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Based on record review and interview the hospital failed to ensure the Condition of Participation for Patient Rights was met by:

1) failing to ensure the Registered Nurse assessed the need to obtain a Social Worker consult for a patient with visible signs of emotional distress after disclosing that she had been sexually assaulted in the hospital for 1 of 1 patients (#1);
2) failing to ensure a patient was assessed for possible injuries (physical and psychological) after complaining of being sexually assaulted by a Registered Nurse employed by the hospital for 1 of 1 patients (#1);
3) failing to ensure a patient's attending physician was promptly notified when a patient complained of being sexually assaulted by a Registered Nurse that worked in the hospital for 1 of 1 patients (#1);
4)failing to develop, approve, and implement a hospital wide policy relative to patient abuse that occurs in the hospital to include a definition of abuse, reporting of abuse by staff within the hospital, investigating the abuse to include the procedures to follow, protecting the patient during the investigation from the alleged abuser, and reporting of the abuse to appropriate agencies as required by La. R.S. (Louisiana Revised Statute) 2009.20 ET SEQ.
(See findings Cited at Q0145).

Based on record review and interview, the hospital failed to ensure all patients were free from all forms of abuse and harassment by: 1) failing to ensure a patient was assessed for possible injuries (physical and psychological) after complaining of being sexually assaulted by a Registered Nurse employed by the hospital for 1 of 1 patients (#1); 2) failing to ensure a patient's attending physician was promptly notified when a patient complained of being sexually assaulted by a Registered Nurse that worked in the hospital for 1 of 1 patients (#1); 3) failing to ensure the Registered Nurse assessed the need to obtain a Social Worker consult for a patient with visible signs of emotional distress after disclosing that she had been sexually assaulted in the hospital for 1 of 1 patients (#1); 4) failing to develop, approve, and implement a hospital wide policy relative to patient abuse that occurs in the hospital to include a definition of abuse, reporting of abuse by staff within the hospital, investigating the abuse to include the procedures to follow, protecting the patient during the investigation from the alleged abuser, and reporting of the abuse to appropriate agencies as required by La. R.S. (Louisiana Revised Statute) 2009.20 ET SEQ. Findings:

