Howdy, and welcome to Responding to Sexual Assault in a Healthcare Institution. My name is Stacy Mitchell. I am a clinical professor at Texas A&M University College of Nursing and the director of the Center of Excellence in Forensic Nursing at Texas A&M Health. First I would like to thank IAFN for the invitation to present this information to you. This presentation is the result of a lively listserv conversation that occurred last year on this topic. I hope to present a variety of perspectives about what happens when a patient is sexually assaulted in a healthcare institution or facility. There are many moving parts involved in the in-house investigation that will occur, and I think it's really important for everyone to have an understanding of how all of those parts fit together and how they also intertwine with the external investigation or the law enforcement investigation. Before we dive in, I would like to tell you a little bit about myself and my background. I have been a registered nurse for over 30 years and a forensic nurse for 29 years. I started my nursing career in the intensive care unit and quickly moved to the emergency department. While working in the ER, I became interested in forensic nursing and attended a sexual assault nurse examiner course, and from there things really took off. I found my passion in forensic nursing. I worked as a SANE for nine years in Virginia at Bon Secours St. Mary's Hospital in Richmond. In 2002, I moved to Houston, Texas to start a forensic nurse death investigator program at the Harris County Medical Examiner's Office. The Harris County Medical Examiner's Office serves the entire city of Houston plus other outlying areas. I was there at the Medical Examiner's Office for about six years, and then I moved to the other arm of Harris County to the hospital district, which is the Safety Net Hospital System. It's basically the public health system for the city of Houston. The Harris County Hospital District, which is now known as Harris Health System, is the fourth largest public health hospital system in the United States. Here at Harris Health, I initiated a forensic nursing program, which served all types of patients who experienced trauma and violence throughout the lifespan. During my time there, I was promoted from Director of the Forensic Nursing Program to Administrative Director, and I took the role of Risk Manager and Patient Safety Director. I also kept the forensic nursing program under my purview. It was there I was really able to implement a trauma-informed approach to the investigation of serious safety events. I was able to hire forensic nurses to investigate and work with staff to identify the root cause of events and to develop strategies to prevent future patient injury. And now I am at Texas A&M University in the College of Nursing. I teach in the Master's Program in the Forensic Nursing track. I also will be teaching in our Doctoral Program when that gets started in the fall of 2022. I am also the Director of the Center of Excellence in Forensic Nursing, and we are having a great time developing education and also other services that are working to make things better in Texas for survivors of sexual violence. So that's just a little bit about me. Here's a short disclaimer. The opinions expressed in this presentation are mine, and mine alone, and not necessarily those of Texas A&M University, IAFN, and of course Harris Health. I will be presenting a couple of cases that occurred during my time as a forensic nurse and also as Risk Manager at Harris Health System. In terms of a conflict of interest, I am disclosing that I am a board member and part owner of a medical device company called MyEcoHealth. I do not have any other financial disclosures to make. Here are the learning outcomes that I hope to accomplish during today's presentation. The first is to summarize the role of the internal and external stakeholders who are investigating a sexual assault in a hospital. I will focus mostly on the internal stakeholders because we know what happens in an investigation of the external stakeholders. You know, and those external stakeholders are law enforcement or child protective services or adult protective services. But for this presentation, I really want to focus on those internal and spend a lot of my time talking about the internal stakeholders. The second objective is to appraise various regulations that influence the in-house investigation and information sharing with external agencies. There are some, there is some information that is actually privileged and confidential and cannot be released to an external agency. And I want to talk a little bit about some of those things and why information is released and why it's not and how the forensic nurse can play an important role. And third, our third objective is to assess the patient needs that must be addressed. So let's go ahead and get started and dive in. Violence occurs in healthcare facilities. We really like to think that the hospital or the clinic is a safe patient care environment. In reality, we see a lot of crime and violence in hospitals, on hospital campuses. If you work in an emergency department, you know that violence can and does occur on a regular basis. The International Healthcare Security and Safety Foundation has looked into violence in healthcare. And this is an organization of hospital security. And most reports that they found focus on the provider, the patient to provider or employee violence. These types of crimes can range from disorderly conduct to rape or sexual assault and even murder. I worked at a hospital very, very early in my career where we actually had a murder. We had a patient murder another patient in the psychiatric facility. So that was quite the event and caused a lot of internal discussion within the hospital. These types of events, sexual assault, murder, aggravated assault, where there can be some serious bodily injury on a patient, these are considered serious safety events or they can also be considered to be sentinel events. Regardless of what they're called within the hospital, they weren't an in-house investigation with a root cause analysis. And in many events, such as a sexual assault, this type of event is even reported to the accrediting and the regulatory bodies for further investigation. Since 1995, the Joint Commission has kept statistics on criminal activity perpetrated on the grounds of health care facilities. During that time, they have recorded 256 reports of assault, rape and homicide. Now, reports to the Joint Commission are strictly voluntary and not all hospitals report to the Joint Commission that an event has occurred and they don't generally provide a lot of the information. We know that violence is consistently found in the top 10 categories of the reports to the Joint Commission. It's there, along with other things like, you know, wrong side surgery. But violence has been consistently found in the top 10 of the events that are reported. There's a significant increase in the types of violent events that are being reported to the Joint Commission. Some of the contributing factors that the Joint Commission identified through reviewing the reports that came in are leadership failures. Does your leadership buy into the culture of patient safety? Does your leadership buy into a just culture? Where do they stand on security issues within the hospital system or the facility or even on campus? Other contributing factors include policy issues. Do you have sound policies that everyone in the facility, in the hospital, understands, has read, has acknowledged, and knows how to respond when there is a violent event or a crime that has occurred on hospital campus? Another contributing factor is the physical environment concerns. You know, what about safety? What about access to patients? What about access to the hospital itself? And so some of those things, we've identified gaps and that has allowed for a situation that has been created to allow for crime and violence to occur within a hospital. Other types of factors include communication failures and human resources challenges. Does your hospital do an in-depth background check? What is the level of the background check? I worked at one hospital where we did have a sexual assault that occurred and, you know, it was a staff member and they, when they did the background check, they only looked at within that state. They didn't look outside of the state and had they looked outside of the state, they would have found that that employee or that staff member had been convicted previously of a sex crime in another jurisdiction and that didn't carry over into the state. So what is the in-depth, what is the background, what is the quality of that background check? And so those are things that can actually be big wake-up calls for hospitals, for human resources departments, for other