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|SOUTHCOAST HOSPITALS GROUP||363 HIGHLAND AVENUE FALL RIVER, MA 02720||Jan. 18, 2011|
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|Based on interview and documentation review it was determined the Hospital failed to ensure ED medical record entries were complete in two (Patient #1 and Patient #4) out of 10 medical records reviewed.
The Hospital policy that addressed adult sexual assaults was reviewed. The Policy stated: A medical screening should be performed to rule out an emerging medical condition. Medical needs of the sexual assault victim always supersede the sexual assault exam. : If the Sexual Assault Nurse Examiner (SANE) is not available or the patient does not meet the criteria than the nurse and physician will provide needed care and services following SANE protocols.
Review of the Hospital's SANE protocols indicated patients need to be medically cleared and after all diagnostic testing is completed if a patient consents to SANE services the SANE is paged. If the SANE does not responded to a second page the ED staff is to complete an evidence collection kit, with the patients consent, including documentation forms following the kit instructions.
Clinical record review indicated Patient #1 presented to the Hospital's ED, at 6:42 PM reporting a sexual assault two days prior and requesting a SANE examination. At 6:59 PM the on-call SANE nurse was paged.
Review of ED documentation indicated the SANE was paged for a second time at 7:33 PM. At 7:30 PM a physical examination was performed by the Physician Assistant (PA) during which Patient #1 was tearful and anxious.
Review of 7:45 PM ED nursing documentation indicated the SANE had not called back. The PA indicated to nursing staff there was no need for a SANE evaluation. Documentation did not indicate why the evaluation was no longer needed.
Review of the PA's documentation did not indicated why the evaluation was not longer needed.
Review of Patient #4's clinical record indicated Patient #4 presented to the ED and reported an alleged sexual assault. Although documentation indicated a sexual assault workup was performed, documentation did not indicate a medical screening/physical examination was performed to rule out an emergent medical condition.