St Barnabas Hospital

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48001 Based on observation, document review, and interview, in one (1) of 11 medical records (MR) reviewed the facility failed to implement physician ordered Airborne isolation for a patient with concern for tuberculosis (TB) and cohort the tuberculosis (TB) patient per facility policy (Patient #21). This failure placed patients, visitors, and staff at risk for exposure to an airborne communicable disease. Findings: See Tag 0749”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 36207 Based on observation, document review, and staff interview, the facility (a) failed to monitor and maintain the operating room (OR) temperature and relative humidity in accordance with its policy and procedures and according to the “Facility Guidelines Institute” acceptable standards of practice and (b) failed to implement its policy and procedure for out-of-range temperature and relative humidity for out-of-range parameters. Findings: The facility failed to monitor and maintain the operating rooms (OR) temperature and relative humidity in accordance with its policy and procedures and according to Table 7-1 Facility Guidelines Institute 2018 Guidelines and ANSI/ASHRAE/ASHE 170 (Ventilation of Health Care Facilities). The acceptable range for Relative Humidity (RH) according to Facility Guidelines Institute is 20-60%. High humidity increases the risk for microbial growth in procedure areas as well as areas where sterile supplies are stored. See Tag 0951”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48001 Based on observation, document review, and interview, in one (1) of 11 medical records (MR) reviewed the facility failed to implement physician ordered Airborne isolation for a patient with concern for tuberculosis (TB) and cohort the tuberculosis (TB) patient per facility policy (Patient #21). Findings: Review of the facility’s Policy and Procedure titled, “Management of Isolation and Multi Drug Resistant Organisms (MDROs),” revised 12/01/23 states: “POLICY: Patients with suspected or confirmed pulmonary tuberculosis (TB) will be placed on airborne isolation ideally, in a negative pressure room, or-one equipped with HEPA filtration (high-efficiency particulate air filter can theoretically remove at least 99.97% of dust, pollen, mold, bacteria, and any airborne particles with a size of 0.3 microns) if a negative pressure room is unavailable at the earliest possible moment and remain on isolation until the isolation order is lifted, based on SBH (St Barnabas Hospital) Health System TB (tuberculosis) guidelines, and input from Infection Control and the infectious diseases consultant. PURPOSE: To provide guidance on isolation practices and limit transmission of tuberculosis (TB) throughout SBH (St Barnabas Hospital) Health System. This policy supersedes all other policies on tuberculosis. I. Administrative Considerations The following administrative considerations are to be made in cases where suspected or confirmed (tuberculosis) TB patients are placed, on airborne isolation: Prioritization of Patients When isolation rooms are not available for all patients, and there is absolutely no alternative but to prioritize patients, the following guidelines can be used to assign AFB (Acid-Fast Bacillus (AFB) sputum tests to identify specific bacteria, such as Mycobacterium tuberculosis) isolation rooms: Those patients who cannot be placed in an AFB isolation room should, at a minimum, be placed in a private room equipped with a HEPA filter, with the door remaining closed at all times. Cohorting The sharing of rooms by (tuberculosis) TB patients is generally not advisable and rarely done however may be considered in extenuating circumstances if the following conditions can be documented: -Both patients are known to be infected with drug susceptible organisms, or both patients’ organisms are known to have the same resistance pattern, and -Both patients are responding to treatment. Tuberculosis (TB) patients may not share rooms under the following circumstances: -A patient suspected of having tuberculosis (TB) will never be placed in a room with a patient known to have tuberculosis (TB). -Two patients suspected of having tuberculosis (TB) will not share the same room. -Patients with unknown or pending susceptibility results will not share a room with anyone. Authority Clear lines of authority will be established in order to coordinate the initiation, maintenance and termination of airborne isolation. -Infection Control personnel will