HospitalInspections.org

Based on document review and interview the facility failed to protect and promote each patient's rights as evidenced by:

The failure to ensure proper monitoring of a patient with an altered mental status after a fall and alcohol intoxication (Patient #1).

The failure to ensure a patient with an altered mental status was chaperoned during radiological testing in an area where no employees of the same sex were present (Patient #1).

The facility's failure to protect patients resulted in the alleged sexual assault of one patient (Patient #1).

The failure to ensure all patients received notice of rights (Patient #32).

The failure to ensure all patient's rights are reviewed with patients (Patients #1-#36).

The failure to ensure all patients know how to file a complaint/grievance (Patients #29-#33).

The findings included:

Patient #1 was brought to the facility's emergency room on January 12, 2014 due to alteration in mental status after a fall and alcohol intoxication. On January 13, 2014 while in the facility's radiology department Patient #1 was allegedly sexually assaulted by Staff #16 between approximately 1:10 am to 1:50 am. Time discrepancies in Patient #1's medical record exist between the radiology staff and the nursing staff. Patient #1 was left in the radiology department with an altered mental status and alcohol intoxication with no same sex staff members. Patient #1 had a documented history while in the emergency room of attempting to get up out of bed without the assistance of the nursing staff. Patient #1 was identified as a fall risk in the admission documentation by Staff #11. Documentation in Patient #1's medical record prior to going to diagnostic radiology reports an epidsode of unresponsiveness where Patient #1 became "limp." Patient #1's initial blood alcohol level at 10:28 pm on January 13, 2014 is documented as 398 mg/dl in the medical record. "Potentially lethal concentration greater than 400 mg/dl" is documented in the laboratory test description in Patient #1's medical record. Patient #1's weight is documented as 52.16 kilograms.

Patient #32 was interviewed on May 28, 2014 at approximately 12:00 pm. Patient #32 and Patient #32's husband stated the patient never received a packet with information relating to complaints or Patient Rights. Patient #32 reported he/she received no information at admission. Patient #32 denied being visited by a volunteer who went over the admission packet.

Thirty medical records were reviewed the afternoon of May 27, 2014 (Patient Records #1-#30). Five patient interviews were conducted on May 28, 2014 at approximately 12:00 pm (Patient #29, #30, #31, #32, and #33). No patient record reviewed had evidence that Patient Rights were reviewed. No patient interviewed recalled a review of Patient Rights by hospital staff.

Five of five patients interviewed on May 28, 2014 at approximately 12:00 pm were unaware of how to file a complaint/grievance (Patients #29, #30, #31, #32, and #33).

Based on a review of the facility's policy entitled "Patient Rights and Responsibilities", staff interviews, patient interviews, and clinical record reviews, the facility failed to inform each patient of the patient's rights in advance of furnishing or discontinuing patient care in thirty six (36) of thirty-six (36) patients, (Patients #1-36). .

The findings included:

1. A review of 36 patient clinical records revealed no evidence that Patient Rights were reviewed with any of the 36 patients upon admission or at any time during the patient's inpatient stay (Patients #1-36).

2. An interview was conducted with Staff #1 and Staff #8 on 05/28/14 at 2:00 p.m. and Staff #1 stated that he/she was unsure of when a patient receives the Patient Rights information and whose responsibility it is to go over the information with the patient. Staff #1 stated that hospital volunteers visit each patient during their stay and answer questions that the patient may have regarding patient rights, among other topics.

Staff #8 stated that upon admission a patient handbook is given to each patient, and this handbook includes an explanation of Patient Rights. When asked if the admitting representative goes over the Patient Rights with the patient Staff #8 stated he/she was "not sure". Staff #8 stated it was also the responsibility of the nurse to point out the handbook to new patients.

Staff #13 was interviewed on 05/28/14 at 2:13 p.m. Staff #13 went over the admission process for new patients and stated that regardless of how a patient is admitted (through the Emergency Department, a direct admission to a floor, or through inpatient admissions) all patients are given the same information by the registrar to include Patient Rights and Responsibilities. Staff #13 stated that the registrar does not go over the Patient Rights information, but he/she will ask all patients if they have any questions and answer them. For direct admissions to a unit Staff #13 states that the registrar will tube the information to the unit and it is the responsibility of the admitting nurse to go over the information with the patient.

3. Interviews were conducted with five (5) current patients on 05/28/14 between 12:00 p.m. and 1:00 p.m. (Patients #29, 30, 31, 32, and 33). Of the five patients interviewed, one stated that he/she did not receive a patient handbook (Patient #32). Patient #29 states that he/she was given paperwork about Patient Rights, but that no one went over it with him/her. Patient #30 stated that he/she received a "packet of information" upon admission, but he/she was unable to say what the packet included. Patient #30 stated that no one went over the information with him/her. Patient #31 stated that he/she signed "a patient rights paper" but that he/she did not read it and no one went over the information with him/her.
Patient #32 and the patient's husband both reported the patient did not receive any Patient Rights or admission paperwork. Patient #33 and the patient's daughter reported the patient had received an admission packet. Patient #33's daughter reported no one had specifically gone over Patient Rights during the admission process.

4. A review of the facility's policy entitled, "Patient Bill of Rights and Responsibilities" revealed that the Patient Handbook includes the Patient Bill of Rights and Responsibilities and is to be given to patients upon admission to the hospital. The policy states that, "The Admitting Office person registering the patient at the time of admission or the admitting nurse will inform the patient of the location of The Patient Handbook.". The policy includes forms for the patient to sign regarding Medicare discharge rights, Authorization for Hospital Treatment, and an Important Message from Tricare, however there is no place in the policy specifying that a patient is to sign that they received their Patient Rights. The policy does not specify with whom the responsibility lies for going over the Patient Rights information with new patients.

Based on a review of the facility's policies entitled, "Complaint and Grievance Management" and "Patient Bill of Rights and Responsibilities", document review, staff interviews, and patient interviews, the facility failed to inform each patient whom to contact to file a grievance.

The findings included:

1. Interviews were conducted with five (5) current patients on 05/28/14 between 12:00 p.m. and 1:00 p.m. (Patients #29, 30, 31, 32, and 33). All patients interviewed denied being informed about the facility's complaint process and none of the patients knew the process for filing a complaint (Patients #29, 30, 31, 32, and 33).

2. An interview with Staff #13 on 05/28/14 at 2:13 p.m. revealed that contact information for filing a complaint is listed on the form "Patient Rights and Responsibilities" that is given to patients upon admission to the hospital. Staff #13 stated that questions are answered by registration personnel if the patient has a question during admission, but the registration staff does not routinely go over the complaint process with new patients.

3. A review of the facility's policy entitled, "Complaint and Grievance Management" revealed an extensive policy outlining the hospital's process for handling complaints and grievances, however, this policy contained no mention of how the facility will inform patients of how they may file a grievance or make a complaint.

A review of the facility's policy entitled, "Patient Bill of Rights and Responsibilities" revealed a list of patient rights, however there is no mention of the patient's right to file a complaint or grievance and there is no instruction to the patient on how to file a complaint. No contact information is listed in this policy.

During the survey a form entitled "Patient Rights and Responsibilities" (not the policy; this is a separate form) was provided to the surveyors. This form included contact information for the Office of Licensure and Certification (OLC) and specified that a patient may contact the OLC or Joint Commission with complaints. No contact information was given for Joint Commission on this form. An interview was conducted on 05/28/14 at 2:13 p.m. with Staff #13. Staff #13 stated that this form is given to all patients on admission.

Based on document review and interview the facility failed to ensure the privacy and safety for one of thirty patients (Patient #1).

The findings included:


Thirty medical records (#1-#30) were reviewed on May 27, 2014 beginning at 12:30 pm. Patient #1's medical record was reviewed beginning at approximately 12:30 pm. Patient #1 was brought to the above named facility on January 12, 2014 at 8:47 pm by ambulance. Patient #1 was admitted to the above named facility's emergency room on January 12, 2014 at approximately 8:47 pm. Documentation in Patient #1's medical record indicates Patient #1 fell outside a restaurant and presented with altered mental status and alcohol intoxication. Patient #1 reported to EMS (emergency medical services) he/she drank three (3) beers and took two (2) .5 mg Klonopin (used for seizure disorders or panic disorders) during the evening. Documentation in Patient #1's EMS record indicates he/she denied a history of seizures. Patient #1's initial alcohol level is documented as 398 mg/dl at 10:28 pm in the medical record. "Potentially lethal concentration greater than 400 mg/dl" is documented in the laboratory test description in Patient #1's medical record. The rapid drug screen done at 10:25 pm is documented as negative.