1) failing to ensure a patient was assessed for possible injuries (physical and psychological) after complaining of being sexually assaulted by a Registered Nurse employed by the hospital for 1 of 1 patients (#1).
During a face to face interview on 9/15/2010 at 2:50 p.m., Emergency Department Charge Nurse S34 was asked to describe the procedure for handling patients that allege sexual assault. S34 indicated the assessment of sexual assault survivors included the patient's description of the incident. S34 further provided the surveyor with a form titled, "Medical Exam for Sexual Assault" which she indicated was the hospital's guide for completing a sexual assault assessment. Review of the form revealed (in part) a section titled, "History of Incident: Briefly note general circumstances; Date and time of incident; Type of sexual contact: Genital, Oral, Anal, Physical Abuse other than sexual; Vaginal or rectal bleeding since incident. . . Physical Exam: General Description; Physical and Emotional Status; General Body Surfaces: Torn clothing. . . Description of Trauma: Indicate a abrasions, lacerations, contusions, hematomas, burns and marks of hands, belts, ropes, etc. . Do fingernails have dirt, blood, debris underneath?"
During a face to face interview on 9/16/2010 at 7:15 a.m., Registered Nurse S36 indicated she had been informed by Patient #1 in the presence of the patient ' s sister on 9/07/2010 around 10:00 p.m. that Patient #1 had been inappropriately touched by Registered Nurse S1. S36 further indicated Patient #1 indicated S1 had kissed her and fondled her breast and vagina. S36 confirmed that she had not documented the complaint in Patient #1 ' s medical record and had not performed a re-assessment of the patient ' s physical and/or mental status after the alleged incident of sexual assault (sexual contact without the explicit consent of the recipient: fondling).
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. S5 further indicated when Patient #1 had indicated that S1 had "touched her below", that she had not clarified whether it was above the blanket, below the blanket/underclothes, or if there had been any vaginal penetration. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 further indicated she had not performed a nursing assessment on Patient #1 after the report of sexual assault by Registered Nurse S1. S5 indicated she (S5) had not thought to do a nursing assessment on Patient #1. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or that a nursing assessment post allegation of sexual assault had been performed.
2) failing to ensure a patient's attending physician was promptly notified when a patient complained of being sexually assaulted by a Registered Nurse that worked in the hospital for 1 of 1 patients (#1).
During a face to face interview on 9/16/2010 at 7:15 a.m., Registered Nurse S36 indicated she had been informed by Patient #1 in the presence of the patient ' s sister on 9/07/2010 around 10:00 p.m. that Patient #1 had been inappropriately touched by Registered Nurse S1. S36 further indicated Patient #1 indicated S1 had kissed her and fondled her breast and vagina. S36 indicated she had not informed the patient ' s physician of the alleged sexual assault of Patient #1.
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. who alleged that she had been sexually assaulted by Registered Nurse S1 on 9/06/2010.S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 further indicated she had not notified the patient ' s (#1 ' s) physician of the allegation of sexual assault by Registered Nurse S1. S5 indicated she (S5) had not called the patient ' s (#1 ' s) physician because the patient had made it clear (verbally) that she did not want anyone to know what had happened to her. S5 confirmed that the physician would not have been afforded the opportunity to order Social Services Consult, Medication, and/or a Sexual Assault Exam without having knowledge of the alleged incident. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or notification of the patient ' s physician of the alleged sexual assault.
During a face to face interview on 9/16/2010 at 10:00 a.m., Chief Medical Officer S26 indicated as a physician he would expect to be called in the event that a patient under his care claimed to be sexually assaulted.
3) failing to ensure the Registered Nurse assessed the need to obtain a Social Worker consult for a patient with visible signs of emotional distress after disclosing that she had been sexually assaulted in the hospital for 1 of 1 patients (#1).
During a face to face interview on 9/15/2010 at 3:05 p.m., Case Management Director S35 and Licensed Certified Social Worker S40 indicated they had no recall of ever working with Patient #1. Both indicated a patient that had been sexually assaulted should be offered aftercare counseling and/or crime victim services upon discharge from the facility. S40 indicated that physicians could order a psychiatric consult if they felt any sexual assault survivor was in need of immediate attention; as evidenced by suicidal ideation, homicidal ideation, or significant symptoms of anxiety/depression.
During a face to face interview on 9/15/2010 at 2:50 p.m., Emergency Department Charge Nurse S34 indicated that patients that present to the Emergency Department complaining of sexual assault are examined by a nurse and a physician. S34 indicated all sexual assault patients seen in the Emergency Department were assessed and treated for their physical and mental well being. S34 indicated patients were provided with a handout that listed Social Service Resources available for follow-up treatment as needed. S34 indicated Emergency Department nursing staff would not want any sexual assault patient to be sent out (discharged) without a list of resources.
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. who alleged that she had been sexually assaulted by Registered Nurse S1 on 9/06/2010. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 confirmed that she had not consulted Social Services or Case Management and that Patient #1 had not been provided any support service programs for follow-up at the time of her discharge from the hospital on 9/08/2010. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or social service referrals for psychological support as needed upon discharge.
Review of the hospital policy titled, " Sexual Assault, 3790 " presented by the hospital as their current policy revealed in part, " victims of rape, attempted rape, carnal knowledge, or crime against nature presenting to the emergency Room will have treatment in an appropriate manner. All victims will be provided physical, emotional, and psychosocial treatment during the Emergency Room visit and after discharge. . . The patient will be placed in a safe room as soon as possible. . . An assessment will be completed by the RN to include both subjective and objective data. . . Offer the patient support services by contacting Social Services. " Review of the hospital form titled, " Medical Exam for Sexual Assault " attached to policy 3790 revealed in part, " History of Incident: Briefly not general circumstances, Date and time of incident, type of sexual contact: Genital, Oral, Anal. . . Physical Exam: Physical and Emotional Status. . . Treatment: Venereal disease prevention, Prevention of possible pregnancy. . . Disposition: Social Services. . . "
Review of Reference Material presented by the hospital as available to their emergency department staff titled, " Sexual Assault, 6th Edition of Emergency Nursing Principals and Practice " revealed in part, " Sexual assault can be defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient, including such activities as forced sexual intercourse, sodomy, child molestation, incest, fondling, and attempted rape. . . In a landmark study of 94 rape victims, Burgess and Holmstrom first identified rape-trauma syndrome, a cluster of symptoms experience by survivors of sexual assault. Symptoms include somatic, behavioral, and psychological reactions. The framework of rape-trauma syndrome includes recognition of the long term reorganization a survivor goes through when recovering from the assault. Reorganization may take weeks or even years. . . The extent of emotional injury cannot be estimated. Each person ' s response to a sexual assault is different. Individuals may laugh, cry, tell a joke, or become catatonic. Patients may blame themselves for fighting back or for not fighting back. Inform the patients that their actions helped get them through the ordeal, regardless of what action was taken. Patients may believe they caused the rape. . . Remind these patients that they have the right to decide what to do with their own bodies and that no one has the right to hurt them. . . A head to toe physical assessment is completed to assess for all injuries "
Review of the hospital policy titled, " Assessment/Reassessment, #PC-033 " presented by the hospital as their current policy revealed in part, " Interdisciplinary Plan of Care: 3. The RN (Registered Nurse) will consult interdisciplinary team members for identified patient problems. The consulted department/individual should then proceed with an appropriate assessment, as indicated by the standards of practice for that discipline. " Risk Manager S4 indicated the intent of this policy includes the notification of physicians by nursing staff regarding any significant change in condition.
4) failing to develop, approve, and implement a hospital wide policy relative to patient abuse that occurs in the hospital to include a definition of abuse, reporting of abuse by staff within the hospital, investigating the abuse to include the procedures to follow, protecting the patient during the investigation from the alleged abuser, and reporting of the abuse to appropriate agencies as required by La. R.S. (Louisiana Revised Statute) 2009.20 ET SEQ.

