HospitalInspections.org

Based on interview and record review, the facility's Emergency Department (ED) staff failed to follow the facility's Patient Care policy (direction for staff after identification of suspected patient abuse/neglect) and the Victim of Violence policy (direction for staff after identification of a patient assault) for one (#20) of one patient when she was allegedly sexually assaulted in the ED.
The facility failed to recognize and take immediate steps to minimize the opportunities for assault to other patients who could not verbally communicate or use the nurse call light.
The cumulative effect of these deficient practices had the potential to place all patients who were unable to communicate, at risk for their health and safety (also known as Immediate Jeopardy - IJ).
The average number of patients seen in the ED was 185 daily (66,660 per year).
The facility staff implemented actions to abate the IJ and provided an acceptable plan of correction to minimize any further immediate risks by the end of the survey.

Based on interview and record review, the facility failed to ensure:
- Emergency Department (ED) staff followed the facility's Patient Care policy and Victims of Violence (VOV) policy when staff did not recognize and report (to their supervisory staff) the alleged sexual assault of one patient (#20) of one patient while in the ED;
- All staff was re-educated in identifying at risk patient's (such as those who cannot verbalize a safety concern or those who cannot use a nurse call light) because of their medical condition;
- All staff was re-educated on the Patient Care policy and VOV policy for reporting sexual assault to their own supervisory staff;
- Interventions were put into place to prevent further possibilities of assault.

These deficient practices and lack of following established policies for suspected or actual sexual assault had the potential to cause an adverse outcome for all patients who were at risk.

Observations were made for 13 patients in the ED. Interviews of 19 patients (four in the ED) and 39 staff including Registered Nurses (RN) Physical Therapist (PT), Clinical Partners (CP), Security, Physicians, Unit Secretaries, and Administration were completed during the survey. The facility census was 313.

Findings included:

1. Record review of the facility policy titled, "Patient Care Policy: Assessment, Investigation and Reporting of Suspected Abuse/Neglect" revised 12/04/12, showed direction for facility staff:
- To describe the process for assessment, investigation and reporting of suspected abuse/neglect.
- To protect the rights and safety of all patients by assessing, investigation, and reporting suspected abuse and neglect.
- In the event a patient, or his/her representative, makes an allegation that abuse or neglect of the patient occurred while a patient was on the hospital's campus, or if abuse or neglect of a patient is witnessed by staff, the following steps shall be followed:
- The staff member receiving notification of the allegation that abuse or neglect has occurred and/or has witnessed the abuse or neglect on the hospital campus, shall notify their CSN (Clinical Support Nurse) or department equivalent, who will then notify the Administrative Supervisor and Security (if appropriate).
- The CSN or department equivalent shall notify the Team Leader or Director responsible for the unit on which the alleged abuse or neglect occurred after securing the safety of the patient.
- The CSN or department equivalent coordinated, notifying attending physician/psychiatrist, and as needed seek necessary order for appropriate consult, treatment or interventions.
- Notify Risk Management, who will work with the Director/Team Leader to begin an investigation, determine if disclosure is needed.

2. Record review of Patient #20's medical record showed the patient was brought to the ED on 06/19/13 at 2:46 PM with altered mental status and headache which caused her to be unable to communicate or move her extremities. The patient was promptly evaluated for neurologic causes of these symptoms. The patient was unable to answer questions related to her condition or to her history.

3. Record review of the ED documentation dated 06/19/13 showed that between 5:05 PM and 5:45 PM the patient's monitor alarm sounded and a nurse entered the room. There was a visitor in the room. Although the patient was still unable to speak or use the nurse call light, the patient utilized eye movements and facial expressions to notify the Registered Nurse, (RN) that she was uncomfortable with the visitor.
Further review of the medical record showed that at 5:41 PM Staff R, ED RN, documented, "patient tells RN she is afraid of visitor and does not wish to have him in the room. Patient reports inappropriate activity from visitor since being in the ED and is scared. Visitor asked to leave, charge nurse notified, Patient is alert and answering questions appropriately".

4. Record review of facility undated document titled, "Risk Management Investigation" showed that the Risk Management department was made aware of the patient's concerns on the afternoon of 06/20/13 and the internal investigation began. The document further showed that after investigation of the incident, staff assessed "No opportunities were identified (for improvement)".