coordinate all airborne isolation activity. -Infection Control personnel will be notified of all patients admitted with suspected or confirmed infectious tuberculosis (TB). -Initiation and enforcement of airborne isolation procedures is the responsibility of all involved hospital staff in conjunction with infection control personnel.” During a tour of the Emergency Department (ED) on 07/22/2024 at approximately 2:15PM, with Staff V, ED charge nurse, it was observed patients were separated in cubicles with blue curtains. Staff V, ED charge nurse, when asked why the curtains had different colors stated, “the darker blue curtains are where isolation patients are kept when there are no isolation rooms available.” A patient was observed in cubicle 9 (Patient #21) and Staff V stated the patient was on airborne isolation. The surveyor observed the curtain was not completely closed around the cubicle and there were patients in the adjacent cubicles 8 and 10. Per Staff V, these patients in cubicles 8 and 10 were not on isolation. It was also observed that there was no signage for Airborne Isolation at cubicle #9. Review of the medical record (MR) for Patient #21 identified: the patient presented to the ED on 07/22/2024 at 10:13AM via EMS (Emergency Medical Services) with complaints of shortness of breath, chest pain, productive cough blood tinged for 2 days, hypertensive, tachycardic, tachypneic and hypoxic. Physician, Staff S assessment at 10:50AM includes past medical history: acute kidney failure, anemia, diabetes mellitus type 2, nicotine dependence, tuberculosis (TB) positive 1996, pneumonia x 2, and asthma. Physician ordered Airborne isolation at 10:29AM for abnormal chest x-ray with concern for tuberculosis (TB), labs, AFB (Acid-Fast Bacillus sputum tests to identify specific bacteria, such as Mycobacterium) culture, ECG (electrocardiogram, a quick test to check the heartbeat). During interview on 7/22/2024 at 2:15PM, Staff V, ED Charge Nurse, reported they have two isolation patients, one in cubicle 9 on airborne isolation and one in cubicle 15 on contact isolation. They currently have 2 isolation rooms which are in use therefore the patients in cubicles 9 and 15 have to be mixed in with the rest of the ED patients. Staff V, further stated, normally, patients on isolation in the main ED is given an isolation cart, a mask, along with a HEPA (high efficiency particular air) filter until a room is identified for isolation. Staff V acknowledged and it was observed that there was no HEPA filter with the patient on airborne isolation in cubicle 9. Staff V further acknowledged she was informed of the need for an airborne isolation room however none was available, and she did not inform her supervisor. When asked how this affects the two adjacent patients, in cubicle 8 and 10, to cubicle #9, staff V, stated she was unable to comment. During interview on 7/22/2024 at 3:00PM, Staff X, Infection Control Director, verbalized what the protocol for patients on airborne isolation included, a negative pressure room, isolation cart for staff with supplies, a sign placed outside of the room, if an isolation room was not available a HEPA filter should be placed with the identified patient. Staff X further stated, when a patient is placed on airborne isolation, the Electronic Medical Record (EMR) will flag the order and that’s how the department is notified. Staff X acknowledged there was no HEPA filter in cubicle #9 for the patient that was on airborne isolation at the time of observation. During interview on 7/22/2024 at 3:15PM, Staff R, RN for patient in cubicle 9, acknowledged patient was on airborne isolation however there were no rooms available, and it was reported to the charge nurse per protocol. During interview on 7/22/2024 at 3:20PM, Staff S, ED attending for patient in cubicle 9, reported patient in cubicle 9 has an abnormal chest X-ray and an order for airborne isolation was placed. Acknowledged he is aware there were no isolation rooms available, and acknowledged the unavailability of the room was never bumped up the chain of command.