HospitalInspections.org

Based on document review, interview and observation the facility failed to provide privacy and a safe environment resulting in an unsafe environment for patient #1 and potentially all patients seeking treatment in the emergency room department. Findings include:

On 8/13/2013 at approximately 1630 during document review of adverse event reports it was determined patient #1 was allegedly sexually assaulted by patient #2 on 6/3/2013 at approximately 0030 in the emergency room of the facility. A documented statement by ER staff RN #1 states she observed patient #2 with his hands down the undergarments of patient #1. When the ER staff RN #1 noticed patient #2 with his hands down patient #2's undergarments she shouted out "what do you think you are doing" and patient #2 was escorted by the security guards to another secured area. The statement of events from ER staff RN #1 was obtained and reviewed where it is written "the patient was not yelling, screaming, or pushing the other patient away from her person". The statement further states patient #1 had both hands placed on the side rail of the stretcher. The patient care area where patient #1 was assigned had the curtains pulled and was not in clear view. Additional statements from staff #N, O, P, Q, R and S stated they had been in the patient care area where patient #1 was located at the time of the alleged sexual assault.. Staff members #N, O, P, Q, R and S provided documented affidavit stating they never heard patient #1 call for help.

On 8/13/2013 at approximately 2030 patient #1 was interviewed via phone. When asked to explain the order of events that occurred patient #1 stated she had been brought to the facility because of back pain. She stated that patient #2 had been wandering the area in which she had been triaged to and approached her asking if she was in pain. She further explained he started rubbing her back and she had asked him to stop. She stated he then placed his hands down her underpants and his face in between her legs. She stated she had tried to push him away and yell out for help. She stated she thought of yelling "fire" but thought she would be prosecuted for doing so. She was then asked if she had a call light she could have used to summon help and she said "the emergency room (at the facility) does not have call lights."

On 8/14/2013 at approximately 0930 a second tour of the emergency room was conducted. During the tour a call light was noted in the window area of ER bay #36. The call light was not within reach of the patient laying on the stretcher in the bay. When the call light was activated, staff failed to answer the call light. At approximately 0956 on 8/14/2013 staff #I was asked what was expected of staff when call lights were activated by patients. Staff #I. stated "staff are expected to answer call lights in a prompt manner". Further observation and tour of the unit failed to show any call lights available for patients to use in ER bay numbers one through thirty-eight. Staff #T was asked why patients were not given call lights after being placed in a bay for treatment and it was stated "a patient safety initiative from our parent company had call lights removed from the ER bays in order to prevent self harm". Call lights in bays 11 through 22 were not found.