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.

ORANGE REGIONAL MEDICAL CENTER 707 EAST MAIN STREET MIDDLETOWN, NY 10940 March 22, 2016
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and interview, it was determined the facility failed to monitor, analyze, track and trend the quality of the care that was outsourced to an agency.

Findings include:

The facility's quality assurance and performance and improvement data was requested on March 22, 2016 for the contracted service to provide advocacy and Sexual Assault Forensic Examinations for victims of assault.

During an interview conducted on March 22, 2016 at 2:00 PM, the Chief Quality Officer stated there was no data or analysis of this service.
This is not in compliance with their policy for performance improvement.

The facility's "2015 Performance Improvements, Quality and Patient Safety Plan" states, the objective of the program is "to ensure that the outcomes of care/services delivered by the medical staff, professional, and non-professional staff is continuously monitored, evaluated and improved."
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on medical record review, document review and staff interview, it was determined that the facility failed to follow its policy for the care of patients that presented with a complaint of sexual assault and failed to document the disposition of forensic evidence. This finding was evident in one (1) of seven (7) medical records reviewed. (Patient #5).

Findings include:

Review of the medical record for Patient #5 revealed this sixteen year old patient presented to the emergency department (ED) on February 22, 2016 at 11:38 AM with a complaint of "unplanned sexual encounter." The patient was examined by a provider but there was no documented account of the assault. The patient was alert and oriented, nervous and anxious. The patient's pain score was 4 on a scale of "0" no pain to "10" the most severe pain, but there was no documentation of the location, onset or pattern of the pain.

There was no documented evidence that the Sexual Assault Forensic Examiner (SAE) arrived and/or that the sexual assault forensic examination was provided as per facility's policy for provision of care for sexual assault victims.

The facility's policy titled "Patient Abuse: Sexual Assault Victims: Adult, and Patient," last reviewed 1/16, states: "When a patient presents to the Emergency Department and indicates that she/he has been a victim of sexual assault, the triage nurse will immediately notify the Charge Nurse. The patient (victim)...will have the services of the Rape Crisis Program advocate and the Sexual Assault Examiner explained and offered." The policy states the process for initiating contact with the Rape Crisis Victim Advocate and the protocol for the sexual assault forensic examination.

The facility's staff could not report the location or disposition of the kit and forensic evidence, which is not in compliance with the facility's sexual assault policy.

The policy also states "The ORMC Healthcare Team will be respectful in their communication with and treatment of victims of rape and sexual assault, maintaining sensitivity to the trauma that such patients have experienced. The healthcare team will allow time to listen to and acknowledge the rape or sexual assault victim's feelings of anxiety, depression, pain and helplessness."
There was no documented evidence in the facility's medical record that this policy was followed as there was no documentation that the incident was discussed or that the patient's emotional needs were addressed.

The findings which were identified in the medical record were shared with Staff B, the Information Technologist during an interview on March 21, 2016 at 2:30 PM.


Review of the medical record for Patient #1 identified; patient presented on January 18, 2016 at 8:48 PM with a complaint of sexual assault that day at 6:00 PM, after she had just met the assailant. The advocate and SAE nurse who are contracted employees, provided care to the patient. A medical screening examination and complete work-up was done which included pregnancy test, hepatitis function panel, HIV and a urine culture.
The police was present and evidence, which included a rape kit, was collected but there was no documentation of the disposition of the kit.

The facility's staff could not report the location or disposition of the kit and forensic evidence.
This is not in compliance with the sexual assault policy which states "all specimens will be handed over to the police officer in the Emergency Department" or "stored in a locked and secure area in the SAE room for a period up to 60 days." The policy also sates the ED nurse will maintain the chain of evidence for all specimens: the police officer will sign the "Transfer of Evidence to Police" form and the "chain of evidence flow sheet" will be secured along with the specimens collected.


The findings which were identified in the medical record were shared with Staff B, the Information Technologist during an interview on March 21, 2016 at 2:30 PM.