Initial triage nursing note documentation on January 12, 2014 at 8:52 pm reports Patient #1 had "ground level fall per EMS." Documentation further reports Patient #1 had episode of non responsiveness while under the care of EMS. Documentation by Staff #11 during triage states Patient #1 was talking and answering questions. Documentation by Staff #11 states Patient #1 answered "yes" when asked if he/she was being hurt by someone. Staff #11 documented on January 12, 2014 at 9:00 pm Patient #1 was changed into a gown and placed on the cardiac monitor.

Initial examination of Patient #1 by emergency room physician at 8:53 pm on January 12, 2014 describes neurological status of Patient #1 as "drowsy, slurred speech, answers questions but slowly, heavy odor of alcohol on breath and moves all extremities spontaneously." General appearance of Patient #1 documented by emergency room physician as "awake, alert and oriented times three."

Documentation by Staff #11 at 12:20 am on January 13, 2014 reports Patient #1 was observed sitting up on the edge of the bed. Patient #1 informed Staff #11 he/she had vomited in the sink. Patient #1 complained of his/her head really hurting and feeling like passing out. Documentation by Staff #11 reports Patient #1 was encouraged to get back into the bed. Staff #11 reports Patient #1 became "limp and was assisted to the ground." Documentation by Staff #11 states Patient #1 was lifted back into bed with the assistance of another emergency room staff registered nurse. Staff #11's documentation states Patient #1 responded once in bed and repeated multiple times his/her head really hurt and felt like vomiting. Documentation by Staff #11 states the emergency room physician was notified. Documentation by Staff #11 at 12:56 am on January 13, 2014 reports Patient #1 received Zofran (medication for nausea and vomiting) 4 mg intravenous push and a computerized tomography (CT scan) without contrast (dye) of the head was ordered.

Documentation by Staff #11 at 12:56 am on January 13, 2014 reports Patient #1 was brought to diagnostic radiology by another registered nurse by stretcher and would go to CT scan after the x-ray.

Review of radiology documentation (films were reviewed which showed the time stamps of when the films were done) was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:25 am. The audit trail of Patient #1's medical record while in radiology was also reviewed. Review of the elbow films revealed the following:

Elbow film ordered- 12:02 am January 13, 2014
Audit trail documentation reports Patient #1 arrived in Diagnostic Radiology at 1:03 am on January 13, 2014 entered by Staff #10.
Staff #9 assisted Staff #10 with Patient #1's elbow x-ray due to Patient #1's altered mental status.
First view of the elbow was completed 12:58 am 1/13/2014 per the actual film.
Last view of the elbow was completed 1:04 am 1/13/2014 per the actual film.
Audit trail documentation reports film completed at 1:11 am on January 13, 2014 entered by Staff #10.
Patient #1 transported via stretcher to holding room across the hall from the CT scan room by Staff #10.

An interview was conducted with Staff #9 at 7:45 am on May 28, 2014 by two Medical Facilities Inspectors. Staff #9 reported he/she assisted Staff #10 on January 13, 2014 at approximately 1:00 am with the elbow x-ray of Patient #1 due to Patient #1 "was not cooperating." Staff #9 clarified "not cooperating" by stating Patient #1 "was not moving." Staff #9 reported it took two radiology technicians to complete the x-ray because Patient #1 was not responding and Staff #10 positioned Patient #1's arm. Staff #9 reported Patient #1 was taken to the holding room across from the CT scan room after the elbow x-ray was completed by Staff #10.

Staff #10 was interviewed on May 28, 2014 at 8:35 am by two Medical Facilities Inspectors. Staff #10 reported Patient #1 was not awake and was not moving during the elbow x-ray on January 13, 2014 at approximately 1:00 am. Staff #10 reported he/she tried to wake Patient #1 up but got no response. Staff #10 reported he/she never saw Patient #1 move or respond verbally while in Diagnostic Radiology. Staff #10 stated he/she was to the point where he/she made sure Patient #1 "was breathing." Staff #10 verified Staff #9 assisted with Patient #1's elbow x-ray. Staff #10 reported he/she held Patient #1's arm in place while Staff #9 took the x-ray. Staff #10 confirmed he/she took Patient #1 to the holding room across from the CT scan room. Staff #10 verified he/she told Staff #16 that Patient #1 was in the holding area. Staff #10 reported he/she left the CT Scan Department and returned to Diagnostic Radiology where Staff #9 was present. Staff #10 reported he/she did not look at the monitor which allows Diagnostic Radiology to view the holding room after leaving Patient #1 in the CT scan holding room. Staff #10 reported he/she did not know when Staff #16 had taken Patient #1 into the CT scan room.

Staff #10 reported sometimes the emergency room staff cannot help with patients because they are too busy. Staff #10 reported it is not unusual for the radiology staff to have to move patients by themselves. Staff #10 reported one incident where "a drunk 21 year old" female was brought to Diagnostic Radiology and was difficult to move. Staff #10 reported he/she does not typically go over to the CT Scan Department at night due to the physical layout of the Radiology Department.

Review of the CT scan head films was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:35 am. The review revealed the following information:

Head CT Scan without contrast ordered on Patient #1 at 12:31 am on January 13, 2014.
Audit trail documentation revealed Patient #1 arrived in CT Scan Department at 1:10 am entered by Staff #16 on January 13, 2014.
Audit trail documentation entered by Staff #16 revealed the examination began at 1:10 am on January 13, 2014.
Actual CT image of the head documentation reports first image taken on 1/13/14 at 1:21.16.
Actual CT image of the head documentation reports last image taken on 1/13/14 at 1:21.15.
Audit trail documentation revealed examination completed at 1:52 am entered by Staff #16 on January 13, 2014.

Staff #3 was asked about the time discrepancies while Patient #1 was in Diagnostic Radiology and CT Scan. Staff #3 reported the audit trail information can be entered after a test is completed. Staff #3 reported it would take about twenty seconds to complete a head CT scan without contrast. Staff #3 reported normally two staff members are present in the CT Scan Department on the night shift. Staff #3 reported the CT aide was "off the night of January 13, 2014." Staff #3 reported the CT aide who was off was of the same sex as Patient #1. Staff #3 reported the CT aide had recently (not in January) been off for weeks due to surgery.

Staff #14 was interviewed on May 28, 2014 between 7:45 am and 9:00 am and verified there were time discrepancies in Patient #1's medical record between the radiology times documented and the times documented in the nursing notes by Staff #11 and other emergency room nursing staff. Documentation by Staff #16 entered into the audit trail reports Patient #1's CT scan was completed at 1:52 am on January 13, 2014. Documentation by Staff #11 reports Patient #1 returned from x-ray at 1:20 am on January 13, 2014 and was placed back on the cardiac monitor. Staff #14 reported these discrepancies were due to the incident with Patient #1. Staff #14 reported the nursing notes were not entered in live time. No evidence of a late entry was found in Patient #1's medical record. The Root Cause Analysis document reviewed on May 27, 2014 noted the time discrepancies were due to the difference in hospital clocks.

Nursing note documentation by emergency room staff registered nurse dated January 13, 2014 at 1:21 am reports Patient #1 was observed trying to get out of bed. Upon entering the room the registered nurse documented Patient #1 stated "I need to talk to someone. I think I was just raped wherever I was just getting imaging done." Staff registered nurse (unavailable for interview at time of the complaint investigation) documented Staff #11 notified of Patient #1's statement. Staff registered nurse documentation at 1:25 am on January 13, 2014 reports Patient #1 placed back on the monitor. Patient #1 reported I can see no one is going to take me seriously. Documentation by Staff #11 reports the charge nurse notified. Documentation by emergency room charge nurse indicates Staff #15 notified and on the way to the emergency room.

