HospitalInspections.org

Based on a review of facility documents and staff interview (EMP), it was determined that the Tyrone Regional Health Network failed to maintain a Control Register, as described in their adopted policies, of individuals who present to their Emergency Department seeking assistance for one of one patients identified (PT1) and failed to follow adopted policies related to triage and the generation of an Emergency Department record for a sexual assault patient, for one of one patients identified (PT1)

Findings:

"Policy Stat ID: 5184776 ... Next Review: 11/2019 ... EMTALA - Central Log Scope: Emergency Department. Purpose: To maintain a system for tracking the care provided to each individual who comes to Tyrone Hospital Emergency Department for an emergency medical condition. Procedure: 1. The central log will include an entry for EVERY patient that comes to the ED seeking treatment. ... 2. Data entry to the log shall not delay the medical screening exam, necessary treatment or stabilization. ... 3. The log must contain: a. the name, age, gender; b. time and means of arrival; c. complaint and disposition; d. whether the individual: i. refused treatment; ii. was refused treatment; iii. Left without being seen (LWBS); iv. Stabilized and transferred (include facility name and time of transfer); vi, admitted and treated; vii. Discharge including date and time. 4. Tyrone Hospital will retain the central log, medical and other records related to the individual's ED visit for a minimum of seven (7) years. ... ."

Review of policy entitled "Hospital Protocol/Procedure on Sexual Assault", undated, revealed, "Purpose: To provide the highest quality of care for the physical and psychological treatment of sexual assault survivors (SAS) including services relating to assessment and prophylactic treatment of sexually transmitted diseases, counseling regarding the assault, and information and services related to emergency contraception. Scope: Emergency Department Physicians. Emergency Department Nurses ... The philosophy upon which this protocol is based includes the following beliefs: 1. That all victims of sexual assault have the right to prompt and sensitive physical and emotional care and that they have the right to refuse this care ... 1. All patients (SAS) will be triaged and an Emergency Department record generated. Sexual assault survivors are generally an ESI level 3 or higher as sexual assault results in physical and emotional trauma. 2. Patients should be offered the services of a trained sexual assault counselor. If the patient wants the counselor, the ED nurse should immediately call ... to arrange for a counselor to come into the hospital. 3. Assessment and exam of the patient will take place privately in Room 1 of the ED. 4. The ED nurse will ascertain from the patient the nature of the assault and explain the nature and function of the sexual assault evidence collection kit (rape kit). If the patient agrees to the collection of evidence then the ED nurse shall call the SAFE nurse into the hospital to perform the forensic exam ... 6. The patient will be provided ... B. Tests and exams as medically indicated to determine presence or absence of STD's such as gonorrhea, syphilis, Hepatitis B, and HIV. C. With patients consent, initial dose, up to 72 hrs, of prophylactic treatment as deemed appropriate by attending physician ... ."


1. An interview with EMP3 on June 4, 2019, at 10:00AM, revealed "(A patient) walked in, and was visibly upset, and asked if we do rape kits. I never encountered this question before. I got EMP4 and (they) said (they) would come out as speak withthe patient. (The patient) said (they) just wanted a rape kit ... EMP4 said we would have to call the nurse in. We have a SANE nurse, but it was (their) weekend off. (The patient) asked how long it would take, and EMP4 said (they) didn't know, and told (the patient their) best bet, if (they) wanted it done quickly, was to go to Altoona. I didn't get (their) name, because (they) didn't want ER ... To me, (they) refused the ER, and said (they) just wanted a rape kit. ... I've never been presented with a person who requested a rape kit. (They) seemed frazzled, (the patient) was upset ... ."