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 36207 Based on observation, document review, and staff interview, the facility (a) failed to monitor and maintain the operating room (OR) temperature and Relative Humidity (RH) in accordance with its policy and procedures and according to Facilities Guidelines Institute (FGI) 2018 Guidelines and (b) failed to implement its policy and procedure for out-of-range temperature and relative humidity for out-of-range parameters. Findings include: Table 7-1 Facility Guidelines Institute (FGI) 2018 Guidelines and ANSI/ASHRAE/ASHE 170 (Ventilation of Health Care Facilities). The acceptable range for Relative Humidity (RH) according to Facility Guidelines Institute is 20-60%. Review of facility’s policy and procedure manual for “Temperature and Humidity Control in the Operating Environment” dated 1/16, it states: The Relative Humidity (RH) of air should be between 30-60% within the operating room. a) Each OR’s temperature, humidity, and pressure will be recorded on the Temperature and Humidity log by nursing staff and validated by a member of the Department of Engineering. b) If the Parameters remain out of range despite interventions from the Engineering, infection control will be consulted to do a risk assessment. Then Clinical team will decide if the procedures can continue. On 7/10/24, between 11:00 AM and 12:00 PM during the tour of the operating room (OR) suites, the Relative Humidity (RH) readings, immediately after surgery, were observed on the thermostat wall device as: in OR 4 - RH 75%, and OR 5 - RH 67%. According to the FGI 2018 edition, the acceptable range for RH within the operating room is 20-60% and the temperature is 68-75 degrees F (20-23 degrees C). On 7/10/2024 at 2:00 PM, review of the operating room Daily Temperature and Relative Humidity Log revealed that the relative humidity for OR rooms #3, #4, and #5 were 70%, 75%, and 67% respectively. A concurrent review of patient surgery log on 7/10/2024 revealed that the facility performed procedures/surgery in these operating rooms with relative humidity above acceptable ranges. During an interview on 7/12/24 at 11:30 AM, Staff A, Chairman, the Department of Anesthesiology, and Staff B, Chief Quality Officer, acknowledged the findings and stated, “The facility uses the ORs even when the RH is higher than the acceptable range.” Review of the facilities OR Daily Temperature and Relative Humidity Log dated 7/1/2024 to 7/10/2024, revealed no documented evidence of comments/interventions to address out-of-range parameters specifically Humidity. No documented evidence of escalation to Nursing Infection Control for risk assessments. Similar findings on out-of-range Humidity readings were identified in the review of the OR Daily Temperature and Humidity Readings log, dated April 2024 to July 2024, Examples: On 7/9/24: OR 4 - RH 64%, OR 5- RH 63%; morning before surgery On 7/7/24: OR 4 - RH 63% OR 5 - RH 63%; morning before surgery On 6/14/24: OR 1- RH 66%, OR 2- RH 69%, OR 3- RH 71%, OR 4- RH 74%, OR 5- RH 74% and OR 6- RH 71% morning before surgery On 5/29/24: OR 3- RH 71% morning before surgery On 5/21/24: OR 4- RH 70% and OR 5- RH 68% morning before surgery On 4/12/24: OR 2- RH 65%, OR 3- RH 66%, OR 4- RH 73%, OR 5- RH 74% and OR 6- RH 65% morning before surgery A concurrent review of the patient surgery log revealed that the facility performed procedures/surgery in these operating rooms with a relative humidity that were out of range for days between April 2024 to July 2024. There was no documented evidence, that the facility implemented corrective actions for out-of-range relative humidity or any evidence of clinical risk assessments, prior to conducting surgeries and utilizing the OR suites when the Relative Humidity readings were out of range. These findings were acknowledged by Staff A, Chairman, the Department of Anesthesiology, Staff B, Chief Quality Officer, and Staff C, Senior Director of Facilities who were present during the tours. During a tour of the Central Sterile, on 7/12/24 at 11:45 AM, it was noted that the sterile storage area Relative Humidity (RH) was 61%. Staff C, Senior Director of Facilities validated the finding at the time of the tour. Review of the Daily Temperature and Humidity log for the Central Sterile area dated, July 2024, confirmed the findings. Similar findings of out-of-range Relative Humidity readings were identified for the following days, On 7/12/24 at 8:00 AM - RH 61% On 7/11/24 at 8:00 AM- RH 65% On 7/10/24 at 8:00 AM- RH 62% On 7/9/24 at 8:00 AM - RH61% These findings were confirmed during interview with Staff A, Chairman, Department of Anesthesiology, and Staff C, Senior Director of Facilities on 7/12/24.