departments within the healthcare facility to say, hey, we need to do things a little bit differently. When sexual assault occurs in a hospital or in a healthcare facility, it can definitely garner media attention and sometimes, you know, it really sheds the light on the facility and some of those gaps that we talked about, you know, some of those contributing factors that were on the previous slide. Here are a couple of examples of pretty high-profile sexual assault cases that occurred in facilities. The first one on the photo on the left is a booking photo of Dr. Shafiq Shaikh. He was a resident at the time at Baylor College of Medicine and he was working at one of the hospitals within the Harris Health System and this occurred when I was risk manager and also over the forensic nursing program. Dr. Shaikh sexually assaulted a patient that was not his. He was a resident. He was on call overnight and he was in-house and he assaulted a patient not once but three times over about a two-hour period. He would go into her room and assault her and then leave and then come back and he assaulted her over a shift. The patient made an outcry and we had forensic nursing obviously involved and risk management and patient safety were involved along with the Houston Police Department. They investigated and he was arrested and he pled guilty to sexual assault. The second image is if you may be aware of Nathan Sutherland. He was a nurse in Arizona who sexually assaulted an incapacitated patient at a long-term care facility and later she gave birth as a result of the assault. He was sentenced to 10 years in prison but I recall seeing this story on the news. It made national news. Both of these stories made national news and really shined the light on some of the gaps that how do we create an environment? How do we tighten our policies and procedures and the things that we do to keep our patients safe? The third image on the far right is an image of the Bayside Agent Care Facility and this is actually in Australia. Here was an employee who actually sexually assaulted several patients at this facility. This made national news within Australia but I put this case in here to show that sexual assault and sexual violence in healthcare facilities is not exclusive to the United States. It happens all over the world and it's an issue and we need to be able to identify ways to address it and to prevent it so that our patients can feel safe while they are in the hospital. I mean they're giving up a lot and they're very vulnerable in our healthcare facilities and it's our duty to ensure a safe patient care environment for them. So who are perpetrators of violence in the healthcare setting? Pretty much anyone. Anyone can assault their patients. We have seen healthcare providers and that includes physicians, nurses, technicians, nurse techs, patient care techs, whatever you call that type of position in your healthcare facility. We have seen that pretty much anyone could assault their patients. Contractors who have access to the patients who come and go with different equipment, with the reps, they could potentially assault their patients. We've seen patients assault other patients and patients assault healthcare providers. We've also seen visitors assault patients as well as healthcare providers. So pretty much any kind of scenario that you can think of could potentially happen in a healthcare setting. So when there is an event that occurs, so let's say a patient is sexually assaulted within a hospital, there are several overarching goals for the in-house investigation and there are some things that every department is invested in. And every department within that hospital wants to be able to do the right thing for that patient. And so number one, obviously the first thing that needs to happen is take care of the patient. The patient must be treated, injuries must be treated, necessary support for that patient must be provided. Does that mean calling family? Does that mean calling an advocate to be with them in a hospital? Whatever that patient needs to help them feel safe. The second overarching goal is we need to involve law enforcement in this. If the patient is an adult and is able to consent and they want to involve law enforcement, then as a healthcare provider, I feel like we need to make that, be able to facilitate that phone call. I am not going to hand the patient a phone and say, you need to call the police. No, I will call the police for them and say, hey, I have a patient here who has reported a sexual assault and I need to have either patrol or detective, whatever your response is in your jurisdiction, to come out and take a report and to talk with this patient. We need to call law enforcement automatically if it's a child that's assaulted within the hospital, if it's a disabled adult or an elder. And that also triggers those mandatory reporting laws as well. So we have to contact Child Protective Services and Adult Protective Services to let them know what has happened. And then the third overarching goal for the in-house investigation is to identify that breakdown. What happened? What broke down or what set the stage for this assault to have occurred? Is there something that as a facility we can do to prevent this from happening again? So we have to identify the systemic issue. Is there a systemic issue, number one? And if there is, what is it? And then how do we fix it? Or is it a process failure? And what that process failure is and then how do we correct that process failure? And in this piece, whatever is identified that needs to be fixed, it must be evaluated and measured. And we're going to talk about some of the different folks who investigate and their responsibilities in the next few slides. Okay, let's take a look at who investigates these cases. Typically, when there is a criminal act that occurs, law enforcement is going to be involved, provided that the patient says, yes, I want law enforcement involved if they're an adult. If it's a child or an elder, we're going to make those phone calls. That's our external stakeholder. They are going to conduct a criminal investigation that is going to be parallel to this in-house investigation. And if you have a protective service agency involved, then they too will be conducting their own investigation. So you potentially could have three parallel investigations happening at the same time for this one event. And it's very important because to understand that, because there's going to be crossover in information. There's going to be information that needs to be shared amongst the different agencies. And there's that collaboration piece that's so important. The forensic nurse has an amazing role in this type of investigation, not only to respond, but to also help be the go-between between the hospital and the external stakeholders. So who's going to investigate abuse and neglect or assault in a healthcare facility? Take a look at this list. This is a really long list of internal stakeholders or internal departments that will all play a role, depending on who the perpetrator is, in this in-house investigation. And we will talk about each one of these roles in a little bit in depth as we go through the rest of the presentation, because I want you to have an understanding and understand their perspective and their role as to why they need to do the things that they do. For anyone who's not familiar or has ever been involved in an in-house investigation, it can be a little confusing on what is the role. It may look like that some of these folks, the risk manager or the patient safety department or compliance or accreditation, they may be, you know, unfeeling or their job is to only protect the hospital and they're not worried about the patient. Sometimes yes, sometimes no. Sometimes they're worried about everything. You know, it depends on the hospital. It depends on how the departments are set up. And it also depends on how the in-house investigation is handled, who will take the lead. And so let's dive in and talk about each one of these roles and what they do when there is an in-house investigation. Okay, let's look at risk management. We're going to take them and we're going to go ahead and deal with risk management first off. There's, you know, often a lot of angst about when risk management is involved. You know, a lot of people think that, oh, their only role is to mitigate incidents and to protect the hospital and, you know, they don't worry, they don't care about the patients. They don't care about what happened. They don't care about the events that occur. They don't care about patient injury, which is actually far from the truth. Risk managers care about all of those things, but they have a delicate balance. You know, how do I work within a hospital system? How do I, you know, investigate and mitigate and identify strategies? And how do I work