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Based on review of hospital documents and interviews with staff the facility failed to ensure patient rights were exercised and met as evidenced by the failure to ensure all sexual assault survivors that presented to the ED were provided with transportation to a designated Forensic Examination facility for a sexual assault exam performed by a Sexual Assault Nurse Examiner (SANE).

Findings were:

A review of the hospital policy titled "Sexual Assault, ER 1.29, Policy Stat ID:5836335; Last Revised:01/2018" stated in part "PROCEDURE 4. ED RN will perform primary basic assessment and explain procedure for evidence collection and patient options regarding forensic exam and use of Certified Sexual Assault Nurse Examiner (SANE).
If patient would like the evidence collection to be performed by a Sexual Assault Nurse Examiner (SANE), the patient will be referred to a designated Forensic Examination hospital and the ED RN will document in the EHR utilizing the "Release of Sexual Assault to an Alternate Facility" form.

Designated Forensic Examination Facilities
1. Adult and Pediatric
a. Ben Taub Hospital: 713.873.8601

A review of the hospital policy titled "Complimentary Local Transportation, L-7, Policy Stat ID:5836335; Last Revised:01/2003", stated in part "PURPOSE: The purpose of this policy is to ensure, through the implementation of prudent and reasonable controls, that Tenet Facilities provide complimentary local transportation in a manner that:
A. Promotes greater access to medical care for patients living in a Tenet Facility's Service Area;
B. Promotes patient safety and ease of care;"
The policy also stated "C. Payment for complimentary local transportation shall be made with vouchers provided by a Tenet Facility."

An interview was conducted with day shift ED Charge RN, Staff #10 on 2/26/19 at approximately 1:50 pm in a hospital conference room. Staff #10 stated that "During the day shift we contact case management for cab vouchers. Overnight I know they have had difficulty with getting cab vouchers. At night it's a little more problematic for them. It was probably a case of not knowing who to go up the chain to. We need to figure out who will hold a few cab vouchers at night but the process has not yet been approved."

Based on review of documentation and interviews with the facility staff, and patient #1's daughter; the facility failed to protect the safety and rights of patient #1 causing mental anguish for the patient and his family. Patient #1 was transferred to the wrong SNF (skilled nursing facility).

Findings were:
Review of Patient's Rights and Responsibilities, 1.73, last revised 4/2017, 3. stated, "Rights and responsibilities are noted with the expectation that observation of these will contribute to more effective patient care and greater patient satisfaction." Policy ID 5270301,

Patient Care Discharge Planning stated, "identifying the patient/family needs and resources required for an effective and safe transition from the hospital to his/her discharge destination.

Physician Certification Form Statement for Ambulance Transport, 9/5/2018. Destination: Park Manor Cy Fair, Cypress Station. A line was drawn through Cy Fair.

Review of the MOT reveal patient #1 was to be transferred to Park Manor of Cypress Station. Report was given to staff nurse at Cypress Station per staff #14.

An interview was conducted with staff #14 RN, 2/26/19 1130 at the facility. Staff #14 said when she discharged patient#1 to SNF she reviewed the MOT form, called the receiving nurse listed gave report. Gave EMS the name, address and room number the patient was going to. At the time of the interview staff #14 reviewed copy of the MOT for patient #1, verified what was written. MOT stated transfer patient to Cypress Station Park Manor. The form was completed by case management.

An interview was conducted at ll05 2/26/19 at the facility with staff #6 CM. Staff #6 said they receive a call from patient #1 daughter asking where is my father, he is not here at Park Manor Cypress Station. After making calls, patient #1 was found at Park Manor Cy Fair, the wrong SNF. Staff #6 said she investigated but didn't know if EMS drivers got the addresses mixed up or the staff. Cypress Station Park Manor is where patient #1 should have been taken. Park Manor Cy Fair is where the patient was taken. The surveyor asked staff #6 what is the policy for transferring patients to SNF? Staff #6 said they do not have a policy for discharges to SNF. The process is for case managers to complete an MOT form, place in the medical record so the nurse completing the discharge can give report to the receiving facility, give the room number to EMS. During the interview the finding were confirmed by staff #6.

