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Based on interview, record review, review of the facility's policies and documents, and review of local law enforcement officer (LEO) documents, the facility failed to ensure that all patients presenting to the Emergency Department (ED) received a Medical Screening Examination (MSE) for one (1) of 20 sampled patients, Patient 1 (P1). P1 presented to the ED on 06/03/2025 for an examination following an alleged sexual assault. However, the facility did not have a Sexual Assault Nurse Examiner (SANE) available at that time and did not complete an appropriate MSE during the encounter.

The findings include:

Cross Refer to 2406.

Based on interview, record review, review of the facility's policies and documents, and review of local law enforcement officer (LEO) documents, the facility failed to ensure that all patients presenting to the Emergency Department (ED) received a Medical Screening Examination (MSE) for one (1) of 20 sampled patients, Patient 1 (P1). P1 presented to the ED on 06/03/2025 for an examination following an alleged sexual assault. However, the facility did not have a Sexual Assault Nurse Examiner (SANE) available at that time and did not complete an appropriate MSE during the encounter.

The findings include:

Review of the facility's policy titled, "EMTALA Examination, Treatment and Transfer of Individuals Who Come to the Emergency Department," last reviewed 06/2024, revealed EMTALA obligations were activated when an individual requested examination or treatment of a medical condition within a dedicated emergency department (DED), or an individual requested examination or treatment for an emergency medical condition (EMC) while on hospital property other than a DED, or when a prudent layperson would recognize that an individual on hospital property, other than in a DED, required examination or treatment of an EMC even without a request for same. Further review revealed the facility provided to any individual who came to the ED an appropriate MSE within the capabilities of the DED, including ancillary services routinely available to the DED, to determine whether an EMC existed, regardless of the ability to pay. The policy also stated the MSE would be conducted by an individual determined qualified by Hospital Medical Staff Bylaws or Rules and Regulations. Continued review revealed the policy applied to all individuals who sought or needed an examination and/or treatment for a medical condition.

Review of the facility's policy titled, "Management of Suspected Assault Victims to Include Sexual Assault," last revised 11/2024, revealed acute medical screening shall be performed according to EMTALA and could be performed by the ED physician or designee, which could include the mid-level provider or the patient's attending physician. The review also revealed the primary nurse shall stay with the patient throughout the examination and collect any external evidence by using the Sexual Assault Evidence Collection Kit for exams that took place within 96 hours of the assault. Continued review revealed, for an examination following an acute incident, defined as less than 96 hours, an ED physician or mid-level provider must perform a medical screening exam, provide care for any medical injury, and notify the rape crisis center. Additional review revealed for verification of the SANE on call, staff utilized the Sexual Assault Forensic Examination (SAFE) algorithm for contact information.

Review of the facility's algorithm "Care for Sexual Assault Patient," undated, revealed a step-by-step guide to follow when a patient presented to the facility following a sexual assault. Further review revealed when a patient wanted a SAFE and was reporting an alleged sexual assault, staff called the local law enforcement dispatch and requested a police officer and SANE, and the document contained the number. Continued review revealed if a SANE was not available, the facility completed the SAFE exam.

Review of the "SANE Call-Out Roster" revealed there was not a nurse on-call after 12:00 AM on 06/04/2025 and noted that each hospital was responsible for their own examinations.

Review of the "Sexual Assault Nurse Examiner Program Agreement," effective 01/01/2025, between the local city and county government (Government) and the facility, revealed the Government provided skilled clinical personnel to operate the SANE program, and the facility agreed to provide a clinical area for the Government to implement its SANE program. Further review revealed the Government, through its SANE program, provided SANEs, on an as available basis to the facility, to perform the services, as appropriate, including performance of medical forensic evaluations, interviewing of patients who made a complaint of sexual assault, explanations of medical forensic care to patients, and collection of the patient consent forms from the patient before providing any medical forensic care. Other services included identification, packaging, and preservation of forensic evidence; creation of records of the medical forensic examination; and the maintenance of confidentiality for all such records, within the parameters specified and communication with law enforcement officers and other agencies as needed. Continued review revealed the understanding that nothing in the agreement shall be interpreted as to require the Government to ensure that it shall have SANEs available to perform any and all services referenced in the Agreement 24 hours of each day of the calendar year. Further review revealed nothing in the Agreement shall be interpreted as to remove any obligation of the facility to perform sexual assault nurse examinations in compliance with all applicable state law, where and when applicable.

