Paramedic #1 stated that he/she had had a basic EMTALA training in orientation.

The facility failed to ensure that their EMTALA Medical Screening Examination and Stabilization policy and procedure was followed as evidenced by patient #21's mother who was acting on his/her Pt. #21) behalf was told that the facility could not provide an examination to an alleged pediatric rape victim (#21) on 11/3/2018.

6. A telephone interview with ED Medical Director (MD #5) on 11/14/18 at 2:20 p.m. in the conference room revealed that MD #5 stated that he/she had worked at the facility for approximately one and a half (1.5) years. MD #5 explained that he/she was not aware of any incidents related to a rape victim presenting to the ED that occurred recently. MD #5 stated that all patients presenting to the ED would check in if they want to be seen. MD #5 explained that all patients would receive a Medical Screening Exam (MSE) and the need for treatment would be determined based on the result of the MSE. MD #5 stated that in the case of a pediatric sexual assault victim, the child would undergo an MSE. In addition, the sexual assault center, child abuse division, and county sheriff would be informed. MD #5 further stated that sexual assault victims are seen as an emergency medical condition. MD #5 stated that he/she had had EMTALA training.


4. Medical Staff Bylaws, Rules and Regulations

1. A review of the facility's Medical Staff Bylaws, Rules, and Regulations, revealed that in addition to a physician, Qualified Medical Persons may perform a Medical Screening Examination. Individuals in the following professional categories who have demonstrated current competency in the performance of Medical Screening Examinations and who are functioning within the scope of his or her license and policies of the Hospital, have been approved by the Board of Trustees as Qualified Medical Personnel: Physician Assistants, Nurse Practitioners, Behavioral Health Registered Nurse, Licensed Marriage and Family Therapists, Licensed Professional Counselors, Licensed Clinical Social Workers, and Psychologists, Nurse Midwives, and Labor & Delivery Registered Nurses for obstetrical patients. The facility failed to ensure that their Medical Staff Bylaws, Rules and Regulations were followed as evidenced by failing to ensure that a medical screening examination was provided for patient #21 on 11/3/2018 when a Nurse Practitioner and ED physician were on duty when the patient presented to the ED.


5. Advanced Practice Practitioner Schedule

1. The hospital's Advanced Practice Practitioner's (APP) schedule for the month of November 2018 was reviewed. The APP's schedule revealed that an Advanced Practice Practitioner was in the ED and available to provide a MSE for Patient #21 on 11/3/2018.


6. Policies and Procedures

A review of facility policies and procedures included but was not limited to the following:

1. EMTALA- Medical Screening Examination and Stabilization policy, revised 03/2017, revealed that the policy's purpose is to establish guidelines for providing appropriate Medical Screening Examinations (MSE) and any necessary stabilization or an appropriate transfer for the individual. The policy further revealed that an EMTALA obligation is triggered when an individual comes to a Dedicated Emergency Department (DED) and
-- The individual or a representative acting on the individual's behalf requests an examination or treatment for an emergency medical condition (EMC).
-- A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. The facility failed to ensure that their policy and procedure were followed as evidenced by failing to ensure that a medical screening examination was provided when a prudent layperson observed and concluded from Patient #21's appearance or behavior needed an examination or treatment for an emergency medical condition of alleged sexual abuse.

If an EMC is determined to exist, the individual will be provided necessary stabilization treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g. no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity, or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law. The policy also revealed an MSE is performed by, only a qualified physician with appropriate privileges, other qualified licensed practitioner (LIP) with appropriate competencies and privileges or a qualified staff member who is qualified to conduct such an examination through appropriate privileging and demonstrated competencies. An MSE, stabilizing treatment or appropriate transfer will not be delayed to inquire about the individual's method of payment or insurance status or conditioned on an individual's completion of a financial form, an advance beneficiary notification form, or payment of a co-payment for any services rendered.


