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RUTLAND REGIONAL MEDICAL CENTER 160 ALLEN ST RUTLAND, VT 05701 June 23, 2011
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on staff and patient interviews and record review the hospital failed to assure that an appropriate MSE (Medical Screening Examination), to determine whether or not an EMC (Emergency Medical Condition) existed, was conducted for 2 of 4 applicable patients who presented to the Emergency Department (ED) (Patients # 1, 4) Findings include:

1. Per review of ED record, Patient #1 arrived in the ED on 6/16/11 with a chief complaint of sexual and physical assault and was triaged at 10:11 PM by Nurse # 1, who identified themselves as being a Sexual Assault Nurse Examiner (SANE) nurse. After the triage process the patient was placed in the family waiting room, but was informed by Nurse #1, that although h/she is able to conduct the SANE exam, their shift was over at 11:00 PM and they were unable to stay. The Shift Manager of the ED attempted to reach an "On Call" SANE nurse, but was unsuccessful resulting in Patient #1 being informed by Nurse #1 a SANE exam could not be performed on 6/16/11. The patient was not made aware a SANE exam could still have been conducted by an assigned nurse and ED physician. The patient was apprised by Nurse #1 to return at 11:00 AM on 6/17/11 and h/she would be working and available to perform the SANE exam. Nurse #1 also informed the patient she could drive 68 miles to Burlington, VT and seek treatment at Fletcher Allen Medical Center. Unaware of her rights to obtain a Medical Screening Exam, or the opportunity to have another nurse assist with her immediate emotional and physical needs, and not being apprised of the formal transfer process to a tertiary hospital, Patient #1 was told to sign the "Refusal of Medical Screening" form with the acknowledgement she would return to the ED at 11:00 AM on 6/17/11. Per interview on 6/22/11 at 2:10 PM, Patient #1 stated " I did not ask to leave...I did not know I was refusing help....I did not refuse an exam......I was very upset".

Per review of hospital policy "Sexual Assault Protocol" (last approved 8/1/2010) when a sexual assault victim presents to the ED the Triage nurse is to advise the shift manager of the patient's arrival. Upon notification, the shift manager is to contact a SANE nurse. The policy further states: " If a SANE is not available, the shift manager will assign the victim to a staff nurse who will initiate the sexual assault protocol. The pelvic exam with specimen collection and documentation of same will be done by the physician" . Per interview on 6/24/11 at 8:37 AM the Shift Manager confirmed h/she was informed on the evening of 6/16/11 by Nurse #1 that Patient #1 had presented to the ED with a complaint of being sexually assaulted. The Shift Manager confirmed calls were made to the "on call" SANE nurses, but no one was available. However, after informing Nurse #1 there were no SANE nurses available h/she was unaware what was said to the patient by Nurse #1. Although the Shift Manager was aware of the hospital policy regarding assignment of a nurse when a SANE nurse is unavailable, this option was not considered by either the shift manager or Nurse #1 nor was there the consideration of ensuring a MSE was conducted regardless of whether the patient consented to having a SANE exam performed. Per interview on 6/24/11 at 8:45 AM the Nursing Director for Emergency Services stated "all patients need to be seen by an ED physician."

Per interview on 6/22/11 at 4:50 PM, Nurse #1 confirmed h/she failed to explain on 6/16/11 to Patient #1 the difference between a SANE exam and a Medical Screening Exam prior to having the patient sign the refusal form for medical screening and failed to inform her a female nurse could have accompanied the patient when examined by the ED physician. Per interview on 6/23/11 at 4:05 PM, Nurse #1 also confirmed although h/she has been trained as a SANE nurse, h/she was unaware of the hospital policy pertaining to assigning the victim of a sexual assault to another staff nurse if a SANE nurse is unavailable.