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 10686 Based on observation, document review and interview, in four (4) of fifteen (15) medical records reviewed, the facility failed to: (a) Ensure patient care and safety needs were met with call bell mechanism in place for patients/patient’s representative to call for assistance. (Patients #14 and #15). (b) Implement care and management to prevent elopement of patients identified in the ED as high risk for elopement. (Patients #1 and #10). (c) Ensure co-ordination of Psychiatry and Medical services for patient who refused the sexual assault rape kit, when the patient was evaluated no capacity for decision making and consent for treatment. (Patient #1) Findings: See A Tag 1103.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 10686 Based on observation, document review and interview, in four (4) of fifteen (15) medical records reviewed, the facility failed to, (1) ensure patient care needs and safety were met by having a call bell mechanism in place in the ED for patients/patients’ representative to call for assistance, (2) ensure care and management to prevent elopement of patients identified in the ED as risk for elopement, (3) ensure co-ordination of Psychiatry and Medical services for patient who refused the sexual assault rape kit, when the patient was evaluated as having no capacity for decision making and consent for treatment. (Patient #1, #10, #14, #15). Findings include: 1. On 3/21/2024 at 1:15 PM, during a tour of the Emergency Department (ED) with ED leadership, a patient (Patient # 14) was observed in area A/B standing in front of a stretcher and wearing a hospital gown. The patient stated when he needed assistance he gets up, looks, and calls for the nurses. On 3/21/2024 at 1:20 PM, Staff C, ED Registered Nurse (RN), assigned to area A/B, was asked how she responds to call for assistance. Staff C went to Patient #14 cubicle with the surveyors and checked the wall panel. Staff C identified the call button outlet with no wiring or connection. Staff C stated the ED had no call button system since she was hired few weeks ago and the ED had no manual call bells for patients. The surveyors observed a patient’s son (Patient # 15) came out from the cubicle 15 and stated they had difficulty calling for staff assistance, there was no call button at bedside, and family wanted to speak with a nurse or a doctor. The patient’s son stated the patient was unable to get up and speak with a tube from the neck. Patient # 15 was observed with a tracheostomy tube (an opening into the trachea from outside the neck for air and oxygen to get into the lungs). The tube was connected to a machine. Patient # 15 bedside was observed with a call button outlet on the wall panel with no wiring or connection. Similar findings of ED patient care areas, where wall panel had call button outlets but with no connections, were observed in Main ED area cubicle 16 A/B, and Main ED area C. These findings were validated with the ED staff during the tour. Staff B, ED Covering Director of Nursing (DON), and Staff A, ED Medical Director, who were present during the tour, acknowledged the no call bell mechanism in place in the ED. During interview with Staff E, ED RN Educator on 3/21/2024 at 1:47 PM, Staff E stated, for years, there was a change in the guidelines regarding the use of call bells in the entire ED to support removal of ligature risks for patients at risk. Staff E stated call buttons have wires and high- risk patients may put the cord around their neck. Staff E stated there were no high-risk patients in the Main ED. Staff E explained behavioral patients who are high-risk for ligature are placed in the Behavioral Area ED 4 which do not have call bells, and ED 4 is a locked unit with security. The facility staff were unable to provide a policy and procedure and/or documentation regarding the use and/or discontinuance of the call bell system in the ED. 2a. Review of the Medical Record for Patient #1 identified: On 1/25/2024 at 2:39 PM, ED Registered Nurse (RN) Triage Note documented, Patient #1 was brought in by Emergency Medical Service (EMS) for suspected drug use and possible smoke inhalation due to smoke in apartment. The patient was drowsy, responsive to shaking and able to state name, birth date and knew she was at the Hospital. The patient was placed on elopement precautions. There was no documented evidence the elopement status was communicated by nursing to the physician. There was no documented evidence a physician’s order for elopement precautions was entered in the medical record. On 1/25/2024 at 2:39 PM, the ED Provider Note documented: Unable to perform Review of Systems (ROS) due to mental status change. At 3:20 PM, RN noted Interventions: High Risk Elopement Precautions. At 5:10 PM, RN noted patient was received in yellow