Patient #1 was allegedly sexually abused while hospitalized by a Registered Nurse, and the hospital, after becoming knowledgeable of the allegation of abuse, failed to have a process outlined in a policy to follow to initiate a comprehensive investigation of the incident, remove the nurse from working in the hospital, and immediately, according to state law, report the abuse within 24 hours of becoming knowledgeable of the abuse.

The following staff were interviewed: Risk Manager S4 on 9/13/2010 at 3:00 p.m., Director of Nursing S33 on 9/16/2010 at 7:55 a.m., and Chief medical Officer S26 on 9/16/2010 at 10:00 a.m. All interviewed confirmed there was no hospital policy regarding "Patient Abuse" S4, S26, and S33 were unable to produce a policy that included a process outlined in policy to initiate a comprehensive investigation of the incident, remove the nurse from working in the hospital, and immediately, according to state law, report the abuse within 24 hours of becoming knowledgeable of the abuse.









25892

Based on record review and interview the hospital failed to ensure a Registered Nurse supervise and evaluate the nursing care for each patients as evidenced by: 1) failure to ensure a patient was assessed for possible injuries (physical and psychological) after complaining of being sexually assaulted by a Registered Nurse employed by the hospital for 1 of 1 patients (#1). 2) failure to ensure a patient's attending physician was promptly notified when a patient complained of being sexually assaulted by a Registered Nurse that worked in the hospital for 1 of 1 patients (#1), and 3) failing to ensure the Registered Nurse assessed the need to obtain a Social Worker consult for a patient with visible signs of emotional distress after disclosing that she had been sexually assaulted in the hospital for 1 of 1 patients (#1). Findings:
Review of Reference Material presented by the hospital as available to their emergency department staff titled, " Sexual Assault, 6th Edition of Emergency Nursing Principals and Practice " revealed in part, " Sexual assault can be defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient, including such activities as forced sexual intercourse, sodomy, child molestation, incest, fondling, and attempted rape.
1) failure to ensure a patient was assessed for possible injuries (physical and psychological) after complaining of being sexually assaulted by a Registered Nurse employed by the hospital for 1 of 1 patients (#1):
During a face to face interview on 9/15/2010 at 2:50 p.m., Emergency Department Charge Nurse S34 was asked to describe the procedure for handling patients that allege sexual assault. S34 indicated the assessment of sexual assault survivors included the patient's description of the incident. S34 further provided the surveyor with a form titled, "Medical Exam for Sexual Assault" which she indicated was the hospital's guide for completing a sexual assault assessment. Review of the form revealed (in part) a section titled, "History of Incident: Briefly note general circumstances; Date and time of incident; Type of sexual contact: Genital, Oral, Anal, Physical Abuse other than sexual; Vaginal or rectal bleeding since incident. . . Physical Exam: General Description; Physical and Emotional Status; General Body Surfaces: Torn clothing. . . Description of Trauma: Indicate a abrasions, lacerations, contusions, hematomas, burns and marks of hands, belts, ropes, etc. . Do fingernails have dirt, blood, debris underneath?"
During a face to face interview on 9/16/2010 at 7:15 a.m., Registered Nurse S36 indicated she had been informed by Patient #1 in the presence of the patient ' s sister on 9/07/2010 around 10:00 p.m. that Patient #1 had been inappropriately touched by Registered Nurse S1. S36 further indicated Patient #1 indicated S1 had kissed her and fondled her breast and vagina. S36 confirmed that she had not documented the complaint in Patient #1 ' s medical record and had not performed a re-assessment of the patient ' s physical and/or mental status after the alleged incident of sexual assault (sexual contact without the explicit consent of the recipient: fondling).
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. S5 further indicated when Patient #1 had indicated that S1 had "touched her below", that she had not clarified whether it was above the blanket, below the blanket/underclothes, or if there had been any vaginal penetration. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 further indicated she had not performed a nursing assessment on Patient #1 after the report of sexual assault by Registered Nurse S1. S5 indicated she (S5) had not thought to do a nursing assessment on Patient #1. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or that a nursing assessment post allegation of sexual assault had been performed.
2) failure to ensure a patient's attending physician was promptly notified when a patient complained of being sexually assaulted by a Registered Nurse that worked in the hospital for 1 of 1 patients (#1):
During a face to face interview on 9/16/2010 at 7:15 a.m., Registered Nurse S36 indicated she had been informed by Patient #1 in the presence of the patient ' s sister on 9/07/2010 around 10:00 p.m. that Patient #1 had been inappropriately touched by Registered Nurse S1. S36 further indicated Patient #1 indicated S1 had kissed her and fondled her breast and vagina. S36 indicated she had not informed the patient ' s physician of the alleged sexual assault of Patient #1.