Review of local law enforcement's "Standard Report, JC-3," dated 06/03/2025, revealed P1 had called for assistance on 06/03/2025 after the ex-boyfriend had physically and verbally assaulted her. She also reported he had sexually assaulted her on 06/02/2025 as well as 06/01/2025 in her home. Further review revealed P1 wanted to have a SANE exam, and law enforcement officer (LEO) 1 took her to the only available facility, which was Saint Joseph Hospital, but they did not have the nurse available, and P1 planned to return the following day.

During telephone interview with LEO1 on 06/09/2025 at 10:12 AM, he stated there were four SANEs who rotated call, and the police department had an agreement with them to provide SAFE exams in a dedicated space at the facility.

Review of the local law enforcement's "Department Case Report," dated 06/06/2025, revealed P1 requested a SAFE and went to the facility with LEOs but a SANE was not on duty, and P1 did not wish to stay at the hospital for one to respond. It stated P1 planned to return the following day. Further review of the report, authored by LEO2, revealed upon arrival to the facility, he made contact with P1 while waiting for the SAFE and eventually was informed by a nurse at the facility that they did not have the staffing to perform the SAFE at that time, and P1 would have to wait in the hospital for approximately eight to nine hours until they had a nurse available. Continued review revealed LEO1, who served as an interpreter, and LEO2 informed P1 of this and offered to take her to another facility for the SAFE to be done there or have her come back later to the facility if she did not want to wait. Continued review revealed P1 chose to return later, and LEO2 was informed at approximately 3:30 PM on 06/04/2025 that P1 had returned to the facility.

Review of P1's ED record revealed she presented to the facility's ED on 06/03/2025 at 11:55 PM with the arrival complaint of SANE exam and with ED Physician 1 assigned as her provider. Further review revealed the procedure and treatment was not carried out due to P1 leaving prior to being seen by the health care provider. Continued review revealed no evidence of an acuity being assigned or an appropriate MSE being completed, and P1 was dismissed at 12:40 AM.

During continued telephone interview with LEO1 on 06/09/2025 at 10:12 AM, he stated he brought P1 to the facility on the night of 06/03/2025 around midnight and had been assigned to assist as an interpreter also because she spoke only Spanish. He stated P1 reported she had been physically assaulted and sexually assaulted twice in the past few days. He stated from the ED lobby, she was only gone five to 10 minutes in triage before she returned to the lobby. He stated he was told the facility could not do the exam because there was no SANE on duty. He stated P1 was already a sexual assault victim in an ED, and he felt she should have been seen. He stated there was already a person waiting for a SANE exam, so staff could not see P1. However, he stated ED staff never told them the circumstances. He stated he and LEO2 offered to take P1 to another facility to see if they could do it, but P1 chose to return to the facility's ED the following day.

During telephone interview with LEO2 on 06/11/2025 at 11:58 AM, he stated the facility was the go-to facility. He stated when he arrived, P1 was already in the lobby. He stated staff took P1 back to triage. He also stated when she returned, the nurse took them aside and told them the facility already had a patient, P3, waiting for a SAFE, and the facility did not have the staff to do a SAFE on P1. He stated the nurse told them she was not kicking P1 out, and P1 could have a bed while waiting, but she could not receive the exam until the morning. He stated the LEOs told P1 the options, which included waiting, going to a different facility, or go home and come back for the exam. He stated he believed LEO1 emphasized they could take her to another hospital, but LEO2 did not speak Spanish well enough to confirm. He stated P1 made the choice to go home and return and did return to the hospital later for the exam. He stated this was the first time someone was turned away for a SAFE in his experience, and he had been in this unit for nearly a year. He stated he felt P1 should have been able to get the SAFE, and he wanted to do the interview with the SANE present, so the patient did not have to repeat the details multiple times.

During interview with RN1 on 06/09/2025 at 4:20 PM, he stated he had triaged P1 when she returned the second time. He stated P1 told him she had been to the ED the previous night, and there had not been a nurse available to do the exam. He stated the typical process was to take the patient to a room immediately, get labs, get the medical clearance completed, and then call the SANE. He stated medical clearance entailed getting labs and consulting with the provider. He stated the assigned nurse followed with the provider either by system message or spoke face-to-face, and the provider would determine clearance status after labs results were posted. He stated the process was started at check-in to contact the patient advocate, and the SANE was supposed to be contacted after clearance. He stated there was a dedicated number for SANE call out. He stated P1 had told him during triage that she wanted the SAFE exam. He stated if there was not a SANE on call, then the patient could choose to wait for a SANE, or the ED provider and nurse did the exam.

