HospitalInspections.org

Based on interview, record review, review of the facility's investigation file, and review of the Kentucky Incident Based Reporting System (KYIBRS) document, the facility failed to ensure it had a policy to be followed in the examination of reported victims of sexual offenses for 1 of 20 sampled patients, Patient (P) 1. P1 presented to the Emergency Department (ED) on 04/08/2023 for an examination of an alleged sexual assault. However, the facility did not have a policy detailing the requirements for a Sexual Assault Forensic Examination (SAFE) examination on a non-adult patient, and P1 did not receive the SAFE at the facility.

The findings include:

A request by the State Survey Agency (SSA) Surveyor for the facility's policy related to care for a sexual assault victim was not fulfilled due to the lack of a policy as stated by the Risk Manager on 05/21/2024 at 9:49 AM.

Review of a Lotus (a sexual assault (SA) resource center) poster, revised 11/2021, posted in the ED staff break room, revealed algorithms to follow for both SA victims who were between the ages of zero to 17 and those 18 or older. Further review revealed the algorithms detailed pathways based on specific criteria, then subsequent guidelines for determining whether a SAFE must be conducted in the hospital or at Lotus. Continued review of the Lotus resource poster revealed if there was any type of genital contact or penetration within the prior 72 hours or if the child was a female in puberty reporting vagina to penis contact within the last five days, a hospital exam was appropriate. Further review revealed the hospital should complete a head-to-toe assessment of the minor patient and have appropriate personnel complete the necessary portions of the SAFE. Additional review revealed consent requirements and the credentials required for providers who may perform a SAFE. For pre-pubescent SA victims, the poster noted the requirement for a mid-level provider, a doctor, or a pediatric Sexual Assault Nurse Examiner (SANE). For pubescent SA victims, continued review of the poster revealed a SANE, doctor, mid-level provider, or a pediatric SANE could perform the SAFE. Continued review revealed no language defining pubescent versus prepubescent.

Review of the "KYIBRS" document, Incident #2024108296, dated 04/08/2024, initiated at 7:06 PM, revealed P1's father had contacted the local police department. It stated police arrived at P1's home at 7:10 PM. Further review of the KYIBRS revealed P1 sneaked out of his/her home to meet friends from 1:45 AM until about 6:30 AM. Per the document, P1 met two friends, including one who was a 17 year old male, who made sexual advances and ultimately an alleged sexual assault, including vaginal penetration, in spite of P1 having stated multiple times that he/she did not want to have sexual intercourse. Continued review of the KYIBRS revealed that P1 had become afraid the alleged perpetrator would hurt her, so he/she did not fight him. The document stated P1's father transported him/her to the facility to have a SAFE, which could not be done because P1 was under 14 years of age. Per the document, P1 would have to contact Lotus, which was done, and P1 was to go to Lotus first thing the following day.

Review of the facility's email, dated 05/23/2024 at 9:47 AM, and sent by the Lotus Director of Advocacy, revealed, from the "Kentucky Medical Protocol for Child Sexual Assault/Abuse Evaluation, Identifying a Qualified Healthcare Provider," the evaluation of a child who presented for a concern of sexual assault/abuse must be performed by a physician, SANE, Advanced Practice Registered Nurse (APRN) or Physician's Assistant (PA). Further review revealed if the child was prepubescent, a pediatric/adolescent SANE (SANE P/A) could evaluate the child for sexual assault/abuse in collaboration with a physician, APRN or PA. The document stated if the child had reached puberty, then a SANE or SANE P/A could evaluate the child for sexual assault/abuse. Also, if there was not a SANE available, the most qualified healthcare provider at a facility should proceed with the evaluation. Continued review revealed in order to meet statutory requirements for the care of the sexual assault patient, the exam should be completed at the request of the patient without delay.

Review of P1's "ED Note" revealed it was initiated on 04/08/2024 at 8:00 PM, when Registered Nurse (RN) 2 documented the encounter. Further review revealed P1 arrived with his/her father and a chosen interpreter at 8:45 PM that day, and RN2 escorted him/her to the consultation room for privacy due to the triage room being occupied and the volume of waiting patients in the ED lobby. Continued review of the note revealed police officers arrived ahead of P1 to alert staff to his/her arrival and the reported sexual assault. The note stated the officers had contacted Lotus about the assault concerning the process for pediatric SANE evaluations. The note indicated the staff contacted Lotus to verify the presented information. The note further described RN2's conversation with P1, his/her father, and the interpreter. Per the note, the first option was to have the general examination completed in the facility, including pregnancy and sexually transmitted disease (STD) testing, then to follow with the SAFE at Lotus the following day. Per the note, the second option was for P1 to go to Lotus the following morning for everything to be completed there. Additional review revealed P1 asked RN2 what the SAFE was, and RN2 explained the different samples that would be collected and that P1 could decline some or all of the tests. RN2's note stated P1 told her P1 had not wanted to go through all of this twice, and she chose the second option. The note also indicated RN2 gave P1 the Lotus folder, per the Lotus representative's request. The note stated P1 and his/her father told RN2 they would call Lotus the first thing the following morning to set up the exam. The note stated P1 and his/her father then left the ED at 9:00 PM.