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. who alleged that she had been sexually assaulted by Registered Nurse S1 on 9/06/2010.S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 further indicated she had not notified the patient ' s (#1 ' s) physician of the allegation of sexual assault by Registered Nurse S1. S5 indicated she (S5) had not called the patient ' s (#1 ' s) physician because the patient had made it clear (verbally) that she did not want anyone to know what had happened to her. S5 confirmed that the physician would not have been afforded the opportunity to order Social Services Consult, Medication, and/or a Sexual Assault Exam without having knowledge of the alleged incident. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or notification of the patient ' s physician of the alleged sexual assault.
During a face to face interview on 9/16/2010 at 10:00 a.m., Chief Medical Officer S26 indicated as a physician he would expect to be called in the event that a patient under his care claimed to be sexually assaulted.
3) failing to ensure the Registered Nurse assessed the need to obtain a Social Worker consult for a patient with visible signs of emotional distress after disclosing that she had been sexually assaulted in the hospital for 1 of 1 patients (#1):
During a face to face interview on 9/15/2010 at 3:05 p.m., Case Management Director S35 and Licensed Certified Social Worker S40 indicated they had no recall of ever working with Patient #1. Both indicated a patient that had been sexually assaulted should be offered aftercare counseling and/or crime victim services upon discharge from the facility. S40 indicated that physicians could order a psychiatric consult if they felt any sexual assault survivor was in need of immediate attention; as evidenced by suicidal ideation, homicidal ideation, or significant symptoms of anxiety/depression.
During a face to face interview on 9/15/2010 at 2:50 p.m., Emergency Department Charge Nurse S34 indicated that patients that present to the Emergency Department complaining of sexual assault are examined by a nurse and a physician. S34 indicated all sexual assault patients seen in the Emergency Department were assessed and treated for their physical and mental well being. S34 indicated patients were provided with a handout that listed Social Service Resources available for follow-up treatment as needed. S34 indicated Emergency Department nursing staff would not want any sexual assault patient to be sent out (discharged) without a list of resources.
During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. who alleged that she had been sexually assaulted by Registered Nurse S1 on 9/06/2010. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 confirmed that she had not consulted Social Services or Case Management and that Patient #1 had not been provided any support service programs for follow-up at the time of her discharge from the hospital on 9/08/2010. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault or social service referrals for psychological support as needed upon discharge.
Review of the hospital policy titled, " Sexual Assault, 3790 " presented by the hospital as their current policy revealed in part, " victims of rape, attempted rape, carnal knowledge, or crime against nature presenting to the emergency Room will have treatment in an appropriate manner. All victims will be provided physical, emotional, and psychosocial treatment during the Emergency Room visit and after discharge. . . The patient will be placed in a safe room as soon as possible. . . An assessment will be completed by the RN to include both subjective and objective data. . . Offer the patient support services by contacting Social Services. " Review of the hospital form titled, " Medical Exam for Sexual Assault " attached to policy 3790 revealed in part, " History of Incident: Briefly not general circumstances, Date and time of incident, type of sexual contact: Genital, Oral, Anal. . . Physical Exam: Physical and Emotional Status. . . Treatment: Venereal disease prevention, Prevention of possible pregnancy. . . Disposition: Social Services. . . "
Review of Reference Material presented by the hospital as available to their emergency department staff titled, " Sexual Assault, 6th Edition of Emergency Nursing Principals and Practice " revealed in part, " Sexual assault can be defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient, including such activities as forced sexual intercourse, sodomy, child molestation, incest, fondling, and attempted rape. . . In a landmark study of 94 rape victims, Burgess and Holmstrom first identified rape-trauma syndrome, a cluster of symptoms experience by survivors of sexual assault. Symptoms include somatic, behavioral, and psychological reactions. The framework of rape-trauma syndrome includes recognition of the long term reorganization a survivor goes through when recovering from the assault. Reorganization may take weeks or even years. . . The extent of emotional injury cannot be estimated. Each person ' s response to a sexual assault is different. Individuals may laugh, cry, tell a joke, or become catatonic. Patients may blame themselves for fighting back or for not fighting back. Inform the patients that their actions helped get them through the ordeal, regardless of what action was taken. Patients may believe they caused the rape. . . Remind these patients that they have the right to decide what to do with their own bodies and that no one has the right to hurt them. . . A head to toe physical assessment is completed to assess for all injuries "
Review of the hospital policy titled, " Assessment/Reassessment, #PC-033 " presented by the hospital as their current policy revealed in part, " Interdisciplinary Plan of Care: 3. The RN (Registered Nurse) will consult interdisciplinary team members for identified patient problems. The consulted department/individual should then proceed with an appropriate assessment, as indicated by the standards of practice for that discipline. " Risk Manager S4 indicated the intent of this policy includes the notification of physicians by nursing staff regarding any significant change in condition.