with, you know, the claims? And so they have a very unique perspective and it may seem that they're unfeeling when they really are not. But they do, they truly do care. When I was a risk manager, it was definitely challenging because I was coming from a forensic nursing background of trauma-informed care and how, you know, advocating for the patient, and then I learned a lot about hospital operations and the risk management piece, the insurance claims management, mitigating incidents and events, and also investigating incidents, and I think it really made my investigative skills, looking at some of these in-house events, to be very, very objective, and I had to be, because I wanted to make sure that we didn't go down, you know, the wrong fork in the road, that we really looked at the issues, we looked at the system, we looked at the things that we were supposed to look at and examine to determine what were the failures here in this situation. One of the roles of a risk management is risk financing. They also provide input into policies and procedures. They're a great resource for you when you are developing policies and procedures. The risk manager does meet with patients and families about incidents. They do talk with them, they do provide information to them about what happened, and then what are the gaps, and how is the hospital addressing those gaps, and of course, if there is a lawsuit, then the risk manager is going to play a role in that, potentially, you know, working on a settlement piece, or working with the hospital attorneys. So, they do play a very important role. I don't want you to think that they are only there to protect the hospital, because they're not. They are there to help create that patient, that safe patient environment for our patients. Next, we have quality and patient safety departments. I am talking about them together, because in many hospital facilities, these two departments are merged into one. They may look different in your facility. You may have three separate departments, or your risk and quality and patient safety may be one department. It just kind of depends on the structure of the organization. But, quality and patient safety, there is a lot of overlap in their role, particularly when there is a serious safety event, or a sentinel event that occurs within the hospital. They are responsible for conducting the root cause analysis, and depending on policy, it could be the quality department, or it could be patient safety, that is responsible for pulling everyone together for that meeting, and to really dive in and find the root cause. If you've never been involved in a root cause analysis, a root cause analysis is a deep dive to look at, objectively now, to look at the systemic issues of why a particular event occurred. They're going to ask why, the question why, many times, until they can no longer ask the question why. Why did this happen? Well, why did that happen? Why did this happen? Well, why did that occur? When you can no longer ask why, then you are at the root cause, and then it's the root cause that you need to look at and examine further to say, okay, now how do we fix this? Also, in the root cause analysis, you will identify different factors that will contribute to the event, because it could be a myriad of things. It could be, you know, communication, it could be a poor policy, it could just be a really bad process, or, you know, hey, we don't have anything in place to address an event like this. So, quality and patient safety will identify those contributing factors and present them to administration, and it's generally done in the patient safety or a Sentinel event committee. This type of committee is a high-level committee where there are hospital administrators and other folks. So, it could be compliance, it could be the CEO, the hospital medical director, you know, the chief of staff, you name it, there's going to be a very, very high-level meeting. So, all the information from the root cause analysis is pulled together into a report. Recommendations are also in this report, and it goes to the Sentinel event and patient safety committee, and they will discuss this event, and then they will, you know, say, yes, we want to go ahead and implement these recommendations, or no, we don't like those, we want to add these, or we see this or that, and then it will be ready to be implemented. I want to tell you that the Sentinel event and the patient safety committee meetings are confidential. There are serious, I mean, it can be very serious if someone leaves that patient safety event committee or that Sentinel event committee, and they start talking about what happened. Everyone is kind of sworn to secrecy. It's like Las Vegas, you know, what happens in Sentinel event or patient safety stays in Sentinel event and patient safety, those discussions. The only things that come out of that are the recommendations that are implemented. They're also, quality and patient safety are also charged with evaluating those implementation activities. Are those things working? You know, is everyone educated? Is, what are the processes? Have they been changed? And so, they have that responsibility to make sure that those recommendations are implemented and that they are measured, and there is also a report back to the patient safety or the Sentinel event committee about the evaluation. So, there is that loop closure there, and those two departments are definitely responsible for that. They will be involved in the in-house investigation. They will talk with the patient. They will talk with other witnesses. They will gather evidence, and all of that goes into that root cause analysis discussion. So, there's a lot of background work that will occur before the RCA happens. If you are a forensic nurse and you are involved in a sexual assault case that happens in your hospital or on the hospital campus, you will probably be invited to the root cause analysis meeting, and this is a wonderful opportunity for you to be able to educate this group about your role and about what you found and why those findings are important, and you are also at the table as these departments identify activities to mitigate future events. You are going to play a crucial role in this case, and so I think it's something that, as a forensic nurse, we need to definitely make sure that we're open to and to make sure that we're at the table during these types of meetings. Okay, the next department or group of people that will more than likely be involved in an in-house investigation for sexual assault is the compliance department. The compliance department ensures that a business adheres to the external rules and the internal controls. They are tasked with closely watching that the financial services and that the businesses adhere to the regulation. They identify risks that an organization faces and advises on how to avoid or how to address them. A compliance department is required to have in every hospital. Every hospital has to have one of these. The CMMS, Centers for Medicare and Medicaid Services, really looks at compliance and expects compliance to work with the hospital administrators and department leaders to ensure that there is no waste or fraud or abuse concern. If there are, they're required to have a hotline so that employees can call and make a report that's anonymous. When they receive a report like that, then they will collaborate with other departments to investigate, and they may take the lead or someone else may investigate. They are also there to make sure that the hospital maintains professional standards and that they conduct business in accordance with state and federal laws. They also assist human resources with investigations into matters that involve compliance issues. For an example of that, at one of the hospitals where I worked in my career, we had an admission clerk who was stealing patient information and insurance information in order to perpetrate insurance fraud. When that was uncovered, it was the compliance department who investigated and provided information to HR so that they could begin termination procedures, but then that information also was provided to law enforcement. The FBI came in and they investigated as well, and that admission clerk was arrested and tried and found guilty and is actually got a pretty lengthy prison sentence. Compliance can be really important. They play a very big role in how a hospital functions to make sure that they have ethical standards and that they're professional. Compliance is also a great resource for you as a forensic nurse as you're looking at things like HIPAA, as you are designing different forms to use within your program. They can provide some really important feedback to you as a forensic nurse. Okay, let's talk about the accreditation department. The accreditation department is responsible obviously for the hospital