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SHANDS LAKE SHORE REGIONAL MEDICAL CENTER 368 NE FRANKLIN ST LAKE CITY, FL 32055 June 1, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interview and reviews of medical records and facility policies and procedures the facility failed for perform a medical screening examination on individuals presenting to the Emergency Department seeking emergency medical treatment when a request was made on her behalf for 1 (Patient #27) of 27 samples patients.
Refer to tag A-2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on staff interview and record review the facility failed to ensure that for 1 of 27 patients, (Patient #27), that present to the Emergency Department requesting services were entered into a Central Log.

Findings

Interview with the facility risk manager on 06/01/2015 at 9:15 AM revealed that an Officer with the Lake City Police Department entered the hospital thru the emergency room ambulance entrance on 04/15/2015 between 08:00 and 09:00 with a victim of alleged sexual assault. The Officer proceeded to the Nursing Station with the victim and spoke to the Emergency Department Physician. The Risk Manager stated that the physician was alone at the nursing station and when he was asked by the Officer to perform a rape kit he stated that the facility do not do rape kits and the Officer would need to take the victim to Gainesville. At that point the Officer left the facility without speaking to any other of the facility staff.

Facility documentation failed to reveal that the victim, (Patient #27), was ever logged into the system, or was not any information was documented that identified patient #27. The facility failed to provide any documentation that Lake City Police Department had requested a rape kit be performed. by the ER physician or that the ER physician had informed any of the ER staff of the request for a Rape Kit evaluation made by law enforcement.

Review of the facility policy and procedure titled Emergency Medical Treatment and Patient Transfer with a Revision Date of 09/01/2013 revealed "Central Log means a log the Hospital maintains of all individuals who present to the Hospital seeking emergency medical assistance an the disposition of such individuals, whether the person refused treatment, was transferred, was admitted and treated, was Stabilized and Transferred, or discharged . The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an Emergency Medical Condition. The Central Log Must include patient logs from other areas of the hospital, including Labor and Delivery, where a patient might present for emergency services or receive a Medical Screening Examination instead of a Dedicated Emergency Department.".
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on staff interview and review of medical records and facility policies and procedures the facility failed for perform a medical screening examination on individuals presenting to the Emergency Department seeking emergency medical treatment when a request was made on her behalf for 1 (Patient #27) of 27 samples patients.

Findings

Interview with the facility risk manager on 06/01/2015 at 9:15 AM revealed that an Officer with the Lake City Police Department entered the hospital thru the emergency room ambulance entrance on 04/15/2015 between 08:00 and 09:00 with a victim of alleged sexual assault. The Officer proceeded to the Nursing Station with the victim and spoke to the Emergency Department Physician. The Risk Manager stated that the physician was alone at the nursing station and when he was asked by the Officer to perform a rape kit he stated that the facility do not do rape kits and the Officer would need to take the victim to Gainesville. At that point the Officer left the facility without speaking to any other of the facility staff.

Interview with the Risk Manager on 06/01/2015 at 9:15 AM, revealed that it is the facility policy to perform a medical screening examination for all patients that enter the ER, without exception.

Facility documentation failed to reveal that the victim, (Patient #27), was ever logged into the system, or was not any information was documented that identified patient #27. The facility failed to provide any documentation that Lake City Police Department had requested a rape kit be performed. by the ER physician or that the ER physician had informed any of the ER staff of the request for a Rape Kit evaluation made by law enforcement.

Review of the Policy and Procedure titled EMTALA Medical Screening Stabilization Policy, revised 09/01/2013 revealed : "In general, when an individual comes, by himself or herself, with another person, or by EMS to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department an emergency services offered at outpatient departments of facility) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in active labor; and if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these polices. These same requirements apply if a prudent layperson would believe the individual is in need of an emergency examination or treatment.".

The medical record for patient #27 from Hospital B was reviewed. Review of the Emergency patient Record indicated that patient #27 presented to Hospital B on April 15, 2015 at 8:08 a.m. The patient was triaged as a level 3 at 8:20 a.m. . . . . Further review revealed the patient's " Chief complaint was " Sexual Assault. " The Subjective Assessment indicated in part, " Went home and her mother contacted the Lake City Police and Pt. (patient) is accompanied by officer ...Pt is very distraught, tearful and anxious. " Patient #27 was seen in the Emergency Department by the provider at 0814 am. Review of the HPI (History of Present Illness) revealed in part, " Source of History ... patient. . Location-penetration: vaginal. Location of pain/injury: head (thinks she was punched) . . . Additional hpi notes ...some bleeding afterwards. Went home called police, here with (Lake City policeman) ...Physical Exam-Sexual Assault. . . Female GU (genitourinary) normal external ...no vaginal injury, chaperone present, bleeding ...MDM (medical decision making) . . . Sexual Assault Kit Completed: Physician ...Sexual Assault Management. . . STD (sexually transmitted disease) Prophylaxis given. "

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination on Patient #27 on 4/15/2015, when a request was made on her behalf by the Lake City Police Officer for medical examination and treatment.