Documentation by emergency room charge nurse on January 13, 2014 at 1:40 am reports multiple county police rushed into the emergency room at the above named facility looking for the patient in room #3. Documentation states "a patient just called us stating he/she has been assaulted."

Staff #11 documented a repeat blood draw for alcohol level at 2:05 am on January 13, 2014. Results dated January 13, 2014 at 2:28 am are documented as 344 mg/dl.

Documentation by emergency room charge nurse reports Patient #1 observed getting off stretcher at 2:31 am on January 13, 2014. Patient complaining of being anxious. A county police officer of the same sex of Patient #1 present at Patient #1's bedside at 2:56 am.

Staff #11's documentation dated January 13, 2014 at 3:03 am reports Patient #1 voided and received special instructions per the county police to aide in the preservation of potential evidence. Patient #1 escorted to the bathroom by police and nursing staff. Urine collection labeled and all Patient #1's belongings labeled and given to the police.

Documentation by Staff #11 states Patient #1 transferred by ambulance with police to another Northern Virginia Hospital for a Sexual Assault Nurse Examination (SANE) at 3:25 am.

Staff #11 was interviewed on May 28, 2014 between 9:15 am and 9:50 am. Staff #11 confirmed he/she was Patient #1's primary nurse on January 12, 2014 and January 13, 2014. Staff #11 confirmed Patient #1 was changed into a patient gown and was given mesh underwear upon arrival in the emergency room. Staff #11 verified Patient #1 had stated he/she had been hurt by another person. Staff #11 confirmed there was concern about domestic violence. Staff #11 verified Patient #1 had some bruising on the left elbow but it was difficult to determine the age of the bruising. Staff #11 verified Patient #1 had a history of a fall the evening of January 12, 2014. Staff #11 reported Patient #1 was anxious and requesting a Klonopin. Staff #11 documented Patient #1 was given a Klonopin at 9:33 pm on January 12, 2014. Staff #11 reported Patient #1 was "in and out of it" all evening.
Staff #11 confirmed the documentation of Patient #1 vomiting and complaining of a "bad headache." Staff #11 reported Patient #1 had episode of unresponsiveness which required Patient #1 to be lowered to the floor. Staff #11 denied Patient #1 had fallen. Staff #11 confirmed he/she called for assistance to lift Patient #1 off the floor and place Patient #1 back into bed. Staff #11 reported he/she notified the emergency room doctor and a non contrast head CT scan was ordered. Staff #11 reported "felt something was not right and wanted to make sure Patient #1 did not have a head bleed." Staff #11 volunteered information during the interview that Patient #1 had belongings with him/her and Staff #11 wondered if Patient #1 had alcohol or Klonopin and may have taken some without the knowledge of the emergency room staff. Staff #11 reported Patient #1 had access to his/her belongings while in the emergency room. Staff #11 reported another staff member took Patient #1 to Diagnostic Radiology because he/she was busy with a very sick patient. Staff #11 reported the nurses do not typically stay with the patients while in the Radiology Department.

Staff #11 reported another emergency room staff member came and told him/her about Patient #1 saying he/she had been assaulted while in radiology. Staff #11 stated he/she called Staff #16 and asked him/her "tell me you are not over there alone." Staff #11 reported Staff #16 confirmed he/she was in the CT Scan Department working alone. Staff #11 confirmed it is believed Patient #1 notified the police. Staff #11 verified he/she only went into Patient #1's room to redraw the alcohol blood level once the police arrived at the facility. Staff #11 confirmed all linens, Patient #1's belongings and the containers of Patient #1's urine were given to the police as potential evidence prior to the transfer of Patient #1 to another Northern Virginia Hospital.

Staff #15 was interviewed on May 28, 2014 at 9:55 am. Staff #15 confirmed he/she worked the night of January 13, 2014. Staff #15 verified he/she was notified by the emergency room charge nurse of a "problem in the emergency room and needed to come to the emergency room right away." Staff #15 confirmed upon arrival in the emergency room there were "several county police in room #3." Staff #15 reported he/she was told by the emergency room charge nurse that Patient #1 had told an emergency room nursing staff member the assault took place in radiology wherever he/she had to be on his/her stomach. Staff #15 confirmed this was not said to him/her directly by the nurse who had spoken directly with Patient #1. Staff #15 reported he/she had no contact with Patient #1.

Staff #15 reported he/she went to Radiology and spoke to Staff #9, Staff #10, and Staff #16. Staff #15 stated he/she told all staff to be calm and cooperate with the police.

Staff #9 and Staff #10 were interviewed separately on the morning of May 28, 2014 beginning at approximately 7:45 am. Both Staff #9 and Staff #10 reported they agreed to a DNA (deoxyribonucleic acid) swab test by the police and were placed on leave at the end of the shift on January 13, 2014. Staff #9 and Staff #10 reported they were out on paid leave for three days. Both Staff #9 and Staff #10 reported they did not discuss the incident with Staff #16. Both Staff #9 and Staff #10 reported they had agreed to take a polygraph examination but had not taken one. No DNA evidence was found linking Staff #9 or Staff #10 to the alleged incident.

Staff #7 was interviewed on May 27, 2014 at 3:50 pm. Staff #7 confirmed the county police notified the above named facility of DNA evidence on or about April 14, 2014 linking Staff #16 to the alleged sexual assault of Patient #1 on January 13, 2014. Staff #7 reported he/she worked "very closely" with the police. Staff #7 reported the facility had no video coverage to aide in the criminal investigation. Staff #7 reported Staff #9 and Staff #10 had taken a polygraph examination. Staff #7 reported Staff #16 had refused to take a polygraph examination.

Staff #2 was interviewed on May 27, 2014 at approximately 11:45 am. Staff #2 confirmed Staff #16 was being held without bond in the county jail. Staff #2 confirmed the facility had been notified on or about April 14, 2014 of DNA evidence linking Staff #16 to the alleged sexual assault on Patient #1 the morning of January 13, 2014. Staff #2 confirmed Staff #16 had not worked at the facility since the alleged incident. Staff #2 reported Staff #16 was terminated once the DNA results were reported to the facility.

Five employee files were reviewed on May 28, 2014 at approximately 9:30 am (Employee Files #1-#5). All the Employee Files reviewed had all the required information. Employee File #1 (Staff #16) had a criminal record check prior to employment on 03/06/12. Staff #16's criminal record report had multiple traffic violations. No prior history of criminal activity was noted on the criminal record report of Staff #16.

A copy of the facility's policy titled Patient Hand-Offs was received on May 28, 2014 and reviewed on May 29, 2014 at 9:00 am. Section four titled "Procedural Reports" states inpatients and outpatients who are leaving the unit for a "diagnostic procedure" in another department such as radiology will provide a telephone report to the receiving caregiver. Staff #10 confirmed he/she received a "passport" (form with important patient information such as name, allergies, fall risk, etc.) upon Patient #1's arrival in Diagnostic Radiology. Staff #1 reported the passport is not part of the medical record.

Based on document review and interview the facility failed to ensure the right to personal privacy for one of thirty patients (Patient #1).

The findings included:

Thirty medical records (#1-#30) were reviewed on May 27, 2014 beginning at 12:30 pm. Patient #1's medical record was reviewed beginning at approximately 12:30 pm. Patient #1 was brought to the above named facility on January 12, 2014 at 8:47 pm by Emergency Medical Services (EMS). Patient #1 was admitted to the above named facility's emergency room on January 12, 2014 at approximately 8:47 pm. Documentation in Patient #1's medical record indicates Patient #1 fell outside a restaurant and presented with altered mental status and alcohol intoxication. Patient #1 reported to EMS he/she drank three (3) beers and took two (2) .5 mg Klonopin (used for seizure disorders or panic disorders) during the evening. Documentation in Patient #1's EMS record indicates he/she denied a history of seizures. Patient #1's initial alcohol level is documented as 398 mg/dl at 10:28 pm in the medical record. The rapid drug screen done at 10:25 pm is documented as negative.

Initial triage nursing note documentation on January 12, 2014 at 8:52 pm reports Patient #1 had "ground level fall per EMS." Documentation further reports Patient #1 had episode of non responsiveness while under the care of EMS. Documentation by Staff #11 during triage states Patient #1 was talking and answering questions. Documentation by Staff #11 states Patient #1 answered "yes" when asked if he/she was being hurt by someone. Staff #11 documented on January 12, 2014 at 9:00 pm Patient #1 was changed into a gown and placed on the cardiac monitor.