accreditation. Hospital accreditation has been defined as a self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously approve. Accreditation is just not about standard setting. There's counseling, self-improvement dimensions, there's also parallel issues in evidence-based medicine, quality assurance, medical ethics, and the reduction of medical error. These are key in the role of the accreditation process. Hospital accreditation is one component in the maintenance of patient safety. They're a very, very important department. They are there when the surveyors come, so when your Joint Commission arrives for their survey, when DNB arrives, and then of course there's also a new accrediting provider called the Center for Improvement of Health Care Quality, CIHQ. So now we have three different accrediting bodies in the United States that are credit hospitals and your hospital will partner with one of those three and that's who that surveyor comes in. So when you hear Joint Commission come in, that's when everyone disappears and the hospital is so clean and you're praying, okay I hope the surveyor doesn't ask me anything. Well the person that is with the surveyor is going to be the person responsible for the accreditation within the hospital or within your health care system. They help to ensure that the standards are maintained for accreditation. They collaborate with departments to implement those activities and they evaluate the activities. They're there to help make that hospital a better place, a safer place, and to ensure that the standards for patient safety are being met. They do respond to the accreditation surveys, so when there is that surprise survey, the first person who gets the phone call is going to be the accreditation director or the accreditation manager. The second person is the CEO, but the accreditation director or manager does play an important role when there is a sexual assault within a hospital. When this type of event occurs, this event again is considered to be a sentinel event or a serious safety event, and that hospital is going to be surveyed, okay. Joint Commission is going to come in, or DMV will come in, or CIHQ will come in, and there will be a survey. There will also be the state coming in. CMS may come in to survey. The Office of Civil Rights may show up. There can be multiple surveys for one event, and your accreditation director or manager will be handling every single one of those surveys. They will provide the information to the regulatory agencies, the accreditation organizations, and that will include information about the sexual assault exam that you performed on the patient. They have a right to that information, just like quality and patient safety. They will ask for your records. They don't necessarily want the pictures because nobody wants the pictures, but they will ask for your written documentation, and because that documentation belongs to the hospital, because that documentation is part of that record, they will need to have a copy of it. The accreditation manager and director, of course everything is confidential, and the accreditation director and manager will have that information. So, when a surveyor comes, the surveyor will read that information. We'll look at what the RCA showed. We'll look at the activities that are being implemented and say, yes, we're good to go or no, we're not. You have to give them that information. I know we are very hesitant to give information about our patients and that examination because the information that that patient has told us and provided us in the history and our exam findings are very sensitive, and we take confidentiality very, very seriously as forensic nurses, and it's hard for us to give up that information, you know, without a subpoena, but in these cases, when a sexual assault occurs in a hospital, that information needs to be shared with certain departments within your hospital. Those departments within the hospital, let me assure you, will maintain confidentiality of that information and maintain that document or the information, and it's not shared around. It's not posted. They don't talk about it in the cafeteria. They take the confidentiality of these types of events and the information very, very seriously, just like you do. So, it's important to understand that and that they need that information so that they can respond appropriately to the regulatory bodies and to the accrediting organizations because the last thing that anyone wants is a hospital to lose their ability to accept Medicare and Medicaid. So, if CMS yanks their certificates, then that hospital will close down, and there have been a couple of events that have occurred at hospitals around the country where CMS has been very, very, very, very close to pulling those certificates because there have been severe patient injury, even patient death, and information was either withheld or hidden from CMS, and so we have to be open, but we also have to ensure that we do maintain that confidentiality, and please let me assure you that accreditation does maintain confidentiality. Risk management maintains confidentiality, quality and patient safety, compliance, everyone involved in this in-house investigation understands that confidentiality is critical in these types of cases and will protect that information. Okay, so I loved human resources and medical staff services together because human resources obviously handles employee issues, so that's your staff, that's your registered nurses, your dietary, the admin assistants, the unit clerks, etc. You get the point, and then medical staff services will be involved in investigation when a provider is being looked at as a perpetrator, so that includes your physicians, your physician assistants, and your advanced practice nurses. They all come under medical staff services because they're credentialed, they receive their evaluations, and all of that stuff is kept on file in medical staff services. Medical staff services is also responsible for reporting to the National Practitioner Database if there is a provider that is under investigation, and definitely if you have a physician or another provider who has sexually assaulted a patient, they're definitely going to be under investigation, and so that person will be reported to the National Practitioner Database. That information will definitely follow them in the practitioner database, so if they go and if they quit in the middle of an investigation, that does not look good. If they leave as a result or terminated as a result of the investigation and they seek a job elsewhere, that information that they were what happened, not the actual details of the sexual assault, but the fact that they were either convicted or they were terminated or there was cause found to terminate them from that particular hospital, that information is in the database, and the next hospital or facility will have access to that database. HR and medical staff, they will be involved. They will want to know what's happening with the investigation. They will participate to some extent in the investigation. They may be present at the root cause analysis or maybe they're not. They may be present during the Sentinel event committee meeting or the patient safety committee meeting just to see what was going on so that they can make a determination of how do we start the termination process or what are the next steps. They can coordinate with supervisors with about any performance improvement processes or termination. So medical staff in HR is a department that is going to be around. They may not be directly involved at the point of the information gathering in the in-house investigation, but they will be aware that there is something happening and they will be waiting to hear more information. And of course now we get to the forensic nurse. Yeah, forensic nurse has, this is an incredible opportunity for the forensic nurse. Not only that you are there to immediately provide care and treatment to that patient, you know what exactly your role is. You understand you know the medical forensic exam and you will do exactly what you do for any other patient who is seeking services from you. You'll document the examination findings. You'll make reports as necessary. So you'll contact you know law enforcement if the patient wants it. You will contact you know protective services if the patient falls into one of those categories. You have a great understanding of what the resources that patient needs and you will be able to help facilitate getting those resources. You will participate in the more than likely be called to that root cause analysis meeting. And this is an opportunity for you to really get to know what's going on and how that hospital works. How is this type of investigation conducted and your opinion and your feedback about processes will be very very important. You