HospitalInspections.org

Based on review of Medical Records (MR), facility policy and definitions, and interviews with staff, it was determined the facility failed to:

1. Report sexual assault to law enforcement for one patient presenting to the Emergency Department (ED).

2. Provide stabilizing treatment for a patient presenting to the ED.

These deficient findings did affect one of one MR's reviewed with a chief complaint of sexual assault, including Patient Identifier (PI) # 24, and one of seven MR's reviewed with a psychiatric complaint, including PI # 10, and had the potential to affect all patients served by the facility ED.

Findings Include:

Refer to A 2406 and A 2407 for findings.

Based on review of Medical Records (MR), facility policies and procedures, and interviews with staff, it was determined the facility failed to report alleged sexual assault to law enforcement for a patient presenting to the Emergency Department (ED) with a chief complaint of sexual assault.

This deficient practice affected Patient Identifier (PI) # 24, and had the potential to affect all patients served by the facility ED.

Findings include:

Facility Policy: Alleged Sexual Assault
Policy number: ED.001
Effective date: 2/3/2014

...Policy:

Victims of sexual assault are medically screened for injuries requiring immediate medical attention. If immediate medical treatment is not required, evidence should not be compromised. The patient, after obtaining consent, will be referred expeditiously to the on-call SANE (Sexual Assault Nurse Examiner) for an evidentiary exam.

Procedures:

1. Upon presentation of victim of alleged sexual assault, the patient is triaged and place in private room for initial evaluation to determine physical injuries requiring immediate treatment...

2. When the victim of an alleged sexual assault presents to the ER (Emergency Room) with or without appropriate law enforcement agency, and the following criteria is met, contact the on-call SANE.
...b. Victim wishes to pursue an evidentiary exam...
c. Consent is obtained from victim to contact the on-call SANE and appropriate law enforcement agency...

4. Contact appropriate law enforcement agency after obtaining consent...

7. In the case that immediate medical treatment is required follow above procedure, report is given to SANE that victim requires medical treatment and will remain in the Emergency Department. The SANE may come to the hospital for evidentiary exam, if so a private room will be provided and assistance from staff as needed...



39098

1. PI # 24 presented to the ED via EMS (Emergency Medical Service) ground on 6/8/22 at 11:52 AM with a chief complaint of Sexual Assault.

Review of the Triage Assessment dated 6/8/22 at 11:52 AM revealed the nurse documented, "...Patient states she wants a rape kit performed."

Review of the physician documentation dated 6/8/22 at 12:06 PM revealed the following, "...Patient has signs of trauma along the right side of her face, erythematous discoloration... erythematous discoloration and tenderness to palpation along the right posterior chest wall and flank region... does have some erythematous discoloration and abrasions along the right lateral lower leg... Patient was sexually assaulted this morning, she did admit to vaginal penetration... Patient is requesting a sexual assault kit to be collected...

Review of the physician orders dated 6/8/22 at 12:21 PM revealed orders including a CT (Computerized Tomography) Abdomen/ Pelvis without contrast, Stat (A common used medical abbreviation for urgent), CT Head without contrast, Stat, CT of Maxillofacial (Sinus) without contrast, Stat.

Review of the Patient Notes dated 6/8/22 at 12:50 PM revealed the following documentation by the nurse, "Spoke with SANE (Sexual Assault Nurse Examiner) RN (Registered Nurse) [Name] in regards to patient case. [Name] reports that patient can be advised to come to SANE center in Huntsville at time of discharge."

The patient was discharged at 5:24 PM with diagnoses including Alleged Sexual Assault, Physical Assault, Abrasion, Right Lower Leg, Facial Trauma, Contusion Chest Wall, and Contusion, Flank.

There was no documentation staff contacted appropriate law enforcement per policy. The patient remained in the ED for five hours and 32 minutes.

An interview was conducted on 10/13/22 at 3:48 PM with Employee Identifier (EI) # 2, Service Line Director for Clinical Excellence, who confirmed staff failed to contact law enforcement, per policy.

Based on review of Medical Records (MR), facility policy and definitions, and interviews with staff, it was determined the facility failed to provide stabilizing treatment for one of eight records reviewed with a disposition of home, and did affect Patient Identifier (PI) # 10, and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings include:

Decatur Morgan Hospital Policy: Medical Screening, Stabilization, and Transfer pursuant to EMTALA (Emergency Medical Treatment & Labor Act)
Policy Number: A.EM.001
Effective Date: May 2021

Definitions:

...7. Stabilization - within reasonable medical probability no deterioration of the patient condition is likely to result from, or occur during, transfer.

Huntsville Hospital Health System EMTALA Policy: General Requirements and Definitions
Policy Number: None
Effective Date: 8/29/22

...B. Definitions:

...18. Patient Disposition:

...The following are general terms and definitions used to describe the patient's disposition upon leaving the ED.

...iii. Discharged:

Patients who have received an MSE (Medical Screening Examination) and stabilizing treatment, and whose EMC (Emergency Medical Condition) has been stabilized or resolved. The patient may be discharged home, admitted to the hospital or transferred to another facility.



39098

1. Patient Identifier (PI) # 10 presented to the ED on 10/8/22 at 5:31 PM with a Chief Complaint of Psych (Psychiatric) High Risk. The physician also documented on 10/8/22 at 6:04 PM a Stated Complaint of Neck and Shoulder Pain Post Fall.

Review of the physician orders dated 10/9/22 at 12:01 AM, revealed an order for Shoulder, Left, RAD (Radiology), Stat (A common medical abbreviation for urgent).

A review of the Patient Notes dated 10/9/22 at 1:48 AM revealed the nurse documented "Patient c/o (complains of) L (left) shoulder pain and not being able to rest. Refer to MAR (Medication Administration Record) for further orders."

Review of the physician orders dated 10/9/22 at 1:44 AM revealed an order for Ketorolac 10 mg (milligrams) PO (by mouth) Now, one.

Review of the radiology report electronically signed and dated at 10/9/22 at 8:12 AM, revealed the following Impression: Fracture of the proximal humerus through the base of the greater tuberosity as described.

Further review of the ED visit documentation revealed no treatment or discussion with the patient regarding the fractured arm. The patient was discharged on 10/9/22 at 9:23 AM with a diagnosis of Major Depression.

An interview was conducted on 10/13/22 at 3:52 PM with Employee Identifier # 1, ED Director, who confirmed the patient was discharged to home without stabilizing treatment of the fractured arm.