gown. Patient care and treatment is documented in the medical record. On 1/26/2024 at 7:55 AM, MD noted patient ready to go. There are documented phone calls to patient’s family for pick up at 8:22 AM and at 8:37 AM. A man stated will be there within the hour. On 1/26/2024 at 10:00 AM, RN noted, the patient refused for vital signs. At 11:34 AM, RN documented, patient discharged. There was no documented evidence of a discharge order, patient discharge from the facility and/or discharge education/instruction in the medical record. On 1/26/2024 at 1:42 PM, ED RN Triage Notes; Patient #1 was brought in by ambulance due to the husband who called 911. During telephone interview with Staff J, ED PGY-1 on 3/25/2024 at 2:19 PM, Staff J stated Patient #1 was signed out by previous provider. The patient was awake at that time, with no somatic issues, making arrangement for pick-up and waiting for family (daughter) to pick patient up. Staff J stated she tried to call the daughter but was unsuccessful and another family member said was coming to pick her up. Staff J stated the patient was not officially discharged. The patient will have further final evaluation. The patient did not sign the discharge paperwork yet and was waiting for family to pick up. During the interview on 3/26/2024 at 10:50 AM, Staff L, ED Attending stated he could not remember Patient #1. He stated he reviewed the chart; he did not discharge the patient; could not recall when patient was signed out. During the interview with Staff Q, ED RN on 3/26/2024 at 1:15 PM, Staff Q stated she worked on 1/26/2024 at 7:00 AM to 7:30 PM. Staff Q received handoff from the previous nurse that Patient #1 was set for discharge with personal belongings in a bag at bedside. Staff Q could not remember if the patient was in a yellow gown, it had been a long time. The family was contacted for the patient’s discharge and spoke with a man who said will be in the hospital in an hour and the next call, the man stated on his way. Staff Q explained she went for her break and after her break the patient was not at bedside. She did not ask her colleague and superiors what happened to the patient, under the impression the patient was discharged. Staff Q stated she did not discharge the patient and did not activate the Code E for elopement and did not escalate to superiors that the patient was not at bedside. A few hours later, not documented in the Electronic Medical Record, a man called, claimed to be the patient’s husband, told her the patient was home. The husband was upset why the patient was home. During follow-up interview with Staff N, on 3/29/2024 at 2:23 PM, Staff N explained she was working on 1/26/2024 and was not aware Patient #1 eloped. Staff N acknowledged Patient #1 was not discharged and Patient #1 eloped. During the interview on 3/29/2024 at 2:32 PM, Staff R, Charge Nurse involved was interviewed. Staff R stated she reviewed the record for Patient # 1 and there was no physician order for Elopement Precautions. Staff R stated the nurse identified the patient at risk for Elopement and initiated the elopement prevention with the yellow gown. Staff R stated there was no physician order for discharge and no physician reassessment and education instructions for discharge. 2b. Similar findings of a patient elopement from the Emergency Department (ED) was identified for Patient #10: The patient was transported via ambulance to the ED on 3/18/24 at 10:45 AM, status post fall at home. Patient was triaged as a trauma case. At 10:58 AM Physician assessment documented the patient with a 3 cm laceration to the left eyebrow without active arterial bleeding, patient was alert and oriented x 1, with a past medical history including Alzheimer’s dementia. The patient was placed on elopement precautions. A full neurological exam was unable to be performed due to the patient’s history of dementia. ED physician documented a disposition for the patient to be admitted to the hospital unit for further treatment and care. At 11:00PM, Registered Nurse note, patient eloped from the ED floor. Code E was activated and the patient was later found at the hospital gate by the charge nurse. There is no documented evidence that the physician’s elopement order was implemented. During interview on 4/5/24 at 12:43 PM, Staff Hh, ED RN, stated that on 3/18/24 he was assigned to the care of Patient # 10. He took patient assignment report from the day shift RN and the outgoing nurse did not inform him that Patient # 10 was on elopement precautions. During that time, he observed the