During telephone interview with RN2 on 06/10/2025 at 12:28 PM, she stated she was a day shift charge and worked Wednesday, 06/04/2025. She stated on that morning, the night charge nurse reported to her that the shift had been a super busy night, and there was not a SANE nurse overnight. She stated she did not have much exposure with P1, but P1 was not medically cleared until 3:45 PM, and the SANE was off call after 4:00 PM. Therefore, RN2 stated P1's SAFE was completed by APP1, RN3, and RN4. RN2 stated the priorities for a sexual assault victim were to get the patient to a room, get medical clearance, call the crisis center, police, and then the SANE after the patient was medically cleared. She stated in the absence of a SANE, the ED primary nurse and another nurse carried out the nursing portion of the exam.

During interview with RN3 on 06/10/2025 at 2:25 PM, she stated she and RN4 completed the nurse portion of P1 SAFE on 06/04/2025, and APP1 did the pelvic portion with evidence collection. She stated she had performed SAFE examinations before, and she had orientation on SANE at a previous job. She stated the process for sexual assault patients was they brought the patient to triage, then room the patient, and the provider did an MSE and ordered labs. She stated when the patient was medically cleared, the facility offered the SAFE. She stated she was not aware of the SANE schedule, and the Charge Nurse contacted them to see if a SANE was on call. If a SANE was on call, she stated they came to the facility once the patient was medically cleared, and if not, then ED staff did the exam. She stated she was aware of this process prior to the incident. She stated the SAFE should be done within 72 hours to get useful evidence; otherwise evidence could be decayed or gone.

During interview with RN4 on 06/10/2025 at 2:44 PM, she stated the expectation for sexual assault patient care was triage first, room the patient, then the provider did the MSE, and labs were drawn. She stated after medical clearance, a SAFE followed if the patient wanted it. She stated staff must call for the SANE that was on call, but if no SANE was available, the ED staff must complete the examination. She stated the nurses did questioning and paperwork, then the provider did the pelvic exam, collecting samples for evidence. She stated this was the first time she had participated in a SAFE. She stated she understood that a SAFE exam must be done within four days. She stated this was important for evidence collection, and if delayed, the evidence would be gone.

During interview with RN5 on 06/10/2025 at 4:02 PM, she stated her understanding was if a patient asked for a SAFE exam, they must inform the patient if there would be a long wait for the SANE nurse and offer that the exam could be done by ED staff. She stated the process was the patient went to a room fairly quickly, staff discussed what to expect as far as testing, and staff informed the patient there was a forensic nurse who would come to complete the kit should they choose to do so. She stated once the patient was cleared medically, staff found out when to expect the SANE, or if no SANE was available, they informed the patient the SAFE could be completed by the ED nurses and provider. She stated the facility had the SANE coordinator come in to provide education in the past, and the Educator had done smaller educations on this.

During interview with the ED Charge Nurse (CN) on 06/10/2025 at 7:39 AM, she stated she was working on the night that P1 came for a SAFE. She stated she knew now what she did was wrong and had been educated since for how to do better. She stated the ED was unusually busy the night of 06/03/2025, and she precepted an orientee for her first night. She stated by the time P3 [another alleged sexual assault victim] and P1 arrived, she had lost a nurse at 9:00 PM, two more nurses at 11:00 PM, and another nurse was due to end the shift at 3:00 AM. She also stated she had called the House Supervisor to determine if they could get extra help, but that did not occur. She stated shortly before midnight P1 arrived, and P3 was already waiting, both needing a SAFE, and the SANE was going off call at midnight. She stated she was thinking about how to get P3's SAFE completed because the 3:00 AM nurse had never done a SAFE. Then, she stated when P1 arrived, she panicked about what to do to manage both. She stated she had an initial conversation with ED Physician 1 who suggested she should just complete the first one in an hour. However, she stated a SAFE required far more time, and especially with a nurse who had not done one before. She stated she then met P1 in triage, explained what she thought were the options, including there was another patient ahead of her, and it might be until morning before she could have the exam. She stated she knew now P1 should have gotten the MSE by the provider, and also she did not specifically remember there being a midlevel provider on duty. She stated she did let ED Physician 1 know about the conversation she had with P1, and it was felt if they did the labs now, P1 might have to have them repeated by morning. She stated she told P1 she was welcome to stay, but she would have to wait overnight, or she could go home and return. She stated she told LEO1 she was not turning her away, and it was her choice. She stated the SAFE was important to gather the evidence, obtain the labs, and give the medications.

During telephone interview with the House Supervisor on 06/10/2025 at 5:33 PM, she stated she did not recall getting a call about the two alleged sexual assault patients [P1, P3] that night [06/03/2025]. In further interview, she stated when there was no SANE available, it became the ED staff's responsibility to conduct the exam.