25892

25892

Based on record review and interview the hospital failed to ensure a patient's plan of care was updated in response to emotional distress exhibited by a patient after alleging that she had been sexually assaulted in the hospital by a Staff Registered Nurse for 1 of 1 patients (#1) that was still located in the hospital as an inpatient at the time of the allegation out of a sample of three patients that complained of being sexually assaulted while a patient in the hospital (Patient #1 made an allegation of sexual assault on 9/08/2010 while still an inpatient of the hospital. Patient #2's daughter called on 9/10/2010 and made an allegation of sexual assault of Patient #2 (deceased) that allegedly occurred during her 3/12/2010 through 3/25/2010 admission admission to the hospital. Patient #6 called the hospital on 9/15/2010 and made an allegation of sexual assault that allegedly occurred during an admission to the hospital in April 2010). Findings:

Review of Patient #1's "Patient Care Plan Report" revealed no documented evidence of the problem of emotional-distress being identified or any interventions to be utilized by staff in the treatment of emotional-distress.

During a face to face interview on 9/16/2010 at 8:20 a.m., Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. who alleged that she had been sexually assaulted by Registered Nurse S1 on 9/06/2010. S5 indicated Patient #1 had initially disclosed the allegation of sexual assault to Registered Nurse S36 and House Supervisor S27 on 9/07/2010 around 10:30 p.m. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 indicated Patient #1 had obvious signs of emotional distress regarding the alleged incident.
During a face to face interview on 9/16/2010 at 8:38 a.m., Unit Director S5 confirmed there was no update to Patient #1's care plan regarding obvious emotional distress after complaining of sexual assault on 9/07/2010 at 10:30 p.m. S5 indicated she had not thought to update the patient's care plan because the patient had expressed a desire to keep the incident private.

25892

Based on record review and interview the hospital failed to ensure all medical records were accurately written and completed by failing to document in the medical record all assessments and treatments that were provided by the hospital for a patient who had complained of sexual abuse while admitted to the hospital for 1 of 1 patient medical records reviewed for sexual abuse in a total sample of 9 patients medical records reviewed for sexual abuse documentation. (Patient #1)
Findings:

Review of the medical record for Patient #1 revealed she was admitted with a diagnosis of Mastoiditis and MRSA (Methicillin Resistant Staphylococcus Aureus) Sepsis on 08/21/10. Review of the entire medical record for Patient #1 revealed no documented evidence that the patient had complained of sexual abuse or had been sexually abused during her hospital stay from 08/21/10 through 09/08/2010.

