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Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to examine a patient who complained of sexual assault for 1 (#12) of 3 (#12, #18, #19) patients presenting with alleged assaults (see findings tag A-2406).

Based on record review and interview, the hospital's emergency department failed to provide an appropriate medical screening exam for 1 (#12) of 3 (#12, #18, #19) victims of sexual assault who presented to the emergency department from a total of 20 reviewed records.

Findings:

Review of the policy "Emergency Department EMTALA Guidelines," reviewed 04/29/2021, revealed in part, "All patients shall receive a medical screening exam that includes providing all necessary testing an on-call services within the capability of the hospital to reach a diagnosis."

Review of the Emergency Department visit on 11/19/2023 for Patient #12 revealed the following timeline:

2:20 p.m. - Arrival
2:22p.m. - Initial assessment by S5MD
2:31 p.m. - Triage
2:49 pm. - antibiotics ceftriaxone and doxycycline ordered
2:50 p.m. - specimen for urinalysis, STI and pregnancy test collected
3:22 p.m. - advocate contacted and in route to hospital
3:33 p.m. - antibiotic metronidazole ordered
3:36 p.m. - discharge ordered placed by S5MD and S5MD completed his documentation
4:28 p.m. - Sexual assault advocate at bedside
4:47 p.m. - Antibiotics administered- nurse notes delay due to "NO ER ROOM AVAILABLE."
5:30 p.m. - Discharge Instructions were signed

Review of the nursing triage notes from 11/29/2023 at 2:31 p.m. revealed the chief complaint on presentation was "sexual assault Tuesday (11/28/2023) at 0130. Pt worried about STD exposure. Head slammed into concrete and choked during assault. LPD contacted via telephone but did not follow up with pt." Vital signs documented at that time were temperature- 37 degrees Celsius, Pulse-97 beats per minute, respiratory rate- 18 breaths per minute, systolic blood pressure 158 mm hg, diastolic blood pressure- 104 mm Hg, mean arterial pressure- 122 mm HG, oxygen saturation- 100%.


Review of the physician's note from 11/29/2023 and signed at 3:36 p.m. revealed the following History of Present Illness:
The patient presents following alleged sexual assault. The onset was 36 hours ago. The location where the incident occurred was in the street. Circumstance: 1 assailant(s) penetration: vaginal assailant ejaculation. Type of injury: none. Location: vagina. The character of symptoms is none. Risk factors consist of none. Prior episodes: none. Therapy today: see nurses' notes. Associated symptoms: none. Drug facilitated Sexual Assault: alcohol consumed unknown. The last consensual intercourse was unknown. Post assault activities: urination, genital washing, showering or bathing, brushing teeth and changing clothes. Documentation: Police called and advocates called.


Further review of the physician's note from 11/29/2023 signed at 3:36 p.m. revealed the following physical examination:
General: Alert, no acute distress
Skin: warm, no rash
Head: Normocephalic, atraumatic
Neck: Supple, trachea midline, no tenderness, no JVD, no carotid bruit
Eye: pupils are equal, round and reactive to light, extraocular movements intact
Ears, nose, mouth, and throat: Tympanic membranes clear,oral mucosa moist, no pharyngeal erythema or exudate
Cardiovascular: Regular rate and rhythm. No murmur, Normal peripheral perfusion, No edems, no Tachycardia, no Bradycardia.
Respiratory: Lungs clear to auscultation, breath sounds are equal. Symmetrical chest wall expansion, respirations: Regular.
Chest wall: No tenderness, No deformity
Back: Nontender, Normal range of motion, Normal alignment
Musculoskeletal: Normal ROM, normal strength, no tenderness, no swelling, no deformity
Gastrointestinal: Soft, Nontender, Nondistended, Normal bowel sounds, No organomegaly.
Genitourinary: No tenderness
Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. CN II- XII intact, normal sensory observed, normal motor observed, normal speech observed.
Psychiatric: Cooperative, appropriate mood & affect

Review of the physician's impression and plan revealed, "Diagnosis: Sexual assault of adult; Trichomoniasis . . . Disposition: discharged: Time 11/29/2023 15:36:00, to home . . . Patient was given the following educational materials: Trichomoniasis . . . Follow up with: Follow up with primary care provider within 1 to 2 weeks. Counseled: Patient, Regarding diagnosis, Regarding diagnostic test results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions."