will have the opportunity to assist with developing and implementing some of the mitigating activities. You will have the opportunity to help look at policies and review policies and update policies or add to those policies. You may even be asked to participate in the education of all of the staff in the entire hospital about new policies, about what to do when someone makes an outcry, especially if the event was not handled well or properly. So you have a really expanded role or very important role in an in-house investigation and I hope that if I hope well I hope that you never have to experience this. But if you do, if you take care of a patient who has been sexually assaulted in your hospital, just just recognize and know that you have an opportunity to really impact not only that patient's outcome but the system as well and so it's I just want you to keep that in mind. So let's look at some of the challenges that can occur when an event occurs within a hospital when you've got a criminal investigation that is happening. So remember we talked about those parallel investigations you know we have you know the in-house investigation we have the law enforcement investigation and we may have a DFPS investigation or protective services investigation. Well I can tell you that there is definitely a lack of experience or a lack of knowledge on the hospital's part about the criminal investigation about that process and how does that work. You have an opportunity as a forensic nurse to help bridge that gap and to talk with your hospital department so all those people that are involved in that in-house investigation and to provide some education and knowledge about the law enforcement investigation because you work with law enforcement regularly and you understand the process in the courtroom process and etc etc and you can help provide some guidance and some feedback so that the hospital does not really you know kind of step into it. You know the timing of the notification to law enforcement that can be a challenge too because when something like this happens this is an event when a sexual assault happens in a hospital it's an event where you know it's kind of throws everybody off they're like who do I call first you know what do I do first when do we call law enforcement do we call law enforcement do we keep this quiet do what do we do so there are a lot of questions that be that are being asked and if you are consulted early then you can help guide that response and say you know what we really need to have law enforcement involved the patient wants to make a report we need to facilitate that and we need to do that now as quickly as possible. There's also the issue of institutional liability and yes the hospital is thinking about that but they're also thinking we need to get our patient taken care of first. We need to think about issues such as what if the patient wants to be transferred with the patient says I don't feel safe here anymore and moving to another room or another floor or another unit just won't do it just won't cut it and I want to go to another hospital. We come into some up against some issues with EMTALA because that's considered a lateral transfer so what do we do with that and of course people are going to be asking then how do we pay for that or who's going to pay for that should the patient pay for that should the hospital eat those costs of that transfer when do we transfer the patient do we do it after the exam do we do it now do we transfer them to a hospital that has a forensic nurse and let them do it over there at that hospital. So there's a lot of questions that are going to be asked that you as the forensic nurse can help them work through. Law enforcement has no idea what information to request in an investigation that occurs within a hospital. It's much easier when it when an assault occurs in a community because they have kind of their set oh we need to get a B C D and E. When an assault occurs within a hospital there is a lot more information available to them by subpoena that they really that they have no idea you know there's things like you know badge swipes there's also some video camera obviously there's you know audits on a computer if they're checking a computer. One of the things in the Dr. Shake case was after he heard that the patient made an outcry and the forensic nurse was involved he thought the sexual assault kit was going to be processed at the hospital lab and so he kept accessing this patient's records trying to see what the lab results were not knowing that the sexual assault kit is going to the crime lab not the hospital lab and we found that he through an audit of our EMR that he accessed her records over a weekend over 100 times. There's no way there's no reason for any physician to be in somebody's chart a hundred times on a weekend especially when it's not your patient. So that sent up a lot of red flags and that was some critical information and evidence that was presented in court when Dr. Shake was that the that the district attorney had and so so again it's you can be there to help them you can help guide you know hey maybe we need to think about this or you know help law enforcement say hey you might want to ask for this on a subpoena. Hospital processes and relationships with medical schools sometimes those things is particularly if you are in an academic medical center those processes are not well understood by law enforcement and they don't understand the relationship between the medical center or the the hospital and the medical school and you as the forensic nurse can kind of help guide them or say hey maybe you need to talk to so-and-so in compliance they can help explain this because this is a different process than what you're used to there is a different relationship and they can help explain that to you. We also have challenges with evidence preservation there are well-meaning staff members who are going to clean up or throw things away or move things around in an effort because you know we're nurses we love to clean and evidence can be inadvertently destroyed or contaminated that's where education by use the forensic nurse what to do if something like this happens can really play a role and can impact the investigation you know equipment sequestering what if there was a piece of equipment that was involved it needs to be sequestered right away it needs to be examined it needs to be photographed it needs to be you know reported to the FDA if there was a issue with the with the equipment and a patient was hurt or killed so so there's lots of different challenges when a hospital becomes a crime scene and as the forensic nurse again I think you have some unique opportunities to help bridge and be a bridge between the hospital and the law enforcement agency okay the hospital response I mean the hospital must initiate that in-house investigation right away they have to they have to do one sorry but they do it's required by many accrediting bodies and in some states there may actually be legislation or state code that requires that they investigate events for example in Texas we do have a state code we have the Texas administrative code title 25 part 1 chapter 133.48 and that outlines that you know that we have to investigate patient events and definitely a sexual assault on campus or on in a hospital in our hospital is a serious event and it must be investigated by the hospital there are also peer review and quality review laws and so that these events are examined within a confidential process and that information in those peer reviews and quality review and equality committee are confidential confidential and cannot be obtained and released to law enforcement yeah the DA may think otherwise and will work to try and get that information and that will be on them it will be very difficult if that information is submitted to a patient safety organization every hospital through the Patient Safety and Quality Improvement Act and then patients say they have to have a patient safety be affiliated I guess with a patient safety organization and that is an organization that is kind of the clearinghouse or the collection of all of the patient safety information and it affords higher level protections at a federal level as opposed to a state level but at a federal level that quality information and that peer review information there are several cases civil cases that which where information from the PSO would they were trying to obtain that plaintiff's attorneys were trying to obtain information and those cases have actually gone had to go all the way to the Supreme Court of the United States in order to have a verdict or a render judgment as to whether or not the PSO can provide that information sexual assault is considered a sentinel event under Joint Commission and it's also considered under the National Quality Forum as a serious a