In addition, Patient #1 stated on 6/22/11, upon return to the ED on 6/17/11 at 10:45 AM for the SANE exam, Nurse #1 had not informed her she was not required to consent to a SANE exam in order to obtain prescriptions for STD and pregnancy prophylaxis medications. Due to the trauma of the assault, Patient #1 stated she was not sure she wanted to be subjected to the exam but had felt coerced by the nurse to consent. It was not until she spoke with the police and Rape Crisis staff that she was appraised of her rights as a sexual assault victim to include being seen by a physician when she initially requested treatment on 6/16/11 and receiving prophylaxis medications regardless whether she had consented to having a SANE exam conducted.

2. Based on record review and staff interview, there was no evidence of physician assessment and/or Medical Screening Exam (MSE) for Patient #4, who presented to the Emergency Department (ED) on 3/12/11 at 10:16 PM following an assault. The nursing triage notes by Nurse #2 at 10:17 PM stated "Chief Complaint: Pt assaulted, 38 weeks pregnant, complaining of left rib and arm pain, abdominal pain." The "Rapid Pain Assessment" noted that Patient #4 had a constant, aching, sharp pain in the left chest with a numeric pain scale of 8. There was no evidence of a physician assessment/medical screening examination for Patient #4 upon arrival to the ED or prior to transfer to the Women and Children's Unit (WACU) for fetal assessment in accordance with hospital policy & procedure.

"Triage of Pregnant Patients from the Emergency Department to the Birthing Center" (last approved on 8/1/2010) states "All other patients who are 24 weeks, or more, pregnant will be quickly evaluated in the triage room by the Emergency Department Physician, if the patient is in obvious labor or the presenting complaint is determined to be directly related to the pregnancy, the OB Physician will be notified and arrangements will be made to send the patient to the Birthing Center, accompanied by a nurse, if they are stable to do so" and "if a woman presents 20 weeks or more pregnant, who has a deceleration injury or direct abdominal injury, the Emergency Department will treat the patient's injuries and then contact the OB physician about the patient. The patients will then be sent to OB, if they are stable to do so, for fetal monitoring with copies of the Emergency Department Record."

During interview on 6/23/11 at 2:15 PM, the Nursing Director of ED Services and an ED physician confirmed there was no evidence of a physician assessment and/or MSE. The ED physician stated during interview, " Maybe the physician thought she was stable and she was sent to Women & Children's Unit." The lack of documentation of physician assessment was also confirmed on 6/24/11 at 10:05 AM by the Director of Health Information Management.

Documentation by ED personnel did not include the time Patient #4 was transferred, the condition of the patient or who requested the transfer to WACU. Per review of WACU notes, an order was obtained from a WACU physician on 3/12/11 at 11:37 PM for a Fetal Nonstress test. Patient #4 remained on WACU for a total of 44 minutes before returning to the ED. WACU nursing notes on 3/12/11 stated "Primary provider notified. Pt to return to ED." Per record review, there was no documentation by ED staff when patient #4 returned to the ED, condition, location of the patient or evidence of physician assessment by an ED physician or physician from WACU.

Per interview on 6/24/11 at 8:15 AM, Nurse #2 who was the triage nurse when Patient #4 arrived stated "I reported to the charge nurse after triage.. not sure if Dr. was involved.... it would have been his shift.....charge nurse may have told the physician she seemed okay...would need to be seen by the physician for screening before going upstairs." Nurse #2
said h/she did not believe Patient #4 was seen by a physician.

An ED nursing note dated 3/13/11 at 1:17 AM stated " Pt not in either waiting room at this time. Pt was initially sent to WACU for fetal monitoring. WACU reports that they brought pt back down to ED after clearing her." A second ED nursing note dated 3/13/11 at 3:56 AM stated " Pt not in either waiting room for the second time, charge nurse aware." A "Refusal of Medical Screening Exam" stating Patient #4 "left without being seen or informing staff" was signed by Nurse #2. Nurse #2 confirmed during interview on 6/24/11 at 8:15 AM that h/she completed the "Refusal of Medical Screening Exam" when Patient #4 couldn't be found. The patient's name was added to the section the patient/guardian would sign if refusing treatment. Nurse #2 stated h/she didn't know where Patient #4 was brought to (treatment room or ED waiting room) from WACU following fetal monitoring since h/her triage responsibilities ended at 11:00 PM.