Initial examination of Patient #1 by emergency room physician at 8:53 pm on January 12, 2014 describes neurological status of Patient #1 as "drowsy, slurred speech, answers questions but slowly, heavy odor of alcohol on breath and moves all extremities spontaneously." General appearance of Patient #1 documented by emergency room physician as "awake, alert and oriented times three."

Documentation by Staff #11 at 12:20 am on January 13, 2014 reports Patient #1 was observed sitting up on the edge of the bed. Patient #1 informed Staff #11 he/she had vomited in the sink. Patient #1 complained of his/her head really hurting and feeling like passing out. Documentation by Staff #11 reports Patient #1 was encouraged to get back into the bed. Staff #11 reports Patient #1 became "limp and was assisted to the ground." Documentation by Staff #11 states Patient #1 was lifted back into bed with the assistance of another emergency room staff registered nurse. Staff #11's documentation states Patient #1 responded once in bed and repeated multiple times his/her head really hurt and felt like vomiting. Documentation by Staff #11 states the emergency room physician was notified. Documentation by Staff #11 at 12:56 am reports Patient #1 received Zofran (medication for nausea and vomiting) 4 mg intravenous push and a computerized tomography (CT scan) without contrast (dye) of the head was ordered.

Documentation by Staff #11 at 12:56 am on January 13, 2014 reports Patient #1 was brought to diagnostic radiology by another registered nurse by stretcher and would go to CT scan after the x-ray.

Review of radiology documentation (films were reviewed which showed the time stamps of when the films were done) was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:25 am. The audit trail of Patient #1's medical record while in radiology was also reviewed. Review of the elbow films revealed the following:

Elbow film ordered- 12:02 am January 13, 2014
Audit trail documentation reports Patient #1 arrived in Diagnostic Radiology at 1:03 am on January 13, 2014 entered by Staff #10.
Staff #9 assisted Staff #10 with Patient #1's elbow x-ray due to Patient #1's altered mental status.
First view of the elbow was completed 12:58 am per the actual film on January 13, 2014.
Last view of the elbow was completed 1:04 am per the actual film on January 13, 2014.
Audit trail documentation reports film completed at 1:11 am on January 13, 2014 entered by Staff #10.
Patient #1 transported via stretcher to holding room across the hall from the CT scan room by Staff #10.

An interview was conducted with Staff #9 at 7:45 am on May 28, 2014 by two Medical Facilities Inspectors. Staff #9 reported he/she assisted Staff #10 with the elbow x-ray of Patient #1 on January 13, 2014 at approximately 1:00 am due to Patient #1 "was not cooperating." Staff #9 clarified "not cooperating" by stating Patient #1 "was not moving." Staff #9 reported it took two radiology technicians to complete the x-ray because Patient #1 was not responding and Staff #10 positioned Patient #1's arm. Staff #9 reported Patient #1 was taken to the holding room across from the CT scan room after the elbow x-ray was completed by Staff #10.

Staff #10 was interviewed on May 28, 2014 at 8:35 am by two Medical Facilities Inspectors. Staff #10 reported Patient #1 was not awake and was not moving during the elbow x-ray on January 13, 2014 at approximately 1:00 am. Staff #10 reported he/she tried to wake Patient #1 up but got no response. Staff #10 reported he/she never saw Patient #1 move or respond verbally while in Diagnostic Radiology. Staff #10 stated he/she was to the point where he/she made sure Patient #1 "was breathing." Staff #10 verified Staff #9 assisted with Patient #1's elbow x-ray. Staff #10 reported he/she held Patient #1's arm in place while Staff #9 took the x-ray. Staff #10 confirmed he/she took Patient #1 to the holding room across from the CT scan room after the completion of the elbow x-ray. Staff #10 verified he/she told Staff #16 that Patient #1 was in the holding area. Staff #10 reported he/she left the CT Scan Department and returned to Diagnostic Radiology where Staff #9 was present. Staff #10 reported he/she did not look at the monitor which allows Diagnostic Radiology to view the holding room after leaving Patient #1 in the CT holding area. Staff #10 reported he/she did not know when Staff #16 had taken Patient #1 into the CT scan room.

Staff #10 reported sometimes the emergency room staff cannot help with patients because they are too busy. Staff #10 reported it is not unusual for the radiology staff to have to move patients by themselves. Staff #10 reported one incident where "a drunk 21 year old" female was brought to Diagnostic Radiology and was difficult to move. Staff #10 reported he/she does not typically go over to the CT Scan Department at night due to the physical layout of the Radiology Department. Staff #10 reported he/she does not know Staff #16 well.

Review of the CT scan head films was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:35 am. The review revealed the following information:

Head CT Scan without contrast ordered on Patient #1 at 12:31 am on January 13, 2014.
Audit trail documentation revealed Patient #1 arrived in CT Scan Department at 1:10 am entered by Staff #16.
Audit trail documentation entered by Staff #16 revealed the examination began at 1:10 am on January 13, 2014.
Actual CT image of the head documentation reports first image taken on January 13, 2014 at 1:21.16.
Actual CT image of the head documentation reports last image taken on January 13, 2014 at 1:21.15.
Audit trail documentation revealed examination completed at 1:52 am entered by Staff #16 on January 13, 2014.

Staff #3 was asked about the time discrepancies while Patient #1 was in Diagnostic Radiology and CT Scan. Staff #3 reported the audit trail information can be entered after a test is completed. Staff #3 reported normally two staff members are present in the CT Scan Department on the night shift. Staff #3 reported the CT aide was "off the night of January 13, 2014." Staff #3 reported the CT aide who was off was of the same sex as Patient #1. Staff #3 reported the CT aide had been off for weeks (not in January) due to surgery.

Staff #14 was interviewed on May 28, 2014 between 7:45 am and 9:00 am and verified there were time discrepancies in Patient #1's medical record between the radiology times documented and the times documented in the nursing notes by Staff #11 and other emergency room nursing staff. Documentation by Staff #16 entered into the audit trail reports Patient #1's CT scan was completed at 1:52 am on January 13, 2014. Documentation by Staff #11 reports Patient #1 returned from x-ray at 1:20 am on January 13, 2014 and was placed back on the cardiac monitor. Staff #14 reported these discrepancies were due to the incident with Patient #1. Staff #14 reported the nursing notes were not entered in live time. No evidence of a late entry was found in Patient #1's medical record. The Root Cause Analysis provided for review on May 28, 2014 reported the time discrepancies were due to the difference in hospital clocks.

Nursing note documentation by emergency room staff registered nurse dated January 13, 2014 at 1:21 am reports Patient #1 was observed trying to get out of bed. Upon entering the room the registered nurse documented Patient #1 stated "I need to talk to someone. I think I was just raped wherever I was just getting imaging done." Staff registered nurse (unavailable for interview at time of the complaint investigation) documented Staff #11 notified of Patient #1's statement. Staff registered nurse documentation at 1:25 am reports Patient #1 placed back on the monitor. Patient #1 reported I can see no one is going to take me seriously. Documentation by Staff #11 reports the charge nurse notified. Documentation by emergency room charge nurse indicates Staff #15 notified and on the way to the emergency room.

Documentation by emergency room charge nurse on January 13, 2014 at 1:40 am reports multiple police rushed into the emergency room at the above named facility looking for the patient in room #3. Documentation states "a patient just called us stating he/she has been assaulted."

Staff #11 documented a repeat blood draw for alcohol level at 2:05 am on January 13, 2014. Results dated January 13, 2014 at 2:28 am 344 mg/dl.

Documentation by emergency room charge nurse reports Patient #1 observed getting off stretcher at 2:31 am on January 13, 2014. Patient complaining of being anxious. County police officer of the same sex of Patient #1 present at Patient #1's bedside at 2:56 am.

Staff #11's documentation dated January 13, 2014 at 3:03 am reports Patient #1 voided and received special instructions per the county police to aide in the preservation of potential evidence. Patient #1 escorted to the bathroom by the police and nursing staff. Urine collection labeled and all Patient #1's belongings labeled and given to the police.

