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|PRESENCE SAINT JOSEPH HOSPITAL - ELGIN||77 N AIRLITE STREET ELGIN, IL 60123||Nov. 16, 2016|
|VIOLATION: COMPLIANCE WITH 489.24||Tag No: A2400|
|Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. This potentially affected all minors presenting to the Emergency Department (ED) with a alleged sexual assault.
1. The Hospital failed to ensure the patient received stabilizing treatment (A-2407).
|VIOLATION: STABILIZING TREATMENT||Tag No: A2407|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) records review, the Hospital failed to ensure the patient received stabilizing treatment.
1. The Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", (rev 9/15/16) required, "Once the MSE is completed and there is a determination that the patient either does not have an EMC or has an EMC that has been stabilized, the patient may be: treated; discharged if further care is not needed..., patient is given reasonable plan for appropriate follow-up care and discharge instruction...; for patients determined to have an EMC, the hospital shall 1. Examine and treat the patient to stabilize the EMC within the Hospital Capability...."
2. The Hospital policy titled, "Sexual Assault" (rev 11/6/13) required, "...will provide medical treatment services to sexual assault survivors. ...Medical Procedures: a. Medical treatment: Appropriate medical examination and testing will be performed...treatment may include but not limited to: General examination,... Pregnancy test for all females of child bearing age, ...Prophylaxis for sexually transmitted disease..., Tetanus prophylaxis,... Hepatitis B vaccine or hepatitis serology... HIV testing should be considered... Emergency Contraceptive...."
3. The Hospital's "Patient Care Departments Scope of Services 2017" for the Emergency Department, under Patient Population Served indicated "The scope of services provided include but are not limited to trauma, cardiac, medical surgical, pediatric, orthopedic, ENT (ear, nose, throat) psychiatric, urologic, obstetrical/gynecological and neurological. Our Emergency Department is recognized by the State of Illinois for both Level II Trauma Center and Emergency Department Approved for Pediatrics for Emergency Medical Services Region 9."
4. The clinical record for Pt. #1 was reviewed on 11/15/16. Pt. #1 was a [AGE] year old female who presented to the Emergency Department (ED) on 10/19/16 with a complaint of sexual assault. The triage at 12:37 PM indicated a triage level of 3... Vital signs were: T-97.2; P-75; R-18; BP-118/71; Oxygen Saturation 98.2 %. The Physician's history and physical indicated the following, "Chief complaint: Sexual Assault Forensic Exam, ...14 y/o female presents to ED with c/o sexual assault. The history and physical examination included: " General appearance- no acute distress, ...well hydrated; Neck: supple, ... no marks on Neck; Cardiovascular: Heart sounds normal, Regular rate and rhythm; Respiratory: breath sounds nml (normal) & equal, No respiratory distress; Abdomen : Normal exam, Non-tender, normal bowel sounds; Extremities: ...old bruising bilateral knees; Neurological: Normal exam ...no focal deficits; Skin/Hair/Nails: Mild [DIAGNOSES REDACTED] left clavicle; Behavioral Health/Psych: Normal exam. Impression: Alleged sexual assault. Reevaluation notes: Discussed case with Dr...Pediatric attending at ...(Hospital #2)...." At 1:35 PM the physician documentation indicated: " Discussed with DR ...(Hospital #2) discussed care and accepts transfer to ...(Hospital #2). The patient/family was/were counseled about the nature of the medical problem and appropriate follow up was discussed. " The physician's documentation did not include any vaginal/pelvic examination or collection of evidence and Pt. #1 did not receive any further treatment for the chief complaint of sexual assault, as required by policy. Pt. #1 was transferred to Hospital #2 on 10/19/16 at 2:43 PM.
5. The Physician (MD #1) who provided care to Pt. #1 was interviewed on 10/19/16 at approximately 9:30 AM, and stated that there is no protocol specific for pediatric sexual assault victims. MD #1 also stated Pt. #1 received a history and physical exam, but that the actual pelvic examination was not done.
6. The Pediatrician (MD #2) who was on-call on 10/19/16 was interviewed by phone on 11/16/16 at approximately 3:00 PM. MD #2 stated that she was not called about Pt. #1.
7. Pt. #1's clinical record from the receiving hospital (Hospital #2) was reviewed on 11/17/16. The record indicated the following: "Pt. states she was sexually assaulted this morning. Was seen at ...(hospital #1). Transferred to... (Hospital #2) for evaluation and potentially, evidence collection." The clinical record included documentation of a full physical examination by an NP (Nurse Practitioner) indicating the following: "abnormal findings include petechiae lesions and [DIAGNOSES REDACTED] to R (right) breast, and L (left) anterior shoulder which Pt. reports was from...(perpetrator) sucking her R shoulder and R breast. Superficial tears x 2 to fossa navicularis. [DIAGNOSES REDACTED] to mid neck. Injuries c/w history provided. Documentation of treatment included: "Pregnancy prophylaxis...The medication and side effects were discussed...Ella (emergency contraceptive) was administered after negative urine test was confirmed. Zofran was administered to prevent nausea and vomiting. ...Patient was given STD prophylaxis, ... HIV prophylaxis was indicated. The risk and benefits... as well as the instructions for administration and follow-up was discussed..., The patient was prescribed... given the first dose in the Emergency Department and was discharged with remaining 28 day course. The patient is to follow up with ...(children's hospital) special ID (infectious disease) clinic....Discussed importance of medication compliance."