Review of the test results revealed the patient received a pregnancy test, a urinalysis and testing for chlamydia, gonorrhea and trichomonas. There was no testing for Hepatitis B, Hepatitis C, or HIV.

Review of the physician's notes and nursing notes failed to reveal documentation the staff inquired about possible depression, support systems, stress level, coping ability or the presence of traumatic sequelae ( panic attacks, changes in eating or sleeping patterns, or increased anxiety), other than the documented "Cooperative, appropriated mood & affect." There was no documentation the patient was counseled on possible sequelae such as flashbacks, panic attacks or the window between exposure and the detection of some sexually transmitted diseases. Further review failed to reveal her elevated blood pressure was addressed or attributed to the stress of the event.

Review of the discharge instructions revealed the patient was instructed to follow up with her primary care in 1 to 2 weeks and she was provided information about trichomonas and a list of medication. The reason for the follow up with the primary care physician was not given and the patient was not instructed that she would need to repeat the pregnancy test and have additional testing for hepatitis and HIV. The patient was not given a list of resources for mental health follow up.

At 4:32 p.m. S6RN documented, "SANE Advocate at bedside."

In interview on 12/11/2023 between 2:30 p.m. and 2:45 p.m., S1RN and S3RN verified the physician finished his note and exam before the advocate arrived and made no addendums to his assessments. S3RN verified genitourinary exam which documented, "No tenderness," did not specify what was not tender, did not identify what parts of the system were examined, and did not state if bruising or signs of trauma were or were not present. S3RN also verified there was no documentation the patient was given any information or resources for follow up after sexual assault such as the "Survivors Guide" for victims of sexual assault that was part the packet used when specimens were collected. S1RN and S3RN verified there were no instructions to follow up with the "City A" Police Department.

On 12/11/2023 at 3:00 p.m. S5MD was interviewed. S5MD stated the patient came to the emergency department for evaluation for possible sexually transmitted infections and the patient was evaluated and prophylactically treated for all the common sexually transmitted infections. S5MD verified he had experience with treating patients of sexual assault. S5MD verified his documentation in the physical examination of "No tenderness," was not adequate for an examination after a sexual assault, and his examination did not include documentation of the presence or absence of bruising, scratches, tears or swelling on the skin which would normally be evaluated after an assault. S5MD verified his examination did not reflect that an external genital examination was performed. S5MD stated he did perform an external examination of the genitalia, but did not document it. S5MD verified he did not do a speculum examination or a bimanual examination to assess for internal injuries because the patient changed her mind and refused the examination. S5MD verified he forgot to document the patient's refusal after having signed the consents for the examination and collection of specimen. S5MD verified he did not counsel the patient on follow up for sexually transmitted infections or provide emotional or mental health resources because he thought that was the job of the advocate.

On 12/12/2023 at 9:24 a.m., S6RN was interviewed via telephone. S6RN verified she was the charge nurse in the Emergency Department that afternoon. S6RN stated that Patient #12 was initially in the consult room, not an exam room, because the room for gynecological exams was not open. S6RN stated she did not move the patient out of the consult room and into the gynecological exam room until the sexual assault advocate arrived at 4:32 p.m. S6RN stated she did not stay in the room and does not know what happened when S5MD was in the room. S6RN verified her notes and the documented times were accurate and the physician had refused to perform the pelvic examination to collect specimen. S6RN said she was not aware of the physician later changing his mind and agreeing to perform the pelvic examination.

In interview on 12/12/2023 at 9:45 a.m., S3RN verified again that the documentation of "No tenderness," for the genitourinary exam did not identify what part of the body was not tender, what parts of the system were examined, and if there were signs of a sexual assault. . S3RN verified there was no documentation the patient refused collection of the evidence by the physician and no documentation the patient "self-collected." S3RN verified there was no documentation the physician had changed his mind and agreed to perform the pelvic examination and collection of specimen from the vagina.

In interview on 12/12/2023 at 9:50 a.m., S2RN verified that hospital administration had developed a plan for education about treating sexual assault victims for the medical staff and the nursing staff, but education had not yet been provided.