5. Record review of the facility policy titled, "Protective Status for Patients (Victim of Violence - VOV) revised 07/02/11, directed the following:
When victims of violence are identified, appropriate and timely intervention is taken in order to provide for the safety and protection of all patient, visitors and employees. The purpose of this policy is to ensure the proper identification, registration and safety of our patients that present as a Victim of Violence (VOV) during their stay in our facilities to provide protection for all patients, visitors and employees. (Refer to Abuse policy if abuse is suspected).
-Victim of Violence (VOV) includes, but is not limited to Alleged Sexual Assault.
-Notification:
-Emergency Department Clinical Support Nurse or Primary Care Nurse immediately notifies security department of either actual or potential VOV.
-Once the patient is identified as a potential VOV, Security is responsible to notify:
Patient Access
-CSN/Charge Nurse of Unit
-Police/Investigation agency, when appropriate Public Relations or on-call representative for high profile case or other leadership members.
-Administrative Supervisor
Security:
-Security notifies Patient Access
-Goldenrod sticker on patient arm band is applied by Security.
-A Security officer remains with the patient while they are in the Emergency Department as needed to provide for a safe environment.
-Security checks to see that the area is secure.
-Additional protective status is determined jointly with Nursing, Security and the appropriate investigative agency.
Patient Access:
-The patient will be identified in EPIC {the computer medical record system} with three stars *** on the ED Track Board and with a "Yes" in the Private/VOV column on the list.
NURSING UNITS Responsibilities:
-Hands-off information is communicated verbally that the patient is a VOV.
-Notify Security for patient movement/discharge for appropriate escort.
VOV Patient Movement:
-If after the patient has been admitted and requires transfer to another nursing unit:
-Transferring unit notifies Security.
-Security assists in the transfer, as appropriate.
-Security orients the receiving nursing unit regarding the VOV status.
-Security confirms the room has been appropriately secured.
-If the patient needs to be transferred off the unit for a procedure/test (e.g. chest x -ray), follow the same procedure as when patient requires transfer to another nursing unit.

6. During an interview on 07/10/13 at 10:00 AM, Staff Q, ED RN, stated that the patient told her that the visitor had touched her under the covers and that's how he knew she was on her period. Staff Q stated that the patient told her she heard the visitor wash his hands afterwards and heard the visitor tell staff that the patient was on her period. Staff Q stated that the patient stated she was not able to speak or move but was able to hear and was aware of everything that was going on while it was happening. The patient was now alert, oriented and conversant. Staff Q stated she did notify the charge RN of this event but, did not generate an incident report or notify the house supervisor. Staff Q stated that upon reflection, she felt the incident did appear to be sexual molestation but was not sure what additional steps she should have taken. Staff Q stated that she was not aware of any changes in policy or process related to this event since the incident.

7. During an interview on 07/10/13 at 10:35 AM, Staff R stated that the patient told her the visitor pulled the patient's gown up and touched her inappropriately. Staff R advised Staff Q (her preceptor as this was Staff R's first day on the unit) of the allegation and they notified Staff N, Charge Nurse, of the event. Staff R stated she did not complete an incident report or notify the house supervisor. Staff N stated that she did not transport the patient to the 5th floor and didn't know who did.

8. During an interview on 07/10/13 at 10:45 AM, Staff N stated that she was made aware that the patient had been touched under the covers by a visitor and the patient was uncomfortable. Staff N stated that the visitor had been asked to leave and she attempted to call the Security Department but, there was no answer. She notified the triage desk that this patient could not have visitors. Staff N stated that at the time it did not click that this was a sexual assault but that in retrospect it was a sexual assault. Staff N did not notify the house supervisor or generate an incident report.

9. During an interview on 07/09/13 at 9:15 AM, Staff D, ED RN, stated that he had heard of no changes in practice for patients of suspected abuse and neglect and he had not received any additional education on the policies "Abuse and Neglect" or "Victims of Violence" since 06/19/13.

10. During an interview on 07/09/13 at 10:10 AM, Staff J, ED RN, stated that she had received no additional education on the policy for "Abuse and Neglect" or the policy for "Victims of Violence" since 06/19/13 (after the assault).

11. During an interview on 07/09/13 at 10:20 AM, Staff K, ED RN, stated that there had been no change in practice for suspected abuse or neglect and no education or discussion about the reporting of abuse and neglect or discussion about the policy related to "Victims of Violence" since 06/19/13 (after the assault).

12. During an interview on 07/10/13 at 5:10 PM, Staff OO, Charge Nurse, 5th floor, stated that he took report from the ED nurse when Patient #20 was admitted to the 5th floor. Staff OO stated that he was not told that the patient had been molested in the ED or that she was a VOV. Staff OO stated that he was not aware of the situation until the 5th floor admitting nurse did the admission assessment with the patient. Staff OO stated that he notified the house supervisor who stated she was not aware of the situation (alleged sexual abuse/inappropriate touching). Staff OO stated that he was not aware of any visitors for the patient but could not always see the patient's door.

13. Record review of the facility security log dated 06/19/13 showed no entry indicating that Patient #20 was designated as a Blackout/VOV patient (private-no visitors).

14. During an interview on 07/09/13 at 4:15 PM, Staff NN, Director of Security, stated that security must be notified of all Blackout/VOV patients and that notification should/would generate an entry on the security log as well as an entry in the computer system to identify the patient as no visitors/no information.

15. During an interview on 07/09/13 at 9:55 AM, Staff A, ED Director, stated that he was not notified of the occurrence in the ED until about a day later and that he would expect to be notified about something like this in more real time. Staff A stated that an incident report should have been initiated immediately. Staff A stated that he had not been involved to date in any creation of action plans.