During telephone interview with Advanced Practice Provider (APP) 1 on 06/10/2025 at 11:43 AM, she stated she cared for P1 the day she did have her MSE and SAFE [06/04/2025]. She stated every ED patient should get a medical screening exam. She stated she was told P1 had seen the triage nurse only and not by a physician or APP the night before. She stated the importance of timeframes with SAFE for obtaining DNA examples, evidence collection, and the patient's health. She stated there was no reason a SAFE should be delayed. She stated the ED providers, with nursing, were expected to perform the SAFE in the absence of a SANE. She stated she was never a SANE nurse but had training about policies for EMTALA and SAFE. She stated the policies and training had been in place since she had been there and before this incident. She stated with this incident, she did not know whether they ran it by the provider, but she thought ED staff should have known the SAFE needed to be done immediately.

During telephone interview with ED Physician 1 on 06/10/2025 at 2:09 PM, she stated she was covering the ED on Tuesday night, 06/03/2025. She stated her expectation for patients reporting sexual assault was that they were brought to a room, the police were called if the patient wished to file a report, the Patient Advocate was called, and the SANE was contacted. She stated if there was a SANE on call, they came to do the exam, and if not, the Charge Nurse would step in. She stated she did pelvic swabs and offered labs and prophylaxis medications. She stated P3 was back in the room around midnight on 06/03/2025, but there was no longer a SANE on call. She stated she did not have time to do a full exam, and the Charge Nurse reported she did not have time due to losing a nurse at 3:00 AM. Therefore, she stated she instructed the Charge Nurse she needed to see P3 first, before the nurse left. She stated she was fully prepared to see P1 but had a very sick pulmonary edema patient at the same time. She stated later the Charge Nurse reported P1 was not sure about staying/waiting for the SANE and asked if she could get labs done and return later. ED Physician 1 stated there was a concern that if P1 returned, she might have to have labs repeated. She stated the ED staff was getting closer to single coverage by then, but she was not informed the patient had decided to leave, so she did not have the opportunity to speak with P1 and had planned to encourage her to stay. She stated she did not know the second patient (P1) chose to leave. She stated the time required for a SAFE was one to two hours, and she also looked for major injury. She stated the timeframe was important to preserve evidence and to prevent the alleged victim from having to wait in the ED for a long time.

During telephone interview with ED Physician 2 on 06/11/2025 at 10:31 AM, he stated he assumed responsibility for P3 after the change of shift, after she had been there overnight. He stated all the labs and medications had been done by the time he assumed care. He stated they were just waiting for the SANE nurse to arrive and once that happened, P3 was discharged to her. He stated the process for treating sexual assault patients was providers see the patient, do the MSE, get labs and medications ordered, and discharge to the SANE once arrived. He stated when a sexual assault patient presented, providers talked to them, determined if any imaging or other tests needed to be done, then offered the SANE. He stated, if the patient wanted the SANE, staff must make sure a report had been filed with law enforcement and call the SANE. He stated if the SANE was unavailable, he would perform the exam. He stated for documentation, which was handled by nursing, once evidence was collected, law enforcement was present, and law enforcement would let him know if anything else was needed. If there was a SANE, he stated the SANE handled all of that, and the patient would be discharged to the SANE. He stated he had received education for managing sexual assault patients before and had since had to review the policies and attest by signature that he had done so.

During telephone interview with SANE1 on 06/09/2025 at 11:01 AM, she stated she did a SAFE for P3, who had waited about nine hours overnight for the exam. She stated P3 had been at the ED since 10:00 PM the night before, and she came on duty at 8:00 AM that morning. She stated the facility's ED staff told P1 they could not see her in the ED, even though staff usually saw the patient in the ED for medical clearance first before the SANE intervention. She also stated P1 was told they did not have anybody to do her exam, and she would have to come back. When she was called by the Charge Nurse (CN) about P1 that afternoon, she stated she asked why she had not had medical clearance, and the CN told her the facility had not had anybody to do the exam. She stated the policy was, in the absence of a SANE, that a midlevel or physician completed the exam. She stated there was always a nurse present to assist with the kit/collection and maintain the chain of custody. She stated her big concern for P1 was the assault had already happened a couple of days earlier. She stated the ED staff, in conjunction with the MSE, provided the STD and HIV prophylaxis and the Plan B prophylactic treatment (for pregnancy prevention). She stated there was a 72-hour window for that treatment. She stated P1 was barely in the window for this treatment from the first assault, and it would have been better if this had happened when she first presented. She stated, after 72 hours, the medications were not deemed effective and were not given after that timeframe. She stated there was 96 hours post assault for the exam, but the longer they waited, the greater the chance that definitive exam samples could not be collected.

