HospitalInspections.org

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff responded to a patient reported sexual assault. This affected one (Patient #2) out of 10 patients reviewed.

Findings include:

Review of the medical record of Patient #2 revealed she presented to the emergency department (ED) via squad on 01/02/25 at 9:46 PM with complaints of being suicidal. A triage note at 10:04 PM stated the patient denied both suicidal ideation and homicidal ideation, stating she was crying when she called 911 and they misunderstood her. She stated she called due to chest pain, which was gone, and she wanted to go home. A nurse's note at 10:29 PM stated the patient reported a recent admission to a psychiatric facility after a suicide attempt. The patient reported she had been sexually assaulted at the psychiatric facility. She stated that she was feeling suicidal the day prior due to thinking about the sexual assault and the chest pain was due to anxiety. The medical record lacked documentation the patient's report of sexual assault was investigated.

The ED attending physician's note stated the patient denied suicidal and homicidal ideation. She otherwise had no acute medical complaints and was discharged via a medical Uber at 11:37 PM.

Review of the facility policy titled "Reported Sexual Assault," effective 02/1998, stated both sexual assault and sexual abuse refer to any act of sexual contact or conduct performed upon one person by another and without the mutual consent. The procedure outlined in the policy advised staff to assess every patient, every visit in the ED. The CARES Coordinator Department/ Services, with a sexually assaulted patient should contact the on-cal CARES nurse for an evaluation and treatment. The policy revealed the the ape/sexual assault patient is viewed as a priority. The survivor is given privacy as soon as possible. The policy states to refer the patient to the Emergency Department Collection of Forensic Evidence Guideline.

Interview on 04/15/25 at 5:00 PM, ED Manager, Staff C, confirmed the medical record lacked documentation the patient's report of sexual assault at an outside hospital was reported to the CARES Coordinator Department as required by facility policy.