In interview on 09/13/10 at 2:55 p.m. Risk Manager S4 indicated that she interviewed Patient #1 on 09/08/10 at 11:00 a.m. regarding allegations of sexual abuse. S4 indicated that Patient #1 reported that Registered Nurse S1 told her dirty jokes and asked if he could have a kiss if he was able to get blood from her PICC line. S4 indicated that Patient #1 reported that Registered Nurse S1 kissed her and put his tongue in her mouth after he was able to draw the blood. Patient #1 also reported that Registered Nurse S1 had also fondled her breast during the night shift on 09/06/10. S4 indicated that Patient #1 was embarrassed by what had occurred and did not want the hospital staff to be made aware of what had happened. S4 confirmed the above incident was not documented in the patient's medical record.

During a face to face interview on 09/16/2010 at 7:15 a.m., Registered Nurse S36 indicated she had been informed by Patient #1 in the presence of the patient ' s sister on 09/07/2010 around 10:00 p.m. that Patient #1 had been inappropriately touched by Registered Nurse S1. S36 further indicated that Patient #1 indicated S1 had kissed her and fondled her breast and vagina. S36 confirmed that she had not documented the complaint in Patient #1 ' s medical record and had not performed or documented a re-assessment of the patient ' s physical and/or mental status after the alleged incident of sexual assault (sexual contact without the explicit consent of the recipient: fondling). Further S36 indicated she had not informed the patient ' s physician of the patient ' s sexual abuse allegation and documented this notification in the medical record.

During a face to face interview on 9/16/2010 at 8:20 a.m., Medical/Surgical Unit Director S5 indicated she took a statement from Patient #1 on 9/08/2010 at 9:00 a.m. S5 further indicated when Patient #1 had stated that Registered Nurse S1 had fondled her below in the vaginal area. S5 described Patient #1 as having the blanket pulled over her head and crying as she disclosed the incident. S5 further indicated she had not performed a nursing assessment nor had she notified the Patient #1's physician of the allegation of sexual assault by Registered Nurse S1. S5 indicated that she had not thought to do a nursing assessment on Patient #1 at the time of the allegation. S5 indicated that did not call the patient ' s (#1 ' s) physician because the patient had made it clear (verbally) that she did not want anyone to know what had happened to her. S5 confirmed that the physician would not have been afforded the opportunity to order Social Services Consult, Medication, and/or a Sexual Assault Exam without having knowledge of the alleged incident. S5 confirmed that she had not consulted Social Services and that Patient #1 had not been provided any support service programs for follow-up at the time of her discharge from the hospital on 9/08/2010. S5 confirmed the absence of any documentation in Patient #1 ' s medical record indicating the complaint of sexual assault, a nursing assessment post allegation of sexual assault, notification of the patient ' s physician of alleged sexual assault, or social service referrals for psychological support as needed upon discharge.

Review of the hospital policy titled, " Sexual Assault, 3790 " presented by the hospital as their current policy revealed in part, " victims of rape, attempted rape, carnal knowledge, or crime against nature presenting to the emergency Room will have treatment in an appropriate manner. All victims will be provided physical, emotional, and psychosocial treatment during the Emergency Room visit and after discharge. . . The patient will be placed in a safe room as soon as possible. . . An assessment will be completed by the RN to include both subjective and objective data. . . Offer the patient support services by contacting Social Services. " Review of the hospital form titled, " Medical Exam for Sexual Assault " attached to policy 3790 revealed in part, " History of Incident: Briefly not general circumstances, Date and time of incident, type of sexual contact: Genital, Oral, Anal. . . Physical Exam: Physical and Emotional Status. . . Treatment: Venereal disease prevention, Prevention of possible pregnancy. . . Disposition: Social Services. . . "

Review of the hospital policy titled, " Assessment/Reassessment, #PC-033 " presented by the hospital as their current policy revealed in part, " Interdisciplinary Plan of Care: 3. The RN (Registered Nurse) will consult interdisciplinary team members for identified patient problems. The consulted department/individual should then proceed with an appropriate assessment, as indicated by the standards of practice for that discipline. " Risk Manager S4 indicated the intent of this policy includes the notification of physicians by nursing staff regarding any significant change in condition.