reportable safety event depending again depending on the accreditation body of your hospital if you will be it will eat this event will be investigated as either a sentinel event or an NQF serious reportable safety event regardless it will be an investigation that's going to happen and has to happen alright so again in-house investigation should be started immediately upon receiving that report and you know it needs to run up the chain as quickly as possible so that people are notified so that they can get the ball rolling either pull in law enforcement you know call the forensic nurse make sure the patient is safe that is a huge that is like the number one consideration we need to make the patient safety we need to make that patient safe we need to move them do what we need to do to restore a safe patient environment if there is an employee that is involved in the assault then that employee is removed from patient care and pace and placed on paid leave your hospital policy will state how long that employee may remain on paid leave during the investigation and it's usually like three or four days so that means that in-house investigation has got to happen and has got to get started right away and information needs to be gathered you know statements from everyone involved will be obtained and it will be a variety of people who will be gathering that information so for example if you have forensic nursing the forensic nurse may get gather the history from the patient if it's there's an employee that's involved then risk management patient safety one of those groups compliance will interview that employee and then all the information is put together when I was risk manager at Harris Health and I had patient safety to I had the that's how I had it divided out if the patient was the person who was victimized then the patient was seen by the forensic nurse risk management patient safety did not contact the the patient we let the forensic nursing services department handle that we instead the patient safety folks worked with the employee and they would talk with the employee and gather a statement from the employee as quickly as possible if you have a forensic nursing department in the hospital they should be consulted immediately to document the history and injuries and provide that medical forensic examination security footage must be maintained and reviewed and it must be sequestered they need to pull it out from whatever time period risk management or compliance or patient safety needs and then that information that segment of the video is then pulled and placed in another location because if it's going to be important for the in-house investigation it's really going to be important for the law enforcement investigation and by not saving that footage that can really impede both in both parallel investigations also with the in-house investigation so as soon as we work with the patient and we make sure there's a safe environment and everyone is notified then the information is gathered and then quality patient safety risk management whoever's responsible for that root cause analysis they will schedule the root cause analysis meeting and all of those who were involved in the case will be invited to attend that meeting and that's where they start asking the why questions and that meeting will be several hours long I've been involved in several of them that actually were three or four hours and then one root cause analysis meeting I was involved in related to a sexual assault in a hospital lasted pretty much the whole day and we had to book the whole day to go over the information and to really dive into the whys and identify the gaps and what the strategies were going to be recommended to be implemented action plans need to definitely be implemented and evaluated and then the case it will be presented to the patient safety committee or the settlement committee all of that information is privileged and confidential it falls under the peer review laws the quality you know patient safe quality laws and so it may not be available to law enforcement and to the district attorney's office again that is something that I let the lawyers fight out it's not my job to have an opinion about that I would just handle the root cause analysis and handle the strategies and pull everything together for our in-house investigation so what are some strategies for health care to ensure justice for our patients you know really it's about creating and strengthening the safe environment for our patients one of the things that you can do as a forensic nurse is to look at the policies within your hospital system and where can you insert a forensic nursing response where do you see gaps and then provide a response and contact who is the owner of that policy and say hey you know this policy could be stronger if we added forensic nursing here and here and here and that gets forensic nursing embedded into the hospital and into your policy so that you become an integral part of a response when an event occurs you know you know we all want we all want a hospital system where there's no sexual assault where there's no assault on our patients at all but unfortunately it happens and what we can do as a response is to at least try and reduce the risk make the environment inhospitable to perpetrators and safe for our patients and our policies and procedures can help do that another way is to educate the staff about those policies and procedures and what to do and you're a perfect person as a forensic nurse to do that we're really good at you know it talking to law enforcement and the DA's office and gaining their support gaining those external stakeholder supports now let's turn the vision in into that those internal stakeholders and and make them part of you know your team and and have and educate them about your role another strategy is to create a just culture or a culture of safety and this is a culture where employees and staff are very comfortable reporting events there's no fear of retaliation and that's what you want you want to have that culture where whatever happens big small in the middle that your staff and that the staff members are comfortable and feel like yes I can make that report because I know it's going to be addressed and I won't get into trouble for making that report as a forensic nurse we can also encourage hospitals to adopt the start by believing campaign I ran into on one case where a patient reported a sexual assault and the nursing staff did not believe the patient after that we really hit start by believing hard within the hospital and help those nurses to understand that yeah this patient was sexually assaulted and it was an employee and that employee was arrested and that employee was convicted and is in jail and those nurses when they realized that and learned that information it was oh my goodness you know I I will definitely embrace and they began to embrace start by believing so that's a wonderful campaign that you can implement within your own hospital when the other things that you can do is to appreciate everyone's role and work to avoid an adversarial environment it's about collaboration it's about looking at what is best for that patient and how can we work with that patient and how to get them what they need in the event that they're sexually assaulted in your hospital and to respond and to have an appropriate response that is trauma-informed for that patient you can again be the bridge to the external stakeholders and to help kind of be that communication person and to help communicate and to help collaborate so that information that can be shared is shared so there's a lot of there's several strategies and I'm sure you guys can probably think of some other strategies that you could do within your own facility that are specific to your facility and I invite you to to start that work to start laying that that framework and that groundwork so that you have a strong response in the event that a patient is sexually assaulted in your facility okay I've got a couple of examples of cases that I was involved in as either as a forensic nurse or as a director of risk management and patient safety along with forensic nursing so let's take a look at a couple of these cases okay so here is our first case we have an 86 year old female who was bedridden and admitted to a psychiatric unit secondary to her dementia the psych unit is it's a locked unit however once you get past the lock to the key card access the unit is actually very open there are patient rooms there's a nursing station there's a big kind of a great room or a general room where patients would dine or would you know just be and watch TV or and then there was also an occupational therapy room so it was very open patients can move freely throughout the unit and and they had actually psychiatric patients and geriatric patients were mixed into this