Review of the facility's investigation file revealed two police officers arrived at the ED on 04/08/2024 at approximately 8:45 PM, and notified the staff that a 13 year-old female, who was the apparent victim of a sexual assault, would be presenting to the ED with his/her father and pastor. Further review revealed the ED staff began preparing for P1's arrival, including a review of the facility's sexual assault informational poster. Per the report, the ED staff members were unclear if they were permitted to perform a SAFE on a patient of that age and contacted the hospital's SANE to ask about the process with a minor patient. Per the report, the SANE informed staff that her certification only allowed her to perform an examination on a minor patient who was more than 14 years old. Continued review revealed the facility validated the SANE was not permitted to perform the examination under her certification. The SANE had also recommended contacting Lotus, who had a pediatric SANE and would be able to perform the examination. Additional review revealed the ED staff informed the police officer of the information shared by the SANE nurse, and the police officers called other nearby hospitals to see if they had a SANE available. Review of the investigation also indicated a staff member then contacted the Lotus on-call representative to discuss how to proceed. The report stated Lotus told the staff member that the facility could perform the general examination, and Lotus would perform the remaining portions of the SANE which would include evidence collection, photographs of injuries, and performing STD and pregnancy tests. The report also revealed staff had requested Lotus to dispatch a representative to the facility to talk with P1 and be there for the facility's portion of the examination, but Lotus had advised it did not have anyone available. Further review of the report revealed P1 subsequently arrived with his/her father and pastor, and a nurse escorted them to a consultation room for privacy because the triage room was occupied, and other patients were waiting in the lobby. Further review revealed the nurse explained the options of completing the general examination at the facility and the SAFE at Lotus or go to Lotus the following day for the full examination. The report stated P1 told RN2 he/she did not want to have two examinations and chose to have the entire examination performed at Lotus. Per the report, RN2 provided P1 with the Lotus informational packet and reviewed the materials with a plan for P1 to contact Lotus first thing the following morning. The report stated RN2 informed the police officers who had been waiting in the main ED, and they left with P1 and his/her father.

During an interview with the Risk Manager on 05/21/2024 at 9:49 AM, she stated the Lotus Poster did indicate the prepubescent patients required a pediatric SANE to perform the exam, or a SANE could do the noninvasive exam and a mid-level or physician provider could do the invasive portion of the exam. She stated if there had been a policy, they would have had a standard of practice to follow.

During an interview with RN1 on 05/21/2024 at 1:02 PM, she stated she had received the training for SANE, including the required clinical hours, but that was recent. She stated she had submitted paperwork to the Kentucky Board of Nursing (KBN), and she was waiting for final issuance of the certificate, then she would be able to conduct SANE exams independently. She stated she currently could only assist a provider, such as a physician, PA, or APRN. RN1 stated when a patient was admitted with a sexual assault allegation, Lotus was contacted before the patient was examined.

During an additional interview with RN1 on 05/21/2024 at 1:21 PM, she stated she had the Lotus folder they kept in the hospital and Guideline book from Kentucky Sexual Assault Team for review. She stated the guideline book referenced the statute and the Kentucky Association of Sexual Assault Programs website. RN1 stated the law previously provided for separate certification for adult and pediatric victims. Now, she stated the description was by pubescent and pre-pubescent, that was a physiological adult versus a child, but she had no reference for how to determine what category a given victim/patient was in. She stated, in her training, she was taught that for a victim under the age of 14, he/she would require a SANE-P/A provider. RN1 stated there used to be a SANE at the facility, but there had not been one since her departure. She stated she was not aware of a specific SANE policy.

During an interview with RN2 on 05/21/2024 at 2:15 PM, she stated a local police officer came to the facility and told staff they were bringing a 12 year-old sexual assault case to the ED. She stated she told the police officer she was not sure if staff could do a SAFE on a child. She stated she and RN3 reviewed the poster from Lotus, and they called RN1, who was not on duty at that time. RN2 stated RN1 told them the facility did not do a pediatric SAFE. She stated she called Lotus and the representative stated he believed there was a pediatric SANE at another facility. She stated staff was told they could do the general exam, then P1 could come to Lotus for the SAFE, including the photographs and all the evidence collection. RN2 stated the police officer called another hospital to see if they had a pediatric SANE, and the officer told her the officer wanted to get P1 where he/she needed to go. She stated staff and the officer learned the other hospital had an adult SANE but not pediatric. RN2 stated when P1 arrived, the triage room was occupied and there was a line to register, so she took P1 and family back to the consultation room for privacy. She stated she explained to P1 they could do the general exam and Lotus could do the remainder of the exam or that she could go to Lotus for everything. RN2 stated she looked up a policy for protocol with sexual assault and found there was only the "Abuse and Neglect Assessment" policy and not a policy specific to managing patient care after sexual assault.

During an interview with RN3 on 05/22/2024 at 7:39 AM, she stated the police officers came in and alerted staff ahead of P1's arrival. She stated they wanted the SAFE kit done, and so the hospital's SANE was called for advice. She further stated staff understood from the SANE that a head-to-toe assessment could be done but not a SAFE, because it had to be done by a pediatric SANE. She stated part of the confusion was the facility had two posters from Lotus, one apparently more up-to-date, because the posters said different things. She stated it made it harder to know what to do. She stated, afterwards staff went onto the policies and procedures available on the hospital intranet, but did not find one for sexual assault.

During an interview with RN4 on 05/22/2024 at 9:15 AM, she stated she was not aware of a sexual assault victim policy, and staff was expected to use the poster from Lotus if they had a patient who was a sexual assault victim.

During an interview with the Chief Nursing Officer (CNO) on 05/24/2024 at 8:59 AM, he stated his expectation was his staff would ask questions if they came across a problem or situation they were not familiar with and escalate up the line for answers. The CNO stated without a policy, how to manage this instance relied on communication because there was not a policy. He stated the Lotus flyer (poster) was not a hospital policy, but a resource.

During an interview with the Chief Executive Officer (CEO) on 05/24/2024 at 9:08 AM, he stated staff had discovered the Lotus poster was inadequate, and it was clear the facility needed a protocol wrapped in a written policy. He also acknowledged there was a failure with the lack of a policy.