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CHRISTUS ST FRANCES CABRINI HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on record review and interview, the hospital failed to maintain a medical record for each patient that must be accurately written and completely documented as evidenced by failing to document an exam by the SANE (Sexual Abuse Nurse Examiner) for 6 of 6 patients presenting to the ED with a complaint of sexual assault (Patients #1, 3, 7, 9, 13, 16) in a total sample of 20.
Findings:
Review of the hospital policy titled, SANE Program/Activation Mechanism, revealed in part that when a patient with a complaint of a sexually oriented offense presents to the ED and has been medically cleared, if the patient agrees to the SANE, the charge nurse on duty will communicate with the SANE on call to perform an exam.
Review of the medical records for Patients #1, 3, 7, 9, 13 and 16 revealed they presented to the ED with complaints of sexual assault. Further review of the records revealed the SANE was contacted and was present during each visit. Review of the records revealed no documented evidence that an exam was performed by the SANE or that the patient consented or refused an exam by the SANE.
On 06/01/22 at 12:30 p.m., phone interview with S3PA stated that if a patient refuses the exam by the SANE, it should be noted in the patient's medical record.
On 06/01/22 at 2:40 p.m., interview with S2SANE RN confirmed that there was no documentation in the above patients' medical records that addressed the consent or refusal of an exam by the SANE.