2. An interview with EMP4 on June 4, 2019, at 10:17 AM was conducted. EMP4 stated that they were told by EMP3 that (a patient) wanted to know if they (Emergency Department) could do a rape kit. EMP4 stated that they advised the patient that they didn't have anyone there to do a rape kit. EMP4 stated that subsequently the patient was asked if they wanted to be seen by doctor, and stated that the patient didn't want to be seen by the doctor, stating they will go to Altoona. EMP4 stated that the patient gave a lot of details, even stating that the patient told them that they had gone somewhere requesting their security camera footage. Subsequently EMP4 stated that they asked the patient if they needed a ride, and the patient stated a friend would take them. Regarding triage, EMP4 stated that the patients present at the Registration desk, and say that they want to be seen, they are asked what they are there for, and they get their name, and they are either taken back to a bed or to triage.

3. A review of camera footage dated May 11, 2019, revealed that at 4:07PM, PT1 could be seen walking outside the door on (their) phone, at 4:09PM, PT1 was seen coming into the main door. At this point PT1 is out of camera range. At 4:15PM, PT1 is seen leaving the main door, and is back on (their) phone.

4. Surveyors requested the ED Log dated May 11, 2019. It was confirmed that PT1 was not on the Log. In addition, surveyors requested documentation related to PT1. Surveyors were not provided with any type of triage documentation or any evidence that a medical record was generated per their adopted policy.

5. A review of the ED Physician Roster was completed, and a sample of five Credential Files were chosen for review (CF1-CF5). It was noted upon review of the privileges for each file, that all physician privileges stated OB-GYN Emergencies, which included exam of rape victims.

6. A telephone interview with EMP6 was conducted on June 10, 2019, at 11:30AM, with EMP7, EMP8 and EMP9 present. These employees are all from the hospital that PT1 subsequently presented to on the same day as they presented to Tyrone Regional. EMP6 stated, "The patient presented to us complaining of possibly being drugged, and requested a sexual assault exam. The patient thought they had been abducted and drugged ... The patient said they did seek medical treatment at Tyrone, but was told they did not have enough staff to do a rape exam.

Based on a review of facility documents, staff interview (EMP), and medical record (MR), it was determined that Tyrone Regional Health Network failed to follow adopted Protocol/Procedure regarding sexual assault patients, by failing to ensure a triage screening was completed, which then did not allow an appropriate determination concerning the need for a medical screening examination, therefore a medical screening examination was not provided for one of one patients who presented to the Emergency Department. (PT1)

Findings:

Review of policy entitled "Hospital Protocol/Procedure on Sexual Assault", undated, revealed, "Purpose: To provide the highest quality of care for the physical and psychological treatment of sexual assault survivors (SAS) including services relating to assessment and prophylactic treatment of sexually transmitted diseases, counseling regarding the assault, and information and services related to emergency contraception. Scope: Emergency Department Physicians. Emergency Department Nurse ... The philosophy upon which this protocol is based includes the following beliefs: 1. That all victims of sexual assault have the right to prompt and sensitive physical and emotional care and that they have the right to refuse this care ... 1. All patients (SAS) will be triaged and an Emergency Department record generated. Sexual assault survivors are generally an ESI level 3 or higher as sexual assault results in physical and emotional trauma. 2. Patients should be offered the services of a trained sexual assault counselor. If the patient wants the counselor, the ED nurse should immediately call ... to arrange for a counselor to come into the hospital. 3. Assessment and exam of the patient will take place privately in Room 1 of the ED. 4. The ED nurse will ascertain from the patient the nature of the assault and explain the nature and function of the sexual assault evidence collection kit (rape kit). If the patient agrees to the collection of evidence then the ED nurse shall call the SAFE nurse into the hospital to perform the forensic exam ... ."