2. Abuse- (Suspected): Child, Sexual, Elder, and Domestic policy, revised 06/14/2018, revealed that the policy's purpose is to provide criteria which may be used by staff to determine if a suspicion is warranted, and to provide a mechanism for the initiation of medical and psychosocial intervention, as well as reporting to the appropriate agencies. Continued policy review revealed a child is defined as any female who has not reached Tanner Stage 3 (has not begun menses) or is age 11 or younger and any male age 11 years or younger. Abuse is defined as the willing infliction of injury (burning or hitting), unreasonable confinement such as tying to a chair, or cruel punishment such as withholding of food or medication. Abuse may be physical, involve threats, insults or harassment and sexual abuse (including rape or sexual molestation/assault), is defined as unwanted sexual activity with perpetrators using force, making threats or taking advantage of victims not able to give consent to include children, adolescents, and adults. Sexual abuse includes statements from the patient relating to sexual abuse, report from a physician indicating sexual activity at an early age, precocious knowledge of sexuality or sexual terms, presence of sexually transmitted disease in individual thought to be sexually inactive (due to age or physical incapacity), bruising, tears or lacerations to the genitalia and constant hand manipulation of genitals (children). Sexual assault/rape includes trauma to external genitalia or rectum, torn clothing, bruises or lacerations to the head, evidence of sexual intercourse or presence of urine/feces, recent bathing or obsessive desire to wash/bathe, feeling of being dirty and verbal statement of assault. The policy review further revealed that reports and suspicions must be pursed and presumed true. Any staff member who suspects that a patient is a victim of abuse should report their suspicions to Social Services and/or the Nursing Supervisor/Immediate Supervisor. Mandatory reporting required by law will be done by Social Services, Case Management, Emergency Department or Behavioral Health Services. The procedure for reporting suspected abuse of children, required information includes the name and address of the person making the report (may use the hospital address), name/address of the child, parents and caretakers, nature and extent of any injuries or condition from suspected abuse or exploitation, any additional information useful in assessing the type of injuries and identifying the individuals and/or activities responsible, child molestation/sexual assault must be reported to a specific facility, law enforcement in the county the assault took place in must be notified, the crisis center (per facility policy) should be notified of all child patients of sexual assault or molestation to determine if a forensic exam is necessary and to schedule the exam to be done by the crisis center. If the patient presents Monday-Friday from 8 a.m.-5 p.m., the crisis center is called to arrange for the child to present there for the exam. If the child presents after these hours, contact the on-call crisis center representative for direction. The exam may need to be completed by the emergency department physician, depending on the time frame from assault to availability of the crisis center representative. The crisis center representatives are available for consultation 24 hours a day, 7 days a week. If the crisis center exam is scheduled for follow-up, the patient is discharged with instructions to follow up as scheduled for the forensic exam and the patient still receives a medical screening examination and medical care as appropriate prior to discharge. The facility also failed to ensure that this policy and procedure was followed as evidenced by failing to notify the ED Physician and Nurse Practice Practitioner that patient #21's mother had requested a medical screening examination and or treatment as appropriate prior to be told the facility could not provide an examination to an alleged pediatric rape victim.

3. Assessment and Reassessment of the Patient, policy #5534714, revision date 11/5/18, provides a guideline to determine the care and treatment needs necessary to meet the patient's initial needs as well as their needs as they change in response to implementation of care and treatment plans. The process is designed to provide each patient with the best care and treatment possible, taking into consideration the patient's physical, cognitive, behavioral, emotional and physiological status as appropriate. The policy further indicates that assessment and reassessment data are utilized to develop the interdisciplinary plan of care and to revise this plan throughout the course of care. The policy revealed that all patients presenting to the emergency room are triaged (assessed) to determine the chief complaint and assign an acuity.
--Triage is performed by a qualified Registered Nurse (RN) at the time of presentation and may be done in concert with a quick registration. Triage is an information-collecting and decision-making process performed in order to sort injured and ill patients into categories of acuity and prioritization based on the urgency of their medical or psychological. A triage acuity level must be recorded for all patients on all shifts, including ambulance patients.
--The Triage Acuity Levels are as follows:
-Level 1 Resuscitation
-Level 2 Emergent
-Level 3 Urgent
-Level 4 Semi-Urgent
-Level 5 Non-Urgent
--Initial (Rapid) Nursing Assessment- Is part of the Triage Process and should be performed on all patients within 10 minutes of arrival to the ED. A rapid assessment should be used when 2 or more patients are waiting to be triaged.
--Focused Nursing Assessment- A process of evaluation pertinent to the patient's chief complaint, condition, and symptoms. Patients waiting for the initiation of the medical screening exam (MSE) shall have at a minimum a focused reassessment performed at least hourly or more frequently if condition and acuity warrant.

4. Non-Discrimination Statement, policy #3651028, revealed that the facility complies with applicable Federal civil rights laws and does not discriminate on the basis of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law.

7. Credentialing Files

A review of two (2) credential files (#3 and 5) revealed the (2) files contained current state licensure and delineation of privileges. The files included evidence of EMTALA training within the past year.

8. Personal Files

A review of three (3) personnel files (#1, 2 and 4) revealed the three (3) files contained current state licensure and facility required orientation and competency testing. The files (#1 and 2) contained evidence of EMTALA training within the past year. File # 4 did not contain EMTALA training.