HospitalInspections.org

Based on record review, review of facility documentation and staff interviews, the facility failed to maintain an accurately written medical record, as patient #1's physician did not order a SANE exam.

Findings were:

Patient #1 was admitted to the facility on 5-21-25. A review of the history and physical performed by staff #7 on 5-21-25 stated the following as part of the physician's plan:
"5. Suspected elder abuse: We are getting a SANE [sexual assault nurse examiner] and will follow-up with the results."

A review of the admission nursing assessment, nursing notes and case management notes gave no indication that the patient or her daughter had made an outcry to anyone other than the attending hospitalist.

A review of physician's orders revealed no order to transfer the patient to a facility that could perform a SANE exam.

The patient was discharged to a nursing home on 5-28-25. Her discharge summary stated, in part:
"Suspected elder abuse:
A sexual assault exam cannot be completed at BSA is not set up for that. The case manager did try to reach out to police Department Friday evening without receiving a call back calling before she left for the day and now she is out of the time period for proper exam."

Facility policy 26578.12 titled "Abuse and Neglect Identification - Reporting Sexual Assault" states, in part:
"F. Patients presenting with sexual assault or suspected sexual assault will be referred to the nearest SAFE-ready (SANE - Sexual Assault Nurse Examination) facility after having an appropriate medical screening exam.
1. Case Management and/or the RN will:
a. Interview and assess the patient's status.
b. Notify physician of complaint
c. Notify the House Supervisor regarding pending transfer
d. Contact Amarillo Police Department for investigation.
e. Contact SAFE-ready (SANE) facility, alerting them to the transfer
f. Complete Memorandum of Transfer
g. Transfer patient via:
i. APD escort.
ii. Ambulance as indicated by patient status."

In an interview with staff #9 at 10:00 am on 8-4-25, she was asked if BSA Hospital was a SAFE-ready facility and she stated that it was not. She stated that Northwest Texas Hospital was a SAFE-ready hospital and that the patient would have needed to be transferred there by ambulance if she was needing a SANE exam. When asked if a transfer would require a physician's order, she stated that it would.

The above was confirmed in an interview with the Director of Quality and other administrative staff on the afternoon of 8-4-25.