unit which at the time they thought made sense because we have you know elderly patients with dementia they tend to wander and at least they're in this locked area and you know dementia is you know are they you know we found a lot of dementia patients on psych units I know that was the case when I was in nursing school when I did my psych rotation this case occurred in my forensic nursing career I was actually the nurse on this case and I was called in to respond a nursing student walked into this patient's room this 86 year old female's room and found another psychiatric patient actually sexually assaulting her she caught them in the act okay so the nursing student who was I'm quite traumatized notified the charge nurse she was like I have no idea what's going on I walked in this is what I found the nursing student was very very very upset the charge nurse after calming the nursing student down they can't began contacting the administrators of the hospitals she contacted you know obviously the health supervisor the you know risk management the CEO and they were all starting to have a powwow and they said hey we have a forensic nursing program here so hence the forensic nursing team was called and I was activated now this started in the afternoon of the day the nursing supervisor and the hospital administrator decided to really not contact law enforcement or the family right now because they wanted the forensic nurse to come in and conduct the medical forensic exam and then tell them what happened and then they would decide if they would call law enforcement or the family obviously that was not the best decision and I actually refused to do the exam until people had been notified appropriately The patient, it was very clear, the patient had dementia. The patient was unable to provide consent. I said I just can't go in there and do an exam on this patient without their consent or without the consent of someone. I said you know law enforcement needs to be involved. The family would want the police involved but we need to contact the family. So it took them a while to contact the family. It took them a while to contact law enforcement and there was a lot of back-and-forth between the administrators. And finally about three hours later, so we're talking now early evening, yeah it was about six o'clock, seven o'clock in the evening, hospital administrators contacted the police department and the police department authorized the examination. They said yes go ahead and do this exam. And so the story continues. The family was notified. I obtained permission to conduct the examination. Come to find out the administrators didn't really tell the family everything. They just told them that she needed a procedure and would they consent? Of course the family is like yes of course. And then they started asking more questions and then administration finally told them that their loved one was sexually assaulted. And of course the family came up to the hospital, right? Absolutely. So in the meantime I was starting the medical forensic exam about 7-7.30 that evening. So we're you know like four or five hours into this. I conducted the medical forensic exam. I had another nurse come in with me because this patient was bedridden, had dementia. It definitely took two of us to do this examination. And so I conducted the exam. We collected evidence. We took photographs. The patient wasn't really able to provide us any information due to her dementia. And so we talked to the nursing student a little bit. We talked to the detective a little bit. And so we kind of pieced some things together and just documented what we could in in our notes. We collected the bedding from the patient's room and turned that over to law enforcement. We turned over the sexual assault kit. Obviously the medical records were very important. The nursing student wrote a note and then those records obviously went to law enforcement. An incident report was created. The perpetrator was also a psych patient on that unit and so the perpetrator was arrested. And incidentally I did the perpetrator's exam the next day and he was taken to jail after that. There was no other place to put him so he ended up going to the county jail. And so all of the a lot of information was given to law enforcement for this investigation and then there was a lot of information that the hospital had as well for when they conducted the root cause analysis. Some of the other evidence that was present obviously you know we've got the perpetrator, the clothing, the suspect exam, and then of course the nursing student statement. Videos from the hallway showing the perpetrator entering the patient's room were collected as well and they were held for multiple people to see including you know the hospital attorneys, the risk manager, the patient's, the family's attorney because they did get an attorney in this case, and it was also used in the root cause analysis. So what happened with this case? Obviously administration did not handle this case well. It was quite an experience. I felt like as the forensic nurse on this case I felt like you know why is it so hard not to see and to do the right thing because this patient needs to have evidence collected. We need to step up to the plate and contact law enforcement because we have an environment or we had a situation where a patient was sexually assaulted and a patient should not be sexually assaulted when they're in the hospital. The perpetrator ended up confessing. The sexual assault kit was processed at the crime lab and it did confirm you know sexual contact had occurred and of course multiple surveys from state and accrediting bodies. I mean there were so many people that were there at that hospital looking at the event and looking at the response of the hospital and plans of you know implementation plans for keeping this from happening again. So there was a lot of action surrounding this case. I did participate in the root cause analysis of this case and it was a very interesting experience because it was my first time being in a root cause analysis and so I learned a lot about the process. We really looked at all of the you know the why. Why did this happen? What was the systemic issue that allowed this situation to occur and to allow this patient to be assaulted? And so of course the hospital was sued by the family of course and the hospital did settle. There were significant process and policy changes that were implemented and so what they did was they developed a separate geriatric unit and a separate general psychiatric unit and that took a little while to do because there was a lot of infrastructure and lots of construction that needed to happen and but it did happen and we saw that change. Forensic nursing was involved in developing hospital policies related to responding to a sexual assault so we were involved in that and that was really the first time that the team was really on the radar of administration. We did a lot of education to the administrators about criminal activity and reporting. There was a lot of, there were days where I think we were probably they wished we weren't there and that there were days that I know they were grateful that we were. And so it was a it was quite an adventure on this case and I will talk to you about another case that happened later on in my career. Okay this next case example occurred a few years ago later in my career when I was Director of Risk Management Patient Safety and Forensic Nursing and so I'm going to talk to you about the response in this case. Okay in this case a 32 year old male presents to the emergency department with a drug overdose. The nurse that was assigned to the patient's room requested then the patient care tech to place a Foley in this patient. The next time the nurse went into the room the patient reported that the patient care tech performed oral sex on him and the nurse was obviously visibly you know obviously upset and went to the department manager and made the report and told the nurse, the department manager, what had happened, what should she do and the department manager said you know I'll take care of it and unfortunately an incident report was not generated and risk management was not contacted. Forensic nursing response was not contacted so you know we're not starting off really well in this case. Okay so we had that case happen. Two months later a 25 year old male was admitted to the same emergency department with the same diagnosis of an overdose. The same patient care tech was on duty at the time of this case of this patient's arrival and was asked by the registered nurse to insert a Foley in this patient. The patient reported to the registered nurse who came back in to do another assessment that the patient care tech had performed oral sex on him against his will. The emergency department manager was notified. The manager actually became