Based on review of hospital documents and staff interviews the facility failed to ensure registered nurses supervised and evaluated the nursing care for each sexual assault survivor that presented to the ED as evidenced that 1 of 5 ED RNs did not follow hospital policies and hospital training related to nursing care to sexual assault survivors that presented to the ED.

Findings were:

A review of the hospital policy titled "Sexual Assault, ER 1.29, Policy Stat ID:5836335; Last Revised:01/2018" stated in part "POLICY 1. The ED will provide care for the sexual assault patient. 3. The ED Provider is responsible for an evaluation of all bodily injuries associated with the assault and the ED RN will be responsible for evidence collected and documentation of same." The policy also stated "PROCEDURE ...4. ED RN will perform primary basic assessment and explain procedure for evidence collection and patient options regarding forensic exam and use of Certified Sexual Assault Nurse Examiner (SANE).
5. If the patient chooses not to receive evidence collection from a SANE RN, the designated ED nurse will collect basic evidence utilizing the sexual assault evidence collection kit. The designated ED nurse is one who has completed the Forensic Evidence Collection EDU which satisfies the Texas Board of Nursing requirements in Board Rule 216.3(d)(1)."

A review of the hospital document titled "Evidence Collection and Preservation in Sexual Assault Exam Performance Checklist" performed on the afternoon of 2/26/19 revealed
a signed "Sexual Assault Exam Competency Validation" for ED RN Staff #8 dated 2/24/17.

An interview was conducted with ED RN Manager, Staff #4 on 02/25/19 at approximately 3:35pm in his office. He was asked if the hospital ED had a designated RN that performed basic forensic evidence collection on sexual assault survivors. He stated that the ED charge nurses would be the staff that performed the collection.

A telephonic interview was conducted with Night Shift ED RN Staff #8 on 2/26/19 9:34 am. Staff #8 was asked if she remembered a sexual assault patient she was assigned to that needed transportation to Ben Taub forensic clinic for an evidence collection exam. Staff #8 stated she did not remember the specific case. Staff #8 was asked if there was a designated ED RN to collect basic forensic evidence if a sexual assault survivor chooses to have the forensic evidence collected in the hospital ED. She stated that Houston Northwest Hospital did not have a designated nurse to collect basic forensic evidence. She stated she had never performed a basic forensic evidence collection on a sexual assault survivor.

An interview was conducted with ED RN Charge Staff #10 on 2/26/19 at 1:50 pm in a hospital conference room. Staff #10 stated "I let them know that we can perform the evidence collection but there is more to the test than just evidence collection. It was probably a case of not knowing who to go up the chain to."

Based on review of documentation and interviews with the staff, the facility failed to provide an effective and safe transition from the hospital to the SNF for patient #1. Patient #1 was transferred to the wrong SNF.

Findings were:
Review of Discharge planning and information form 9/5/2018, 1912 stated, receiving facility accepting transfer Park Manor of Cy Fair.
Review of discharge Summary 9/5/18 1739, disposition: case management made referral to SNF. Patient accepted by Park Manor Cy Fair. Transfer to Park Manor of Cy Fair SNF. Discharge document/instructions 9/5/18, transfer to another facility. Receiving Facility Accepting transfer: Park Manor Cy Fair.
Policy ID 5270301, Patient Care Discharge Planning stated, "identifying the patient/family needs and resources required for an effective and safe transition from the hospital to his/her discharge destination.

An interview was conducted at ll05 2/26/19 at the facility with staff #6 CM. Staff #6 said they receive a call from patient #1 daughter asking where is my father he is not here at Park Manor Cypress Station. After making calls, patient #1 was found at Park Manor Cy Fair, the wrong SNF. Staff #6 said she investigated but didn't know if EMS drivers got the addresses mixed up or the staff. Cypress Station Park Manor is where patient #1 should have been taken. Park Manor Cy Fair is where the patient was taken.

The surveyor asked staff #6 what is the policy for transferring patients to SNF? Staff #6 said they do not have a policy for discharges to SNF. The process is for case managers to complete an MOT form, place in the medical record so the nurse completing the discharge can give report to the receiving facility, give the room number to EMS. During the interview the finding were confirmed by staff #6.