Documentation by Staff #11 states Patient #1 transferred by Emergency Medical Services with the police to another Northern Virginia Hospital for a Sexual Assault Nurse Examination (SANE) at 3:25 am.

Staff #11 was interviewed on May 28, 2014 between 9:15 am and 9:50 am. Staff #11 confirmed he/she was Patient #1's primary nurse on January 12, 2014 and January 13, 2014. Staff #11 confirmed Patient #1 was changed into a patient gown and was given mesh underwear upon arrival in the emergency room. Staff #11 verified Patient #1 had stated he/she had been hurt by another person. Staff #11 confirmed there was concern about domestic violence. Staff #11 verified Patient #1 had some bruising on the left elbow but it was difficult to determine the age of the bruising. Staff #11 verified Patient #1 had a history of a fall the evening of January 12, 2014. Staff #11 reported Patient #1 was anxious and requesting a Klonopin. Staff #11 documented Patient #1 was given a Klonopin at 9:33 pm on January 12, 2014. Staff #11 reported Patient #1 was "in and out of it" all evening.
Staff #11 confirmed the documentation of Patient #1 vomiting and complaining of a "bad headache." Staff #11 reported Patient #1 had episode of unresponsiveness which required Patient #1 to be lowered to the floor. Staff #11 denied Patient #1 had fallen. Staff #11 confirmed he/she called for assistance to lift Patient #1 off the floor and place Patient #1 back into bed. Staff #11 reported he/she notified the emergency room doctor and a non contrast head CT scan was ordered. Staff #11 reported "felt something was not right and wanted to make sure Patient #1 did not have a head bleed." Staff #11 volunteered information during the interview that Patient #1 had belongings with him/her and Staff #11 wondered if Patient #1 had alcohol or Klonopin and may have taken some without the knowledge of the emergency room staff. Staff #11 reported another staff member took Patient #1 to Diagnostic Radiology because he/she was busy with a very sick patient. Staff #11 reported the nurses do not typically stay with the patients while in the Radiology Department.

Staff #11 reported another emergency room staff member came and told him/her about Patient #1 saying he/she had been assaulted while in radiology. Staff #11 stated he/she called Staff #16 and asked him/her "tell me you are not over there alone." Staff #11 reported Staff #16 confirmed he/she was in the CT Scan Department working alone. Staff #11 confirmed it is believed Patient #1 notified the police. Staff #11 verified he/she only went into Patient #1's room to redraw the alcohol blood level once the police arrived at the facility. Staff #11 confirmed all linens, Patient #1's belongings, and the containers of Patient #1's urine were given to the police as potential evidence prior to the transfer of Patient #1 to another Northern Virginia Hospital.

Staff #15 was interviewed on May 28, 2014 at 9:55 am. Staff #15 confirmed he/she worked the night of January 13, 2014. Staff #15 verified he/she was notified by the emergency room charge nurse of a "problem in the emergency room and needed to come to the emergency room right away." Staff #15 confirmed upon arrival in the emergency room there were "several county police in room #3." Staff #15 reported he/she was told by the emergency room charge nurse that Patient #1 had told an emergency room nursing staff member the assault took place in radiology wherever he/she had to be on his/her stomach. Staff #15 confirmed this was not said to him/her directly by the nurse who had spoken directly with Patient #1. Staff #15 reported he/she had no contact with Patient #1.

Staff #15 reported he/she went to Radiology and spoke to Staff #9, Staff #10, and Staff #16. Staff #15 stated he/she told all staff to be calm and cooperate with the police.

Staff #9 and Staff #10 were interviewed separately on the morning of May 28, 2014. Both Staff #9 and Staff #10 reported they agreed to a DNA (deoxyribonucleic acid) swab test by the police and were placed on leave at the end of the shift on January 13, 2014. Staff #9 and Staff #10 reported they were out on paid leave for three days. Both Staff #9 and Staff #10 reported they did not discuss the incident with Staff #16. Both Staff #9 and Staff #10 reported they had agreed to take a polygraph examination but had not taken one. No DNA evidence was found linking Staff #9 or Staff #10 to the alleged incident.

Staff #7 was interviewed on May 27, 2014 at 3:50 pm. Staff #7 confirmed the county police notified the above named facility of DNA evidence on or about April 14, 2014 linking Staff #16 to the alleged sexual assault of Patient #1 on January 13, 2014. Staff #7 reported he/she worked "very closely" with the police. Staff #7 reported the facility had no video coverage to aide in the criminal investigation. Staff #7 reported Staff #9 and Staff #10 had taken a polygraph examination. Staff #7 reported Staff #16 had refused to take a polygraph examination.

Staff #2 was interviewed on May 27, 2014 at approximately 11:45 am. Staff #2 confirmed Staff #16 was being held without bond in jail. Staff #2 confirmed the facility had been notified on or about April 14, 2014 of DNA evidence linking Staff #16 to the alleged sexual assault on Patient #1 the morning of January 13, 2014. Staff #2 confirmed Staff #16 had not worked at the facility since the alleged incident. Staff #2 reported Staff #16 was terminated once the DNA results were reported to the facility.

Five employee files were reviewed on May 28, 2014 at approximately 9:30 am (Employee Files #1-#5). All the Employee Files reviewed had all the required information. Employee File #1 (Staff #16) had a criminal record check prior to employment on 03/06/12. Staff #16's criminal record report had multiple traffic violations. No prior history of criminal activity was noted on the criminal record report of Staff #16.

Based on document review and interview the facility failed to provide care in a safe setting for one of thirty patients (Patient #1).

The findings included:

Thirty medical records (#1-#30) were reviewed on May 27, 2014 beginning at 12:30 pm. Patient #1's medical record was reviewed beginning about 12:30 pm. Patient #1 was brought to the above named facility on January 12, 2014 at 8:47 pm by Emergency Medical Services (EMS). Patient #1 was admitted to the above named facility's emergency room on January 12, 2014 at approximately 8:47 pm. Documentation in Patient #1's medical record indicates Patient #1 fell outside a restaurant and presented with altered mental status and alcohol intoxication. Patient #1 reported to EMS he/she drank three (3) beers and took two (2) .5 mg Klonopin (used for seizure disorders or panic disorders) during the evening. Documentation in Patient #1's EMS record indicates he/she denied a history of seizures. Patient #1's initial alcohol level is documented as 398 mg/dl at 10:28 pm in the medical record. "Potentially lethal concentration greater than 400 mg/dl" per the documented laboratory test description in Patient #1's medical record. The rapid drug screen done at 10:25 pm is documented as negative.

Initial triage nursing note documentation on January 12, 2014 at 8:52 pm reports Patient #1 had "ground level fall per EMS." Documentation further reports Patient #1 had episode of non responsiveness while under the care of EMS. Documentation by Staff #11 during triage states Patient #1 was talking and answering questions. Documentation by Staff #11 states Patient #1 answered "yes" when asked if he/she was being hurt by someone. Staff #11 documented on January 12, 2014 at 9:00 pm Patient #1 was changed into a gown and placed on the cardiac monitor.

Initial examination of Patient #1 by emergency room physician at 8:53 pm on January 12, 2014 describes neurological status of Patient #1 as "drowsy, slurred speech, answers questions but slowly, heavy odor of alcohol on breath and moves all extremities spontaneously." General appearance of Patient #1 documented by emergency room physician as "awake, alert and oriented times three."

Documentation by Staff #11 at 12:20 am on January 13, 2014 reports Patient #1 was observed sitting up on the edge of the bed. Patient #1 informed Staff #11 he/she had vomited in the sink. Patient #1 complained of his/her head really hurting and feeling like passing out. Documentation by Staff #11 reports Patient #1 was encouraged to get back into the bed. Staff #11 reports Patient #1 became "limp and was assisted to the ground." Documentation by Staff #11 states Patient #1 was lifted back into bed with the assistance of another emergency room staff registered nurse. Staff #11's documentation states Patient #1 responded once in bed and repeated multiple times his/her head really hurt and felt like vomiting. Documentation by Staff #11 states the emergency room physician was notified. Documentation by Staff #11 at 12:56 am reports Patient #1 received Zofran (medication for nausea and vomiting) 4 mg intravenous push and a computerized tomography (CT scan) without contrast (dye) of the head was ordered.

