HospitalInspections.org

Based on patient and staff interviews and administrative document review the hospital failed to protect patient's rights when Patient 1 was sexually abused during an unchaperoned transvaginal ultrasound by the ultrasound tech. (A145)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on patient and staff interview, clinical record and administrative document review, the facility failed to provide an environment free from sexual abuse and mental anguish when Patient 1 was sexually abused by a hospital employee during an unchaperoned transvaginal ultrasound.


This failure resulted in Patient 1 being sexually abused.


Findings:


On 2/7/2013 at 1:34 p.m., during a telephone interview, Patient 1 went to the hospital for an ultrasound. Staff 24 asked Patient 1 if she was comfortable with him doing the ultrasound. Patient 1's response was, "Yes, I guess so". Staff 24 asked Patient 1 to get on the table so he can do the ultrasound of her stomach. Staff 24 told me to take off my clothes and my pants behind the curtain. Staff 24 asked Patient 1 if she was sexually active. Staff 24 requested of Patient 1 to lay down and place her feet in the stirrups. Staff 24 requested Patient 1 to spread her legs for somebody new today(meaning Staff 24). Staff 24 asked Patient 1 if she had a boyfriend and the response was, "no". Staff 24 stated, "I am going to lube you up and down with my fingers". Staff 24 placed lube on his fingers (no gloves) and proceeded to put the lube on Patient 1's vaginal area. Staff 24 asked Patient 1 if she got wet down there? Staff 24 asked if she had oral sex and then asked me if I was comfortable. I told him it was uncomfortable but not painful. Staff 24 continued to ask the following questions: Do you have orgasms and are they with your boyfriend, do you masturbate, if I liked doggie style and if I liked fingers. Staff 24 placed his hand on Patient 1's labia.
Staff 24 got a cloth and started to wipe Patient 1 outside then said he had to wipe her inside to see if there was any blood. Staff 24 placed his fingers inside of Patient 1. Staff 24 said: "you are tight down there". Patient 1 asked Staff 24 how does he know? Staff 24's response was, " I can tell" Staff 24 stated "You are going to make some man happy". Patient 1 stated that she felt very violated.


The hospital's policy and procedure titled "Transvaginal Ultrasound," dated 12/09, indicated ...All male U/S [ultrasound] technologist's will have a chaperon[e] (hospital employed female) present during the procedure."


On 2/7/2013 at 9:37 am, during a telephone interview, Staff 24 (ultrasound technician) stated he did not have a chaperone in the room during the procedure with Patient 1. When asked about comments made to Patient 1, Staff 24 stated "I have nothing else to say" and ended the interview.


On 1/31/13 Staff 24 made a handwritten statement for the hospital. The statement indicated that at various times during the exam sexually explicit questions related to sexual position, whether patient reached orgasm and in what positions were asked by Staff 24. Staff 24 asked Patient 1 if she was ok with him doing the exam. Patient 1 said "yes". Staff 24 stated he thought he had asked Patient 1 if it was ok for him to do the exam since she had to spread her legs for another man. Patient 1 stated it was ok. At that time Staff 24 asked her if she was sexually active - (since we can not do the vaginal exam on virgins). Patient 1 said, "yes". Staff 24 asked when was the last time she had sex? Patient 1's response was, "1 month". Staff 24 asked Patient 1 if it was painful and the response was in certain positions it was painful. Patient 1 was told by Staff 24 he was going to put some gel on her. Staff 24 stated he used some K.Y. gel on his gloved rt [right] hand and put some gel on Patient 1's labia. Staff 24 indicated he put some K.Y. gel on the probe and before inserting it in indicated he told Patient 1 to let Staff 24 know if there was any pain. Patient 1 was experiencing some pain with the probe in certain positions. So Staff 24 asked Patient 1 if "sex for her was enjoyable and if she did have orgasms during intercourse..." After the exam Staff 24's statement indicated he told Patient 1 to let him check if there was any blood coming out (since some patients start bleeding after the exam from the probe). Staff 24 told Patient 1 to spread her legs so Staff 24 could use a towel to wipe and see if there was any blood. Staff 24 stated he had to push the towel into the labia a little bit to see if Patient 1 was bleeding. Staff 24 stated he moved the towel from top to bottom 2 or 3 times and showed Patient 1 that there was some dark brown stuff on the towel and not fresh blood which was normal. Staff 24 did tell Patient 1 there was more chance of bleeding since the vaginal opening was tight and I did say jokingly to Patient 1 that "she would make some man happy". As Patient 1 was leaving Staff 24 stated he told Patient 1 jokingly to find a good man and if Patient 1 did not find anybody - come and look for Staff 24."


The hospital's undated investigative report, indicated Staff 24 was interviewed by the Human Resource Director for the hospital. The report indicated Staff 24 stated he did ask Patient 1 for permission to do the procedure without a chaperone. Staff 24 was aware of the hospital's policy requiring a chaperone while doing the transvaginal exam. The investigative report also indicated Staff 24 stated he did ask Patient 1 about sexual positions, what positions or by what sexual methods she reached orgasm. Staff 24 stated he did use his fingers to spread the labia in order to insert the ultrasound probe, inform Patient 1 she was tight, and Patient 1 would make some man happy in reference to her tightness. Staff 24 indicated he did wipe Patient 1's labia after the procedure.


On 3/5/13 at 2:00 p.m., during an interview, Staff 4 stated she had 12 years experience as an ultrasound technician. She stated when she performed a transvaginal ultrasound she applied the gel to the ultrasound probe and never directly on the patient. She also stated she asked the patient why they are having the procedure, whether they are pregnant or not and whether they are sexually active when appropriate. She stated it was appropriate to ask if they were sexually active because they are not to do the transvaginal ultrasound if the patient has never had sex.


On 3/5 2013 at 2:55 p.m., during an interview, Staff 5 stated he had been an ultrasound technician for 16 years. He has worked at this hospital for two weeks. He stated he would not perform the transvaginal ultrasound without a chaperone. When performing the transvaginal ultrasound he explains the procedure to the patient and gives the patient the option to decline having the procedure. He will then introduce the chaperone to the patient. The patient will have a privacy sheet over her. He shows the probe to the patient and then gives the probe to the patient so she can insert it herself. When asked about whether he used gloves during the procedure he stated he always used gloves. Staff 5 stated he always applied the gel to the probe and not to the patient. When the procedure is done, Staff 5 stated he removes the probe and gives the patient a towel to clean her self. Staff 5 stated he checks the probe to see if there is any blood. He does not wipe the patient to check for blood.


On 3/5/13 at 10:15 a.m., during an interview, Staff 1 stated there was no documentation used to track whether chaperones were used during the transvaginal ultrasounds. He stated he did not follow the technicians around. When asked how patient safety was ensured Staff 1 stated he did not give this issue a whole lot of thought until the incident happened.


The hospital's policy and procedure titled "Transvaginal Ultrasound," dated 12/09, indicated ...All male U/S [ultrasound] technologist's will have a chaperon[e] (hospital employed female) present during the procedure."


The hospital's policy and procedure titled "Patient Rights and Responsibilities Policy", dated 4/9/10, indicated "the patient has the right to: ...Considerate and respectful care. Personal privacy. Receive care in a safe setting, free from verbal or physical abuse or harassment."