The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


A. Based on review of Hospital policy, review of Incident log and report, clinical records review and staff interview, it was determined that for 1 of 1 (Pt. #1) patients alleging sexual assault, the Hospital failed to implement their Sexual Assault policy by not conducting a comprehensive medical examination of the alleged rape victim.

Findings include:

1. The policy titled, "Alleged Sexual Assault Survivor Protocol" was reviewed on 2/28/11 at approximately 11:00 AM. The policy required, "Purpose: to provided guidelines for conducting comprehensive medical exam..."

2. The Incident logs for January 1, 2011 -February 27, 2011 were reviewed on 2/28/11 at approximately 11:00 AM. The Incident logs contained 2 documentation of sexual incidents involving Pt. #1 dated 1/24/11 and 1/30/11.

3. The 2 Incident reports for Pt. #1 were reviewed on 2/28/11 at approximately 11:00 AM. The first report dated 1/24/11 alleged that E #3 (Attending Psychiatrist) directed Pt. #1 "to have sex." The second incident report dated 1/30/11, indicated that Pt. #1 reported being raped by another patient (not identified in the report). Date and time of each incident report was undocumented and the reports lacked documentation that Pt. #1 received an examination or reason an examination was not conducted. However Pt. #1 was immediately relocated to room 439, an all female area of the unit.

4. The clinical record of Pt. #1 was reviewed on 2/28/11 at approximately 10:00 AM. Pt. #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of Bipolar Disorder. The Psychological History assessment dated [DATE] indicated a history of Post Traumatic Stress Syndrome (PTSD) related to physical abuse from previous relationships. The record indicated Pt. #1 has " Flashbacks " of the abuse. The history included allegations of sexual rape in her apartment in the past, in 2002 by a stranger, by a staff at another hospital, and by another patient at this Hospital in 2003. The Attending Physician documentation dated 1/22/11, indicated the following: " The patient is making slow progress overall at this juncture. She is highly delusional and still quite preoccupied with sexual issues from the past, insisting she has been abused on a number of occasions and that no one understand or listens to her.. I told the patient that we certainly want to take her seriously but that there are so many issues related to her having been sexually abused that it seems like perhaps it ' s some sort of diversion from her actually working on identified treatment goals and objectives .... " The clinical record did not indicate that Pt #1 made any allegations of rape against a counselor, E #1, however the clinical record indicated that an allegation was made against her Attending Psychiatrist (E# 3), and other patients in the unit.

A Mental Health Counselor (MHC) documentation dated 1/24/11 at 10:45 PM indicated Pt. #1 reported that E #3 "...told me to take off my pants and to have sex." The record did not include documentation of a patient assessment, examination or that a rape kit was offered after the allegation was made against E #3. The sexual assault allegation identified on the Incident log against another patient was not documented in Pt. #1's clinical record, and no assessment and examination was documented after the report was made of the sexual assault.

5. The Nurse Manger of the Behavioral Unit was interviewed by telephone on 2/28/11 at 2:00 PM. The Manager stated that she was notified of each incidents by the RN who received the reports from Pt. #1. She indicated that Pt. #1 recanted the first allegation involving E #3 during staffing and that Pt. #1 stated that she was confused. However, on the second allegation against another patient, the Manager indicated that the the allegation was not investigated because the psychiatrist indicated that the allegations made by Pt. #1 was delusional.

6. The Clinical Nurse Specialist and the Chief Nursing Officer (CNO) were interviewed on 2/28/11 at approximately 3:15 PM. The Hospital policy on Sexual Assault policy was requested. A Behavioral Health policy was presented, however the policy did not address what to do if a patient was sexually assaulted. The protocol included "Inappropriate sexual activity is interrupted by the person who feels that it is inappropriate...." The Sexual Assault Policy was presented however the CNO and Clinical Nurse Specialist were not familiar with the contents of the policy.

7. The above findings were confirmed during the interview with Clinical Nurse Specialist and the CNO on 2/28/11 at approximately 3:45 PM.