patient was lying on the stretcher, and was wearing their own clothes. The family were present at the bedside. He became aware at 2300 (11:00 PM) hour, the patient was not present in the ED. He immediately informed the charge nurse, and a search of the ED was made, a Code E, which is notification of the security department, and an overhead announcement is made about the missing patient. The patient was found by the night charge nurse near the hospital gate and was walked back to the ED. The patient was examined by the medical doctor and no injury was identified. An elopement precaution order was entered by the MD, security was notified, and the patient was changed into a yellow gown and her belongings were secured by the security staff. The facility’s policy and procedure,” Elopement Prevention and Response Protocol,” revised on 5/2022 states: “I. Policy: To provide a safe environment and implement safety measures to prevent elopements for patients with acute and chronic altered mental status, who lack the ability to make decisions and/or are incapable of protecting themselves from harm. To establish an elopement response protocol in the event of a patient elopement. II. Purpose: To provide guidelines in assessing and identifying patients at risk for elopement To implement safety measures to prevent a patient from elopement. To provide an elopement response action plan in the event of an elopement. III Definitions: II. Elopement: a patient who is not capable of protecting themselves from harm and leaves the facility unnoticed or prior to their scheduled discharge. IV Procedure: A. Elopement Prevention Procedures 1. Emergency Department i. Upon assessment, patients who lack the ability to make relevant decisions and/or are not capable of protecting himself/herself from harm will have elopement prevention protocol implemented. ii Elopement precautions maybe applied at triage or during the course of the ED encounter. iii The elopement prevention protocol is as follows: Elopement prevention order will be entered into the patient medical record. Elopement precautions can be initiated by an RN followed by the physician’s order. Elopement precautions patients will be visually identifiable by staff by designated identifiable yellow colored gown. The patient will be assisted in getting undressed into hospital identifiable yellow gown. Patient belongings and valuable will be removed and secured from patient access. Appropriate levels of observation will be ordered if deemed necessary. Security staff will assist in continuous surveillance and safety monitoring. The elopement precautions will remain in effect in accordance with the patient’s behavior and/or mental status. Elopement status must be included in all patient handoffs.” 3. Review of the Medical Record for Patient #1 identified: On 1/26/2024 at 1:42 PM, ED RN Triage Notes documented, Patient #1 was brought in by ambulance due to the husband who called 911 and stated that patient was possibly sexually assaulted. At 1:42 PM, ED Provider Note documented, the patient’s husband felt patient was sexually assaulted. Notes documented patient was in the ED today and was discharged. Patient reported she took a taxi home, upon arrival home, husband called 911 because he was worried patient was sexually assaulted. The patient denied being sexually assaulted and did not want a pelvic exam. When asked why they were there, patient stated having argument with the husband who called 911. History provided by patient and husband. Physical Exam revealed, but not limited to, General: Alert and Oriented x 3, not in acute distress, mildly flat affect, slightly delayed but responds to questions appropriately. Neuro: speech and attention intact. At 3:07 PM, Provider documented Impression: Suspected mild ETOH (alcohol) intoxication, currently not withdrawing, with previous medical history of psychiatric disorder, currently not psychotic. Possible sexual assault, patient denied and declined Genito-Urinary (GU) exam. At 5:56 PM, ED Attending Physician’s Note, spoke with domestic partner and daughter individually. The patient denied being sexually assaulted or raped but was elusive in more details and wanted to leave. Patient answered orientation questions, date, place, and name, but when asked why she was there, patient stated because she was raped. The physician documented attempted to do Mini Mental Status Exam (screening tool used for cognitive status which includes tests of orientation, concentration, attention, verbal memory, naming and visuospatial skills), but