Documentation by Staff #11 at 12:56 am on January 13, 2014 reports Patient #1 was brought to diagnostic radiology by another registered nurse by stretcher and would go to CT scan after the x-ray.

Review of radiology documentation (films were reviewed which showed the time stamps of when the films were done) was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:25 am. The audit trail of Patient #1's medical record while in radiology was also reviewed. Review of the elbow films revealed the following:

Elbow film ordered- 12:02 am January 13, 2014
Audit trail documentation reports Patient #1 arrived in Diagnostic Radiology at 1:03 am on January 13, 2014 entered by Staff #10.
Staff #9 assisted Staff #10 with Patient #1's elbow x-ray due to Patient #1's altered mental status.
First view of the elbow was completed 12:58 am per the actual film on January 13, 2014.
Last view of the elbow was completed 1:04 am per the actual film on January 13, 2014.
Audit trail documentation reports film completed at 1:11 am on January 13, 2014 entered by Staff #10.
Patient #1 transported via stretcher to holding room across the hall from the CT scan room by Staff #10.

An interview was conducted with Staff #9 at 7:45 am on May 28, 2014 by two Medical Facilities Inspectors. Staff #9 reported he/she assisted Staff #10 on January 13, 2014 at approximately 1:00 am with the elbow x-ray of Patient #1 due to Patient #1 "was not cooperating." Staff #9 clarified "not cooperating" by stating Patient #1 "was not moving." Staff #9 reported it took two radiology technicians to complete the x-ray because Patient #1 was not responding and Staff #10 positioned Patient #1's arm. Staff #9 reported Patient #1 was taken to the holding room across from the CT scan room after the elbow x-ray was completed by Staff #10.

Staff #10 was interviewed on May 28, 2014 at 8:35 am by two Medical Facilities Inspectors. Staff #10 reported Patient #1 was not awake and was not moving during the elbow x-ray on January 13, 2014 at approximately 1:00 am. Staff #10 reported he/she tried to wake Patient #1 up but got no response. Staff #10 reported he/she never saw Patient #1 move or respond verbally while in Diagnostic Radiology. Staff #10 stated he/she was to the point where he/she made sure Patient #1 "was breathing." Staff #10 verified Staff #9 assisted with Patient #1's elbow x-ray. Staff #10 reported he/she held Patient #1's arm in place while Staff #9 took the x-ray. Staff #10 confirmed he/she took Patient #1 to the holding room across from the CT scan room. Staff #10 verified he/she told Staff #16 that Patient #1 was in the CT holding area. Staff #10 reported he/she left the CT Scan Department and returned to Diagnostic Radiology where Staff #9 was present. Staff #10 reported he/she did not look at the monitor which allows Diagnostic Radiology to view the CT holding room after leaving Patient #1 in the CT holding area. Staff #10 reported he/she did not know when Staff #16 had taken Patient #1 into the CT scan room.

Staff #10 reported sometimes the emergency room staff cannot help with patients because they are too busy. Staff #10 reported it is not unusual for the radiology staff to have to move patients by themselves. Staff #10 reported one incident where "a drunk 21 year old" female was brought to Diagnostic Radiology and was difficult to move. Staff #10 reported he/she does not typically go over to the CT Scan Department at night due to the physical layout of the Radiology Department.

Review of the CT scan head films was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:35 am. The review revealed the following information:

Head CT Scan without contrast ordered on Patient #1 at 12:31 am on January 13, 2014.
Audit trail documentation revealed Patient #1 arrived in CT Scan Department at 1:10 am entered by Staff #16.
Audit trail documentation entered by Staff #16 revealed the examination began at 1:10 am on January 13, 2014.
Actual CT image of the head documentation reports first image taken on January 13, 2014 at 1:21.16.
Actual CT image of the head documentation reports last image taken on January 13, 2014 at 1:21.15.
Audit trail documentation revealed examination completed at 1:52 am entered by Staff #16 on January 13, 2014.

Staff #3 was asked about the time discrepancies while Patient #1 was in Diagnostic Radiology and CT Scan. Staff #3 reported the audit trail information can be entered after a test is completed. Staff #3 reported normally two staff members are present in the CT Scan Department on the night shift. Staff #3 reported the CT aide was "off the night of January 13, 2014." Staff #3 reported the CT aide who was off was of the same sex as Patient #1.

Staff #14 was interviewed on May 28, 2014 and verified there were time discrepancies in Patient #1's medical record between the radiology times documented and the times documented in the nursing notes by Staff #11 and other emergency room nursing staff. Documentation by Staff #16 reports Patient #1's CT scan was completed at 1:52 am. Documentation by Staff #11 reports Patient #1 returned from x-ray at 1:20 am and was placed back on the cardiac monitor. Staff #14 reported these discrepancies were due to the incident with Patient #1. Staff #14 reported the nursing notes were not in live time. The Root Cause Analysis documentation review noted the time discrepancies were due to the difference in hospital clocks.

Nursing note documentation by emergency room staff registered nurse dated January 13, 2014 at 1:21 am reports Patient #1 was observed trying to get out of bed. Upon entering the room the registered nurse documented Patient #1 stated "I need to talk to someone. I think I was just raped wherever I was just getting imaging done." Staff registered nurse (unavailable for interview at time of the complaint investigation) documented Staff #11 notified of Patient #1's statement. Staff registered nurse documentation at 1:25 am on January 13, 2014 reports Patient #1 placed back on the monitor. Patient #1 stated I can see no one is going to take me seriously. Documentation by Staff #11 reports the charge nurse notified. Documentation by emergency room charge nurse indicates Staff #15 notified and on the way to the emergency room.

Documentation by emergency room charge nurse on January 13, 2014 at 1:40 am reports multiple county police rushed into the emergency room at the above named facility looking for the patient in room #3. Documentation states "a patient just called us stating he/she has been assaulted."

Staff #11 documented a repeat blood draw for alcohol level at 2:05 am on January 13, 2014. Results dated January 13, 2014 at 2:28 am 344 mg/dl.

Documentation by emergency room charge nurse reports Patient #1 observed getting off stretcher at 2:31 am on January 13, 2014. Patient complaining of being anxious. A county police officer of the same sex of Patient #1 present at Patient #1's bedside at 2:56 am.

Staff #11's documentation dated January 13, 2014 at 3:03 am reports Patient #1 voided and received special instructions per the police to aide in the preservation of potential evidence. Patient #1 escorted to the bathroom by the police and nursing staff. Urine collection labeled and all Patient #1's belongings labeled and given to police.

Documentation by Staff #11 states Patient #1 was transferred by EMS with police to another Northern Virginia Hospital for a Sexual Assault Nurse Examination (SANE) at 3:25 am.

Staff #11 was interviewed on May 28, 2014 between 9:15 am and 9:50 am. Staff #11 confirmed he/she was Patient #1's primary nurse on January 12, 2014 and January 13, 2014. Staff #11 confirmed Patient #1 was changed into a patient gown and was given mesh underwear upon arrival in the emergency room. Staff #11 verified Patient #1 had stated he/she had been hurt by another person. Staff #11 confirmed there was concern about domestic violence. Staff #11 verified Patient #1 had some bruising on the left elbow but it was difficult to determine the age of the bruising. Staff #11 verified Patient #1 had a history of a fall the evening of January 12, 2014. Staff #11 reported Patient #1 was anxious and requesting a Klonopin. Staff #11 documented Patient #1 was given a Klonopin at 9:33 pm on January 12, 2014. Staff #11 reported Patient #1 was "in and out of it" all evening.
Staff #11 confirmed the documentation of Patient #1 vomiting and complaining of a "bad headache." Staff #11 reported Patient #1 had episode of unresponsiveness which required Patient #1 to be lowered to the floor. Staff #11 denied Patient #1 had fallen. Staff #11 confirmed he/she called for assistance to lift Patient #1 off the floor and place Patient #1 back into bed. Staff #11 reported he/she notified the emergency room doctor and a non contrast head CT scan was ordered. Staff #11 reported "felt something was not right and wanted to make sure Patient #1 did not have a head bleed." Staff #11 volunteered information during the interview that Patient #1 had belongings with him/her and Staff #11 wondered if Patient #1 had alcohol or Klonopin and may have taken some without the knowledge of the emergency room staff. Staff #11 reported another staff member took Patient #1 to Diagnostic Radiology because he/she was busy with a very sick patient. Staff #11 reported the nurses do not typically stay with the patients while in the Radiology Department.

