HospitalInspections.org

Based on document review and interview, it was determined that in 1 of 1 clinical record reviewed with a documented allegation of sexual assault, the Hospital failed to ensure a root cause analysis (RCA) was initiated and completed promptly to identify causes and establish corrective action to help prevent reoccurrence and promote patient safety.

Findings include:

1. Hospital policy entitled, " Sentinel Events [Management of], effective 1/2010 " required, " An occurrence that meets any of the following criteria ... Rape ...All sentinel events shall be reported ... immediately ... The Chairperson of the Hospital Oversight Committee shall convene a special meeting to initiate review and investigation of the sentinel event, conduct the root cause analysis of the event and develop an action plan designed to implement improvements to reduce risk as soon as possible ... The root cause analysis will include a corrective action for each of the identified causes and contributing factors ... " The policy lacked requirements of a timeframe for initiation and completion.

2. The clinical record of Pt. #1 was reviewed on 5/8/13 and included that this was a 60-year-old female, admitted to the 6 East medical unit, room 6335A on 4/5/13 from the Emergency Department (ED), with a complaint of rectal bleeding, and a diagnosis of Diverticulitis. E#2 ' s (ED physician) note dated and timed 4/8/13 at 1:53 P.M. included documentation that the patient (Pt. #1) present following alleged sexual assault and requested to complete evaluation. " She states that the medical team discussed need for a Pap smear and rectal exam today during their rounds. A resident physician returned later to take her to an exam room. He placed her in a lithotomy position, examined her vagina and rectum with his fingers. She became alarmed when he then allegedly penetrated her vagina with his penis. She states she pushed him away, told him to stop, called for help, then tried to get out of the room ... "

3. E#4 (Stroger Police Chief) was interviewed on 5/8/13 at approximately 9:35 A.M., and E#4 stated he did not have results of the rape kit yet, as it often takes a while to result. The detective did a full and complete interview at the patient ' s (Pt. #1) home, and found her to be extremely credible.

E#4 further stated that the day after Pt. #1 ' s report, (4/9/13) there was a reference to a second report against Dr. (MD#1). The incident occurred in June 2012, and was reported to the police department in March 2013. The resident (MD #1) was working in Gastrointestinal Fantus Clinic. The detective interviewed this victim (Pt. #2) too. The detective found this witness to be credible also. All of this went to the States Attorney ' s Office. After assessing the victims and witnesses statements, the States Attorney decided to approve charges against Dr. (MD#1). However, E#4 was notified of an e-mail from MD#1, saying MD #1 was leaving the country.

4. During an interview on 5/7/13 at approximately 10:00 A.M. with E#18, Interim Quality Director, E#18 stated that the root cause analysis (RCA) had not yet been done, and that meeting was scheduled for that same day, 5/7/13.

Based on document review and interview, it was determined that in 1 of 1 clinical record reviewed with a documented allegation of sexual assault, the Hospital failed to ensure the patient had access to immediate crisis intervention counseling as required by policy.

Findings include:

1. Hospital policy entitled, "Identification and Management of Suspected Assault or Rape- Adult," (posting date 2/8/13) requires, "... Immediate crisis counseling is available 24 hours per day through Rape Victim Advocacy RVA), Psychiatry, or Social Services. The RVA counselor is paged when the patient is first identified. Such counseling provides a continuous means of support throughout the treatment process and may help the patient begin dealing with the immediate and long term physical, emotional, and social impacts of the assault by mobilizing the patient's personal resources and environmental supports."

2. The clinical record of Pt. #1 was reviewed on 5/8/13 and included that this was a 60-year-old female, admitted to the 6 East medical unit, room 6335A on 4/5/13 from the Emergency Department (ED), with a complaint of rectal bleeding, and a diagnosis of Diverticulitis. E#2 ' s (ED physician) note dated and timed 4/8/13 at 1:53 P.M. included documentation that the patient (Pt. #1) present following alleged sexual assault and requested to complete evaluation. " She states that the medical team discussed need for a Pap smear and rectal exam today during their rounds. A resident physician returned later to take her to an exam room. He placed her in a lithotomy position, examined her vagina and rectum with his fingers. She became alarmed when he then allegedly penetrated her vagina with his penis. She states she pushed him away, told him to stop, called for help, then tried to get out of the room ... "

3. A telephone interview with E#16 (RN/Case Manager) was conducted on 5/9/13 at approximately 8:20 A.M., and E#16 stated she spoke with Pt. #1 on April 8, who said the doctor (MD#1) almost raped her. Pt. #1 said she was told when the doctors were making rounds, that she would get a vaginal and rectal exam, and if they were clear, she (Pt. #1) would be discharged home. When the doctor (MD#1) came back, he didn't have on a labcoat or an ID, but since she had already seen him earlier in rounds, she went with him to the exam room. Pt. #1 said MD#1 did a rectal exam, then proceeded to do a vaginal exam. She (Pt. #1) heard his (MD#1) zipper and felt his penis.

E#16 said she was available as a patient advocate when the doctor (E#2) did the rape kit, to supervise the entire process and offer support to the patient; and explain what the doctor (E#2) and nurse (E#20) were doing, and why. E#16 admitted that she is not part of the Rape Victim Advocacy Team, and it would be out of her role to provide that counseling.

4. During an interview on 5/8/13 at approximately 3:00 P.M. with E#18, Interim Quality Director, E#18 verified that the clinical record of Pt. #1 lacked documentation that the Pt. #1 received crisis intervention counseling during hospitalization.