HospitalInspections.org

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Based on medical record review, document review and interview, the facility failed to ensure that (a) procedures were implemented to protect patients from all forms of abuse and (b) their Emergency Department Sexual Assault Policy was followed. This was evident in 2 (two) of 2 (two) medical records reviewed.

(See Tag 0145)

(See Tag 1104)


This failure to protect patients put all patients at risk for potential abuse and neglect.

Based on medical record review and interview the facility failed to implement their hospital-wide "Chaperone" protocols for all patients undergoing Radiology X-ray procedures. This was evident in five (5) of five (5) medical records reviewed (Patients #1, #2, #8, #9, and #10).


Findings:


Review of Occurrence Report, dated 08/20/16 at 5:20 PM, revealed patient #1, housed in the Emergency Room, reported to hospital employees that during an imaging procedure a sexual assault occurred by a Radiology Department X-Ray technician (Staff #F).

Review Occurrence Report, dated 08/20/16 at 5:30 PM, revealed patient #2, while housed in the Emergency Room, reported to hospital employees that during an imaging procedure sexual assault occurred by a Radiology Department X-Ray technician (Staff #F).

Interviews were conducted on 08/25/16 at 12:15 PM with Radiology Department Supervisors, Staff A (Associate Radiology Technologist I) and B (Associate Radiology Technologist II).

Staff A stated, we met informally on Monday (8/22/16) with our Assistant Director who debriefed us about a new chaperone protocol. We met again yesterday (8/24/16) and were told that "we are supposed to be doing it that way now. But we haven't been able to start doing it yet because we haven't really enough people."

Staff B stated on 8/25/16 at 12:36 PM, " I heard that there was an Email mentioning we ought to start doing the chaperone, but I haven't seen it yet."

On 8/26/16 at 9:45 AM the facility provided a typed document dated August 22nd 2016, authored by Staff C (Assistant Director Radiology Department) titled, "To Radiology Department from Radiology Administration regarding Department Changes regarding Chaperones for X-ray Exams." The document stated, "Please be advised that:

1.All exams for females and minors that may be performed by a male Technologist in all modalities whether in the E.R., on portables, or in the outpatient areas, must have a female chaperone in the room or in the area during the exam at all times.

2. During the portable exams, the Technologists must notify the floor upon arrival for the exam(s) and must request a female Nurse, PCT (Patient Care Technician), or Clerk in the room before and after the exam.

3. The name of the chaperone on the floor must be documented when closing the exam(s)."

A tour of the Radiology Department on 8/26/16 at 1:25 PM revealed Patients #8, #9 and #10 had all received portable x-rays on 8/26/16 and there was no documented evidence in the medical records of a Chaperone, as per Protocol.

During interview on 8/26/16 at 1:35 PM Staff A and B stated, "we don't have a way to document this information in the current (software) system we are working in, we don't have anywhere to put the information. There is no drop down and no way to free text the information."

These findings were confirmed with staff J (Director Quality Management) on 8/25/16 at 1:30 PM.

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Based on document review and interview the facility failed to follow the Emergency Department Sexual Assault Policy. This was found in 2 (two) of 2 (two) medical records reviewed. (Patients #1 and #2)


Findings:


Medical Record for Patient #2 revealed, on 08/20/16 at 4:30 PM, the patient reported to Emergency Department (ED) staff a sexual assault violation by a hospital worker.

The Sexual Assault Assessment Forms revealed missing and incomplete documentation. Specifically, there is no documented evidence of patient signed consent, an authorization release information, there is no provider signature authenticating the document, no evidence of a physical examination by provider, no documentation indicating the date or time of sexual assault, and no location of where the sexual assault had taken place.

On 8/20/16 at 9:19 PM the physician documented a disposition note from the ED and there was no documented evidence of a medical examination post sexual assault.

Medical Record for Patient #1 revealed, on 08/20/16 at 5:45 PM, the patient reported to Emergency Department (ED) staff a sexual assault violation by a hospital worker.

Review of the Sexual Assault Assessment Form for Patient #1 revealed the Provider recorded no documented time of sexual assault.

On 8/20/16 at 9:29 PM the physician documented a disposition note from the ED and there was no documented evidence of a medical examination post sexual assault.

The facility Policy titled, "Sexual Assault Procedures in Emergency Medicine" states, "This policy applies to all adult sexual assault victims to ensure that the survivor is medically treated. Obtain consent for treatment for medical exam and treatment. Forms to be completed are: signed consent, an authorization release information and medical examination (physical diagram) all Sexual Assault Assessment Forms are to be completed."

This was brought to the attention of Staff I (Senior Administrative Director, Patient Care Services) on 8/29/16 at 4:25 PM who acknowledged the finding.