"Policy Stat ID: 5184779 ... Next Review: 11/2019 ... EMTALA - Medical Screening Examination and Stabilization Policy. Scope: All clinical departments. Purpose: To establish guidelines for providing appropriate medical screening examinations and in the individual is determined to have an emergency medical condition, any necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act (EMTALA), 42, U.S.C., Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. Text: When an individual comes to the Emergency Department (ED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospitals ED (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such examination to determine where an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as required by EMTALA. Such stabilization treatment shall be applied in a nondiscriminatory manner (e.g., a different level of care because of diagnosis, financial status, race, color, national origin, or handicap). Procedure: When a Medical Screening Examination is Required An individual must receive an MSE, within the capabilities of the hospital's ED, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if: 1. The individual comes to the emergency department of the hospital and a request is made on his or her behalf for examination or treatment for a medical condition, including where a. The individual requests medication for a medical condition. ... 2. The individual arrives on the hospital property other than the ED and a request is made on the individual's behalf for examination or treatment for an EMC. ... 3. The individual arrives on the hospital property, either in the ED or property other than the ED and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment and that the individual would request that examination or treatment if he or she were able to do so. ... When a Medical Screening Examination is Not Required 1. If an individual present to an ED in the following circumstances, no MSE is required by EMTALA: a. Requests services that are Not examination or treatment for a medical condition, such as preventative care services or drugs that are not required to stabilize or resolve an EMC; ... b. Requests services that are Not for a medical condition such as gathering of evidence for criminal law cases (sexual assault, blood alcohol). When the request made for medical care is only to collect evidence, not to analyze the results or otherwise examine or treat the individual, no EMTALA obligation exists; Examples: If an individual presents to a facility which does not have the capability to perform a rape kit when one is needed, the hospital's obligation is to provide an appropriate medical screening without disturbing the evidence and transfer the individual to a hospital that has the capability to gather the evidence. Transfer must occur only in compliance with hospital policies and procedures. ..."

1. An interview with EMP3 on June 4, 2019, at 10:00AM, revealed "A patient walked in, and was visibly upset, and asked if we do rape kits. I never encountered this question before. I got EMP4 and they said they would come out. The patient said they just wanted a rape kit ... EMP4 said we would have to call a nurse in. We have a SANE nurse, but it was their weekend off. The patient asked how long it would take, and EMP4 said they didn't know, and told the patient their best bet, if they wanted it done quickly, was to go to Altoona. I didn't get their name, because they didn't want to go to the ER ... To me, they refused the ER, and said they just wanted a rape kit. ... I've never been presented with a person who requested a rape kit. They seemed frazzled, the patient was upset ... ."


2. An interview with EMP4 on June 4, 2019, at 10:17 AM was conducted. EMP4 stated that they were told by EMP3 that a patient wanted to know if the Emergency Department could do a rape kit. EMP4 stated that they advised the patient that they didn't have anyone there that could do a rape kit. EMP4 stated that subsequently the patient was asked if they wanted to be seen by doctor, and stated the patient didn't want to be seen by the doctor, stating they will go to Altoona. EMP4 stated that the patient gave a lot of details, even stating that the patient told them that they had gone somewhere requesting their security camera footage . Subsequently EMP4 stated that they asked the patient if they needed a ride to the other hospital, and the patient stated a friend would take them.


3. A review of camera footage dated May 11, 2019, revealed that at 4:07PM, PT1 could be seen walking outside the door while on their phone, at 4:09PM, PT1 was seen coming into the main door. At this point PT1 is out of camera range. At 4:15PM, PT1 is seen leaving the main door, and is back on their phone.

4. In addition, surveyors requested documentation related to PT1. Surveyors were not provided with any type of triage documentation or any evidence that a medical record was generated per their adopted policy.

5. A review of the ED Physician Roster was completed, and a sample of five Credential Files were chosen for review (CF1-CF5). It was noted upon review of the privileges for each file, that all physician privileges stated OB-GYN Emergencies, which included exam of rape victims.

6. A telephone interview with EMP6 was conducted on June 10, 2019, at 11:30AM, with EMP7, EMP8 and EMP9. These employees are all from the hospital that PT1 subsequently presented to on the same day as they presented to Tyrone Regional. EMP6 stated, "The patient presented to us complaining of possibly being drugged, and requested a sexual assault exam. The patient thought they had been abducted and drugged ... The patient said they did seek medical treatment at Tyrone, but was told they did not have enough staff to do a rape exam ... ."

7. Review of MR23 revealed that PT1 subsequently presented to another facility, following the encounter at Tyrone Regional Health Network, and review of that medical record revealed documentation of a medical screening examination, a drug screen and a sexual assault examination.