During telephone interview with SANE 2 on 06/11/2025 at 12:15 PM, she stated she was the program manager for the local SANE program. She stated she sent out a document to the SANEs and detectives with the schedule. She stated she had provided education to staff for probably the third time since they started with the facility and did it two different days each time. She also stated she developed the algorithm when they started the program with the facility. She stated she was contacted by the LEOs about this incident, asking whether patients could be turned away, and there was already somebody who was waiting for nine hours. She stated she contacted the facility about it, but her biggest concern was that the one turned away might have gotten a life sentence of a pregnancy added to the most traumatic thing that ever happened to her. She stated with HIV prophylaxis, they only had 72 hours to administer the medicine for it to be effective. Plus, she stated P1 was not given the proper attention she needed, which made it seem unimportant, and the delay could have hindered the prosecution. She stated she emphasized in education that staff was not judge and jury, and the sexual assault patients needed the same attention that any patient received.

During additional telephone interview with SANE 2 on 06/11/2025 at 6:02 PM, she stated she wanted to emphasize that the agreement outlined SANE coverage was provided as available and that, in the absence of a SANE on duty, providers and midlevel providers were able and expected to provide forensic exams. She stated a concern was the delay for a patient who was already traumatized, thus extending the trauma. She also stated SAFE was a long exam, and for the SANE, one case could require as much as six hours from beginning to end.

During interview with the Market ED Director on 06/06/2025 at 1:30 PM, she stated for sexual assault patients, they received an MSE in the ED, which addressed any injuries; labs drawn for sexually transmitted diseases (STD), human immunodeficiency virus (HIV), and pregnancy if they wanted; and prophylaxis medications if they wanted. She stated, after the MSE, labs, and medications, if there was a SANE on duty, the patient discharged from the ED to the SANE in Room 19 who performed the SAFE. She stated the patient was under the SANE's care. She stated the SANE was contracted with the local government. She stated this process worked when there was a SANE on duty. She stated, if there was not a SANE on duty, the facility's ED physician or mid-level provider performed the exam with primary nurse assistance. She stated they maintained the chain of custody for collection of evidence until the local LEO arrived to collect the evidence.

During additional interview with the Market ED Director on 06/10/2025 at 12:14 PM, she stated she had been covering the ED while the assigned manager was on extended leave. She stated she called the CN each morning to see how the night went. When she called the morning following the incident, she stated the charge nurse reported she might have done the wrong thing, and she immediately talked through the process, the details of the policy, and what should have happened. The ED Director stated her reaction was the desire to fix this to avoid any confusion. She stated P1 should have had an MSE and should have been seen by a provider. She further stated her expectation was that the SAFE would have been done by a provider and assisted by a nurse. She stated she did remember about staffing regarding call offs, but did recall the nurse who worked 7:00 PM to 3:00 AM on 06/04/2025 was a day shift nurse who picked up extra hours. She also stated the nurse orientee was new to the hospital but was an experienced ED nurse. She stated the typical patient load was four patients to one staff member. She stated she thought the total volume of patients that night was 17 or 18. She stated their core staffing after 11:00 PM was usually four nurses and a technician, but that night after 3:00 AM there were two paramedics and two nurses, one of whom was on orientation, and one was the charge nurse. She stated the timeframe for completion of the SAFE was so important because the evidence might degrade as well as a possible injury that could go untreated.

During telephone interview with the Medical Director on 06/10/2025 at 11:30 AM, he stated he expected the SANE nurse would come in, and the facility's provider would get an MSE. He stated he was disappointed their staff got to the point of this situation. He stated ED staff did "a crazy amount" of training on EMTALA. He stated he expected the SAFE to be completed, and if necessary, the SAFE to be performed by the facility's provider/midlevel in the absence of a SANE. He stated whomever was covering in the ED would perform the exam. He stated the expectation for the timeframe was the SAFE was done as soon as possible. He stated he would expect the SANE would start the SAFE in an hour and so would the ED staff. He stated he talked to ED Physician 1, and she was aware of his dissatisfaction about the incident. He stated she reported she had a really sick patient that required extra attention. Also, he stated a SAFE was a lengthy exam. He stated if no SANE was available, then the bulk of the exam was done by the nurse, with the provider doing the genitourinary exam and overall forensic collection of evidence. He stated for preservation and protection of evidence, it was important to collect it as soon as possible. He stated performing the MSE was important because it was not known what else was going on with the patient, with the possibilities that the patient could have hemorrhage or internal damage that should be assessed.