Staff #11 reported another emergency room staff member came and told him/her about Patient #1 saying he/she had been assaulted while in radiology. Staff #11 stated he/she called Staff #16 and asked him/her "tell me you are not over there alone." Staff #11 reported Staff #16 confirmed he/she was in the CT Scan Department working alone. Staff #11 confirmed it is believed Patient #1 notified the police. Staff #11 verified he/she only went into Patient #1's room to redraw the alcohol blood level once the police arrived at the facility. Staff #11 confirmed all linens, Patient #1's belongings and the containers of Patient #1's urine were given to the police as potential evidence prior to the transfer of Patient #1 to another Northern Virginia Hospital.

Staff #15 was interviewed on May 28, 2014 at 9:55 am. Staff #15 confirmed he/she worked the night of January 13, 2014. Staff #15 verified he/she was notified by the emergency room charge nurse of a "problem in the emergency room and needed to come to the emergency room right away." Staff #15 confirmed upon arrival in the emergency room there were "several county police in room #3." Staff #15 reported he/she was told by the emergency room charge nurse that Patient #1 had told an emergency room nursing staff member the assault took place in radiology wherever he/she had to be on his/her stomach. Staff #15 confirmed this was not said to him/her directly by the nurse who had spoken directly with Patient #1. Staff #15 reported he/she had no contact with Patient #1.

Staff #15 reported he/she went to Radiology and spoke to Staff #9, Staff #10, and Staff #16. Staff #15 stated he/she told all staff to be calm and cooperate with the police.

Staff #9 and Staff #10 were interviewed separately on the morning of May 28, 2014. Both Staff #9 and Staff #10 reported they agreed to a DNA (deoxyribonucleic acid) swab test by the county police and were placed on leave at the end of the shift on January 13, 2014. Staff #9 and Staff #10 reported they were out on paid leave for three days. Both Staff #9 and Staff #10 reported they did not discuss the incident with Staff #16. Both Staff #9 and Staff #10 reported they had agreed to take a polygraph examination but had not taken one. No DNA evidence was found linking Staff #9 or Staff #10 to the alleged incident.

Staff #7 was interviewed on May 27, 2014 at 3:50 pm. Staff #7 confirmed the county police notified the above named facility of DNA evidence on or about April 14, 2014 linking Staff #16 to the alleged sexual assault of Patient #1 on January 13, 2014. Staff #7 reported he/she worked "very closely" with the county police. Staff #7 reported the facility had no video coverage to aide in the criminal investigation. Staff #7 reported Staff #9 and Staff #10 had taken a polygraph examination. Staff #7 reported Staff #16 had refused to take a polygraph examination.

Staff #2 was interviewed on May 27, 2014 at approximately 11:45 am. Staff #2 confirmed Staff #16 was being held without bond in jail. Staff #2 confirmed the facility had been notified by the police on or about April 14, 2014 of DNA evidence linking Staff #16 to the alleged sexual assault on Patient #1 the morning of January 13, 2014. Staff #2 confirmed Staff #16 had not worked at the facility since the alleged incident on January 13, 2014. Staff #2 reported Staff #16 was terminated once the DNA results were reported to the facility.

Five employee files were reviewed on May 28, 2014 at approximately 9:30 am (Employee Files #1-#5). All the Employee Files reviewed had all the required information. Employee File #1 (Staff #16) had a criminal record check prior to employment on 03/06/12. Staff #16's criminal record report had multiple traffic violations. No prior history of criminal activity was noted on the criminal record report of Staff #16.

Based on document review and interview the facility failed to protect one of thirty patients from abuse (Patient #1).

The findings included:

Thirty medical records (#1-#30) were reviewed on May 27, 2014 beginning at 12:30 pm. Patient #1's medical record was reviewed beginning about 12:30 pm. Patient #1 was brought to the above named facility on January 12, 2014 at 8:47 pm by Emergency Medical Services (EMS). Patient #1 was admitted to the above named facility's emergency room on January 12, 2014 at approximately 8:47 pm. Documentation in Patient #1's medical record indicates Patient #1 fell outside a restaurant and presented with altered mental status and alcohol intoxication. Patient #1 reported to EMS he/she drank three (3) beers and took two (2) .5 mg Klonopin (used for seizure disorders or panic disorders) during the evening. Documentation in Patient #1's EMS record indicates he/she denied a history of seizures. Patient #1's initial alcohol level is documented as 398 mg/dl at 10:28 pm in the medical record. The rapid drug screen done at 10:25 pm is documented as negative.

Initial triage nursing note documentation on January 12, 2014 at 8:52 pm reports Patient #1 had "ground level fall per EMS." Documentation further reports Patient #1 had episode of non responsiveness while under the care of EMS. Documentation by Staff #11 during triage states Patient #1 was talking and answering questions. Documentation by Staff #11 states Patient #1 answered "yes" when asked if he/she was being hurt by someone. Staff #11 documented on January 12, 2014 at 9:00 pm Patient #1 was changed into a gown and placed on the cardiac monitor.

Initial examination of Patient #1 by emergency room physician at 8:53 pm on January 12, 2014 describes neurological status of Patient #1 as "drowsy, slurred speech, answers questions but slowly, heavy odor of alcohol on breath and moves all extremities spontaneously." General appearance of Patient #1 documented by emergency room physician as "awake, alert and oriented times three."

Documentation by Staff #11 at 12:20 am on January 13, 2014 reports Patient #1 was observed sitting up on the edge of the bed. Patient #1 informed Staff #11 he/she had vomited in the sink. Patient #1 complained of his/her head really hurting and feeling like passing out. Documentation by Staff #11 reports Patient #1 was encouraged to get back into the bed. Staff #11 reports Patient #1 became "limp and was assisted to the ground." Documentation by Staff #11 states Patient #1 was lifted back into bed with the assistance of another emergency room staff registered nurse. Staff #11's documentation states Patient #1 responded once in bed and repeated multiple times his/her head really hurt and felt like vomiting. Documentation by Staff #11 states the emergency room physician was notified. Documentation by Staff #11 at 12:56 am reports Patient #1 received Zofran (medication for nausea and vomiting) 4 mg intravenous push and a computerized tomography (CT scan) without contrast (dye) of the head was ordered.

Documentation by Staff #11 at 12:56 am on January 13, 2014 reports Patient #1 was brought to diagnostic radiology by another registered nurse by stretcher and would go to CT scan after the x-ray.

Review of radiology documentation (films were reviewed which showed the time stamps of when the films were done) was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:25 am. The audit trail of Patient #1's medical record while in radiology was also reviewed. Review of the elbow films revealed the following:

Elbow film ordered- 12:02 am January 13, 2014
Audit trail documentation reports Patient #1 arrived in Diagnostic Radiology at 1:03 am on January 13, 2014 entered by Staff #10.
Staff #9 assisted Staff #10 with Patient #1's elbow x-ray due to Patient #1's altered mental status.
First view of the elbow was completed 12:58 am per the actual film on January 13, 2014.
Last view of the elbow was completed 1:04 am per the actual film on January 13, 2014.
Audit trail documentation reports film completed at 1:11 am on January 13, 2014 entered by Staff #10.
Patient #1 transported via stretcher to holding room across the hall from the CT scan room by Staff #10 on January 13, 2014.

An interview was conducted with Staff #9 at 7:45 am on May 28, 2014 by two Medical Facilities Inspectors. Staff #9 reported he/she assisted Staff #10 with the elbow x-ray of Patient #1 due to Patient #1 "was not cooperating." Staff #9 clarified "not cooperating" by stating Patient #1 "was not moving." Staff #9 reported it took two radiology technicians to complete the x-ray because Patient #1 was not responding and Staff #10 positioned Patient #1's arm. Staff #9 reported Patient #1 was taken to the holding room across from the CT scan room after the elbow x-ray was completed by Staff #10.

