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PROVIDENCE ALASKA MEDICAL CENTER 3200 PROVIDENCE DRIVE ANCHORAGE, AK 99508 May 9, 2011
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure appropriate hospital staff were notified and an Unusual Occurrence Report (UOR) was generated after a patient alleged assault while in the emergency room during a previous visit. As a result, the patient's grievance was not reported and responded to in a timely manner and in accordance with hospital policy. Findings:

Clinical record review on 4/11/11 revealed the patient presented to the emergency room (ER) via ambulance on 3/31/11 with chief complaints of [DIAGNOSES REDACTED] and altered mental status. The patient was admitted for further evaluation and dialysis. She was discharged on [DATE].

On 4/3/2011 the patient was brought to the ER by Emergency Medical Services (EMS) staff from an urgent care center for altered mental status. Documentation by RN #1 at 1:53 pm revealed the patient was crying and stating she had been assaulted. Additional documentation by RN #1 at 1:58 pm revealed the patient repeated she had been assaulted. When RN #1 asked the patient where she was assaulted she stated "here, in a small room". Documentation by RN #2 at 2:34 pm revealed the patient told RN #2 that she was sexually assaulted 'here' 3 days ago. Review of the ER physician's history and physical revealed the patient claimed she was assaulted by someone at the hospital.

Review of the hospital's "Patient Complaint Management" policy and procedure, revised date of 10/07, Included: "...II. Policy In keeping with the philosophy and mission of Providence Health & Services, Providence Health & Services Alaska provides systems to receive, promptly investigate, respond to, and resolve complaints made by patients/residents and their families...IV. Special Considerations A. Patient (resident/client/visitor) complaints must be documented through the appropriate facility complaint or UOR form..V. General Instructions A. Upon receipt of the complaint, document in the electronic UOR (RESPOND Software) or the appropriate format for the facility. 1. If the complaint is regarding a current patient or resident, transfer responsibility for resolution of the complaint to the Manager of the appropriate area..."

During an interview on 4/21/11 at 10:40 am with RN #1 and the Accreditation Program Coordinator Performance Improvement, RN#1 was asked what the process was for reporting if a patient told a nurse they had been assaulted in the hospital. RN #1 stated he would tell the charge nurse and follow up to be sure it had gotten to the supervisor level, and at the very least, the social worker. Asked if he would generate a UOR, he stated if the charge nurse or social worker was there he would leave that up to one of them. The Accreditation Program Coordinator Performance Improvement confirmed a UOR would generate an investigation and also stated that in incidents such as this, the social worker would be called. She confirmed with social service staff that no one in social services had been notified. In addition, she confirmed that physicians can also generate a UOR.

During an interview on 4/11/2011 at 10:15 am with the hospital's Service Excellence Coordinator, she confirmed the patient called her on 4/7/2011 regarding the incident and an investigation was started. Further interview at 12:05 pm with the Accreditation Program Coordinator Performance Improvement, confirmed an unusual occurrence report (UOR) had not been generated until the patient's phone call on 4/7/2011.

As a result, an UOR was not generated and no other staff was notified of the patient's allegation of assault during an ER visit that had been documented by 2 registered nurses and 1 physician. It was not until 4/7/2011, 5 days after the allegation was made, that the incident generated an UOR and an investigation was started. This was in response to the patient calling the hospital and reporting her recollection of the incident.