HospitalInspections.org

Based on record reviews and interviews of three patient records that included discharge summaries (Patient #1, Patient #2, and Patient #3) , it was determined that for two of three (Patient# 1 and Patient #2), patients, the physician failed to include recommendations for medical follow-up.

Findings included:

Record review on 08/12/15 of Patent #1's record reveled the physician ordered him to have a Sexual Assault Nurse Examination (SANE) due to Patient #1 and Patient #2 engaging in sexual activity. Patient #1 was transported on 05/27/15 by the city police to an acute care hospital to have the SANE exam.

Record review of the SANE consultation report, dated 05/27/15, revealed the following recommendations: "repeat RPR (Blood test for syphilis) and HIV (human immunodeficiency virus) in six weeks, three months, and six months. Call Center for Miracles for any concerns. Counseling Recommended."

Record review of Patient #1's Discharge Summary, dictated 06/18/15, did not contain the recommendations from the SANE exam.

Record review on 08/12/15 of Patient #2's Physician's Orders, dated 05/24/15 at 1000, revealed the physician orer patient to have a blocked room for sexual activity and was put on Sexual Acting Out-Victim precautions. Continued review of Physician's Orders, dated 05/;26/15 at 1822, revealed the physician ordered Patient #2 to be taken by city police and facility staff to have test (SANE) done then to be transported back to the facility.

Record review on 08/12/15 or Patient #2's Discharge Summary, dated 07/25/15, did not contain recommendations from the SANE consultation.

Interview at the exit conference on 08/19/15 with the facility Chief Nursing Officer (CNO) confirmed the Discharge Summary should have included the SANE recommendations for Patient #1 and Patient #2 but did not include the SANE recommendations.