Staff #10 was interviewed on May 28, 2014 at 8:35 am by two Medical Facilities Inspectors. Staff #10 reported Patient #1 was not awake and was not moving during the elbow x-ray on January 13, 2014 at approximately 1:00 am. Staff #10 reported he/she tried to wake Patient #1 up but got no response. Staff #10 reported he/she never saw Patient #1 move or respond verbally while in Diagnostic Radiology. Staff #10 stated he/she was to the point where he/she made sure Patient #1 "was breathing." Staff #10 verified Staff #9 assisted with Patient #1's elbow x-ray. Staff #10 reported he/she held Patient #1's arm in place while Staff #9 took the x-ray. Staff #10 confirmed he/she took Patient #1 to the holding room across from the CT scan room. Staff #10 verified he/she told Staff #16 that Patient #1 was in the holding area. Staff #10 reported he/she left the CT Scan Department and returned to Diagnostic Radiology where Staff #9 was present. Staff #10 reported he/she did not look at the monitor which allows Diagnostic Radiology to view the holding room after leaving Patient #1 in the CT holding area. Staff #10 reported he/she did not know when Staff #16 had taken Patient #1 into the CT scan room.

Staff #10 reported sometimes the emergency room staff cannot help with patients because they are to busy. Staff #10 reported it is not unusual for the radiology staff to have to move patients by themselves. Staff #10 reported one incident where "a drunk 21 year old" female was brought to Diagnostic Radiology and was difficult to move. Staff #10 reported he/she does not typically go over to the CT Scan Department at night due to the physical layout of the Radiology Department.

Review of the CT scan head films was conducted with Staff #3 and Staff #12 on May 28, 2014 at approximately 10:35 am. The review revealed the following information:

Head CT Scan without contrast ordered on Patient #1 at 12:31 am on January 13, 2014.
Audit trail documentation revealed Patient #1 arrived in CT Scan Department at 1:10 am on January 13, 2014 entered by Staff #16.
Audit trail documentation entered by Staff #16 revealed the examination began at 1:10 am on January 13, 2014.
Actual CT image of the head documentation reports first image taken on January 13, 2014 at 1:21.16.
Actual CT image of the head documentation reports last image taken on January 13, 2014 at 1:21.15.
Audit trail documentation revealed examination completed at 1:52 am entered by Staff #16 on January 13, 2014.

Staff #3 was asked about the time discrepancies while Patient #1 was in Diagnostic Radiology and CT Scan. Staff #3 reported the audit trail information can be entered after a test is completed. Staff #3 reported normally two staff members are present in the CT Scan Department on the night shift. Staff #3 reported the CT aide was "off the night of January 13, 2014." Staff #3 reported the CT aide who was off was of the same sex as Patient #1. Staff #3 reported the CT aide had been off for weeks (not in January) due to surgery.

Staff #14 was interviewed on May 28, 2014 and verified there were time discrepancies in Patient #1's medical record between the radiology times documented and the times documented in the nursing notes by Staff #11 and other emergency room nursing staff. Documentation by Staff #16 reports Patient #1's CT scan was completed at 1:52 am. Documentation by Staff #11 reports Patient #1 returned from x-ray at 1:20 am and was placed back on the cardiac monitor. Staff #14 reported these discrepancies were due to the incident with Patient #1. Staff #14 reported the nursing notes were not in live time. A Root Cause Analysis provided to the surveyors reported the time discrepancies were due to the difference in the hospital clocks.

Nursing note documentation by emergency room staff registered nurse dated January 13, 2014 at 1:21 am reports Patient #1 was observed trying to get out of bed. Upon entering the room the registered nurse documented Patient #1 stated "I need to talk to someone. I think I was just raped wherever I was just getting imaging done." Staff registered nurse (unavailable for interview at time of the complaint investigation) documented Staff #11 notified of Patient #1's statement. Staff registered nurse documentation at 1:25 am reports Patient #1 placed back on the monitor. Patient #1 reported I can see no one is going to take me seriously. Documentation by Staff #11 reports the charge nurse notified. Documentation by emergency room charge nurse indicates Staff #15 notified and on the way to the emergency room.

Documentation by emergency room charge nurse on January 13, 2014 at 1:40 am reports multiple police rushed into the emergency room at the above named facility looking for the patient in room #3. Documentation states "a patient just called us stating he/she has been assaulted."

Staff #11 documented a repeat blood draw for alcohol level at 2:05 am on January 13, 2014. Results dated January 13, 2014 at 2:28 am 344 mg/dl.

Documentation by emergency room charge nurse reports Patient #1 observed getting off stretcher at 2:31 am on January 13, 2014. Patient complaining of being anxious. A police officer of the same sex of Patient #1 present at Patient #1's bedside at 2:56 am.

Staff #11's documentation dated January 13, 2014 at 3:03 am reports Patient #1 voided and received special instructions per the police to aide in the preservation of potential evidence. Patient #1 escorted to the bathroom by the police and nursing staff. Urine collection labeled and all Patient #1's belongings labeled and given to the police.

Documentation by Staff #11 states Patient #1 transferred by the County Fire Department Emergency Medical Services with police to another Northern Virginia Hospital for a Sexual Assault Nurse Examination (SANE) at 3:25 am.

Staff #11 was interviewed on May 28, 2014 between 9:15 am and 9:50 am. Staff #11 confirmed he/she was Patient #1's primary nurse on January 12, 2014 and January 13, 2014. Staff #11 confirmed Patient #1 was changed into a patient gown and was given mesh underwear upon arrival in the emergency room. Staff #11 verified Patient #1 had stated he/she had been hurt by another person. Staff #11 confirmed there was concern about domestic violence. Staff #11 verified Patient #1 had some bruising on the left elbow but it was difficult to determine the age of the bruising. Staff #11 verified Patient #1 had a history of a fall the evening of January 12, 2014. Staff #11 reported Patient #1 was anxious and requesting a Klonopin. Staff #11 documented Patient #1 was given a Klonopin at 9:33 pm on January 12, 2014. Staff #11 reported Patient #1 was "in and out of it" all evening.
Staff #11 confirmed the documentation of Patient #1 vomiting and complaining of a "bad headache." Staff #11 reported Patient #1 had episode of unresponsiveness which required Patient #1 to be lowered to the floor. Staff #11 denied Patient #1 had fallen. Staff #11 confirmed he/she called for assistance to lift Patient #1 off the floor and place Patient #1 back into bed. Staff #11 reported he/she notified the emergency room doctor and a non contrast head CT scan was ordered. Staff #11 reported "felt something was not right and wanted to make sure Patient #1 did not have a head bleed." Staff #11 volunteered information during the interview that Patient #1 had belongings with him/her and Staff #11 wondered if Patient #1 had alcohol or Klonopin and may have taken some without the knowledge of the emergency room staff. Staff #11 reported Patient #1 kept his/her belongings. Staff #11 reported another staff member took Patient #1 to Diagnostic Radiology because he/she was busy with a very sick patient. Staff #11 reported the nurses do not typically stay with the patients while in the Radiology Department.

Staff #11 reported another emergency room staff member came and told him/her about Patient #1 saying he/she had been assaulted while in radiology. Staff #11 stated he/she called Staff #16 and asked him/her "tell me you are not over there alone." Staff #11 reported Staff #16 confirmed he/she was in the CT Scan Department working alone. Staff #11 confirmed it is believed Patient #1 notified the police. Staff #11 verified he/she only went into Patient #1's room to redraw the alcohol blood level once the police arrived at the facility. Staff #11 confirmed all linens, Patient #1's belongings and the containers of Patient #1's urine were given to the police as potential evidence prior to the transfer of Patient #1 to another Northern Virginia Hospital.

Staff #15 was interviewed on May 28, 2014 at 9:55 am. Staff #15 confirmed he/she worked the night of January 13, 2014. Staff #15 verified he/she was notified by the emergency room charge nurse of a "problem in the emergency room and needed to come to the emergency room right away." Staff #15 confirmed upon arrival in the emergency room there were "several county police in room #3." Staff #15 reported he/she was told by the emergency room charge nurse that Patient #1 had told an emergency room nursing staff member the assault took place in radiology wherever he/she had to be on his/her stomach. Staff #15 confirmed this was not said to him/her directly by the nurse who had spoken directly with Patient #1. Staff #15 reported he/she had no contact with Patient #1.