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.

LOVELACE MEDICAL CENTER 601 DR MARTIN LUTHER KING JR AVE NE ALBUQUERQUE, NM 87102 May 3, 2019
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on record review and interview, the facility failed to have a policy or procedure for rape victims in the Emergency Department. This failed practice resulted in a patient not receiving the treatment needed and places other patients at risk for unmet patient needs. The findings are:

A. Record review of medical chart for P#21 revealed the patient stated she had been raped. NP notes signed and dated 12/02/18 at 8:33 pm indicated, "Mse: 41 yo [year old] female presents pov with c/o "rape" [sic] "earlier", [sic] will not elaborate, no obvious trauma." Triage note by RN signed and dated 12/02/18 at 8:39 pm indicated, "When asked what brought her in she stated 'rape' when asked when she stated 'I don't know some time today.' Denies hi/si [sic] She then became passive aggressive and unwilling to answer any other questions. Called charge nurse and security. Pt then asked again if she wanted the cops called for her complaint she said no and refused to talk. When charge nurse [nurse's name] asked if she wanted medical attention she refused to speak. Asked 3 more times and warned that she will be escorted off property. She continued not to answer any questions and was asked to leave. She grabbed her belongings and left the premesis [sic]."

B. On 05/ at 9:15 am during interview, the ED Director stated, "There is no protocol for rape, we do not have a policy; it is not policy to ask patient to leave. There is no criteria to call APD or to get a SANE nurse here."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to provide an appropriate medical screening examination for 2 (P#20 and P#21) of 22 patients. This failed practice puts patients at risk of not receiving proper medical care resulting in unmet patient needs. The findings are:

A. Record review of medical chart triage notes dated 12/02/18 at 20:33:26 (8:33 pm) for P#21 revealed patient stated she had been raped but "would not elaborate, no obvious trauma." Triage notes dated 12/02/18 at 20:39:40 (8:39 pm) indicated the patient was asked what brought her in and she stated "rape" and "became passive aggressive and unwilling to answer any other questions. Called charge nurse and security. Pt [sic] then asked again if she wanted the cops called for her complaint she said no and refused to speak. Asked 3 more times and warned that she will be escorted off property. She continued to not answer any questions and was asked to leave. She grabbed her belongings and left the premesis [sic]."

B. On 05/01/19 at 9:15 am during interview, the ED Director stated, "There is no real protocol for rape. There was no screening exam because the patient left before the exam could be completed. But no one would ask her to leave. They just wouldn't." He also stated, "There is no SANE nurse on staff, one would have to be called in. We will call APD if the patient asks. But we have no criteria to call APD or to get a SANE nurse. Could we have done more? Yes. Maybe we could have called Pastoral at that hour, it would have been difficult to get Behavioral [department] here."

C. On 05/01/19 at 9:15 am during interview the Chief Medical Officer stated, "A SANE exam is usually done and APD called. Behavioral [department] should have been involved."

D. Record review of medical chart for P#20 revealed chief complaint of a [AGE] year old male "arrived POV with parent stating there is growth on his penis which had been there for 3 weeks." Vital signs and labs were taken. There was no evidence of the patient's penis was not examined.

E. On 5/01/19 at 11:30 am during interview, the ED Director stated he "would expect that a provider would look at that."