patient answered everything incorrectly including the previously correct questions. Plan to get psychiatric evaluation, for psychiatric condition and capacity, as family stated patient had become more disorganized. On 1/26/2024 at 7: 05 PM, ED Attending Physician Note: Patient was calm and answered some questions. Patient again refused a sexual assault kit at this time. Given the inconsistent exams at different times, will get psychiatry to evaluate. At 10:11 PM, ED Physician Note, the patient now requesting vaginal exam and wanted it now. Will obtain rape kit to perform at this time. At 10:24 PM, Physician Note, the patient did not want to wait for the exam, stated they had a right to refuse the rape kit. Patient did not want the exam. Patient did not want HIV medications. Patient stated knowing their rights and did not want the test. At 10:57 PM, the patient was medically cleared pending psychiatric admission. Patient was admitted to inpatient psychiatry at 11:16 PM. During the patient stay the in the ED, there was no documented evidence that a determination discussion was conducted with the Primary Care Team regarding the patient’s capacity for the refusal of a sexual assault exam. During interview on 3/26/2024 at 11:30 AM, Staff A, ED Medical Director, who worked as an ED attending that day, stated he spoke with the patient’s husband and daughter separately. The patient’s husband stated he was worried patient was sexually assaulted. Staff A stated the patient was alert and oriented. She was asked initially and in multiple occasions if she was sexually assaulted, the patient stated she was not sexually assaulted. The patient refused the sexual assault exam and the pelvic exam multiple times. The patient however stated she was in the ED because she was raped, and patient got frustrated. There was pressure from the husband for the exam. Staff A indicated a privileged attending can determine patient’s competency. Staff A stated Psychiatry was consulted for evaluation. During interview with Staff O, ED Attending on 3/26/2024 at 12:45 PM, Staff O stated recollection of the patient who was admitted for elevated alcohol level and was disorganized. Staff O indicated the husband verbalized the patient may have been sexually assaulted. Staff O stated the primary team offered the rape kit, but the patient refused. Staff O explained it was best for the patient to be in the hospital and make sure she was safe. Staff O stated at that time, the patient was violent to staff, aggressive and impulsive. The patient did not have the capacity. The patient could not participate with basic questions and treatments offered. During interview on 3/27/24 at 10:45AM, Staff Gg, Patient Relations Representative, recalled receiving a complaint on 1/26/24 via telephone from the sister of the Index case # 1. After filing the complaint, she immediately informed the emergency department medical director via email regarding the complaint she received from the patient’s sister and the medical director responded to her communication via email. Staff Gg spoke with the patient in the ED (Emergency Department) on the afternoon of 1/26/24 in the presence of another staff member with the patient’s permission. The patient agreed to speak with them. Staff Gg asked the patient about the events that occurred on the way home after the ED treatment. The patient denied that a rape event occurred on the way home on 1/26/24. The medical director offered the rape kit test to which the patient responded no. Staff Gg also stated the patient’s sister walked into her office and requested to speak with the Director of Patient Relations and she immediately called the director who spoke with the sister at that time. She was unaware of what arrangement was made between the director and the patient’s sister since it was a telephone conversation between the two. The director is no longer employed at the facility. Review of the of the facility’s policy and procedure titled, “Health Care Proxy/Advance Directives/Bioethics review,” revised on 02/23, states: I. POLICY/PURPOSE: 6. To ensure the rights of comatose, incompetent or minor patients. II. PROCEDURES: 8. When treatment decisions must be made and there is not agreement between family/proxy and physician the following mechanism for problem resolution should be followed as is necessary: >Discussion involving the Patient Experience Leadership or hospital designated staff and the family/proxy. >Involvement of legal counsel and/or petition to a court of law (through Risk Management Department).”