concerned and called the risk manager on duty that day and said hey this is the second time someone has made or a second or third time that someone has made this you know allegation for a better word against this patient care tech you know what do I do? Well the risk manager that I had hired that was assigned to this particular hospital in the system because we had several hospitals in the system. She was immediately said I'm on the way. I'm on my way down there. I'm going to talk to you. I'm going to talk to the patient. I'm going to talk to a lot of people. So the risk manager she made a beeline for the emergency department and talked with the patient. She gathered that history and it was like yes this patient care tech did this and this and so we'll go to the next slide and I will tell you more about what happened. So since the risk manager was a forensic nurse, the risk manager said hey we're calling forensic nursing and we got after she talked with the patient so we got that ball rolled in right away. So then the forensic nurse who was on duty at the time at the hospital came down to the emergency department and conducted the medical forensic exam. The patient said yes he wanted to make a police report and so the forensic nurse facilitated that phone call called law enforcement and a patrol officer arrived and took the report. In the meantime the risk manager had started the investigation, had contacted human resources because it was a staff member and that staff member immediately was pulled from staffing and he was sent home that patient care tech he was sent home and placed on administrative leave. Patient safety was notified. The administrator of the hospital was notified. Compliance was notified as well as the CEO for the entire system was notified that this was happening. Risk management has scheduled a meeting to discuss the case with the assigned detective and in the meantime a total of three reports to the emergency department about this technician were found. So that emergency department manager went back and looked in her personnel file that she kept her manager's notes and found oh there's a total of three reports not two. There's three and so she provided that information as part of the investigation. So that information went to law enforcement as well as to the risk manager and patient safety department. So the risk manager and patient safety that those two departments were combined at the hospital where I worked and so the risk manager was also the patient safety investigator. They contacted the two other patients from those previous reports and just kind of said hey can you tell me a little bit about what happened and they got the exact same history. They pulled everything together, developed a report, made recommendations to the department manager as well as to human resources. The root cause analysis was completed and there was additional policies and processes were implemented after the administration approved the plan at the patient safety committee. So there were a lot of things that were happening. The root cause analysis happened pretty quickly and they were able to drill down on what had happened and they found some human resources failures in terms of background checks and so those policies and processes were definitely tightened up. The accreditation manager was notified about the event that we've had a patient care tech who has been and of course patient care tech was fired and he was arrested. But the accreditation manager actually self-reported to the state, to the health department and to our accrediting body which was DMV and said this is what happened. We did the root cause analysis. This is what we processes that we're going to do, the strategies that we're implementing. Everything has been approved and we're in the process of implementing. We did get a survey. They came in, they looked at all the documents again and they said yes you're on the right track and so there were no non-conformities that were issued at that point. Risk management met with law enforcement and they helped facilitate the release of information. Risk management worked with law enforcement to make sure that when the subpoenas were received that the information was gathered and released in a timely manner. So some of the information that was available to law enforcement and information that was used in the root cause analysis. Obviously the employee records. We were able to look at that employee's records, look at his evaluations, look at the manager's notes that the manager had kept with the other two reports. In the manager's notes, if you keep manager's notes or you need to make sure that you don't have any PHI in them, instead of saying oh this patient and their patient's name made this complaint against whoever the staff member, really put in like the medical record number or the account number. Don't use the names because you need to be very very careful about that or either just don't put any of that and just say on this date on this time you know this patient or this person made a complaint because you want to be careful about PHI. There was also security footage of the tech in the hallway entering the treatment area because initially when the tech was interviewed by law enforcement, he actually said no no no I was not assigned to that patient. I was all for another section of the emergency department and I never went near that patient. The security footage actually showed otherwise. Of course they had the medical forensic record, they had images, and they had the sexual assault evidence collection kit. The patient's statements was very important as well as those other patients, the two other patients that had reported an assault by this patient care tech. Their statements were critical as well and they were used in not only the root cause analysis but they were used by law enforcement in their investigation. So of course you're guessing by what happened the employee was terminated from his position. He was arrested and he ended up pleading guilty to sexual assault. The emergency department manager was reprimanded because she didn't make those reports on those two previous cases and had she made that first report we potentially may not have had two more victims in this case. The emergency department manager had to attend mandatory education regarding incident policies, processes, when to report, who to whom to report, and why that is so important to make those reports. While this case started off really poorly, once the ball got rolling with risk management involvement, it got better. The response was immediate, the response was thorough, it was objective, and it was very unbiased. All of the things that needed to be done to examine the processes and the failures were done and strategies were implemented to reduce that risk of this type of event ever happening again. So what are some opportunities for the forensic nurse? I've kind of threaded that through this presentation but I want it to kind of summarize right here. As a forensic nurse you are in a really good position to make a strong impact within your hospital system. You have the knowledge to provide that immediate response to the patient. You understand trauma informed care, you understand evidence collection, you know what the resources are and what resources that patient may need. So you can provide that immediate response. You can also provide guidance and feedback in the RCA in the process and your unique knowledge set and skill set can help identify strategies that can reduce possible future events. So your input will be critical in the RCA and you should ask, you know, hey can I be a part of the RCA? I think I have some feedback. I can provide some information that can help as we develop strategies. You know, policy revision, policy development, having a forensic nursing program intertwined and the services that you provide can be very critical for a variety of reasons. It strengthens the response. It also helps to make that program your forensic nursing program, you know, so that you don't feel like you're indispensable and they need you and you are a critical part of that response when an event occurs on the hospital campus or in your hospital itself. You have an opportunity to educate staff about trauma-informed response and reporting. In one case that I talked to you about the staff in which the staff did not believe the patient at all. Through education and implementing Start by Believing, we were able to really turn that around and help show that nursing staff that, you know, you need to believe and we need to provide trauma-informed response to that patient. And then, of course, you can bridge that, be the bridge to the communication between the outside stakeholders and the internal departments. You understand what's going to go on on the outside. You understand that the law enforcement investigation is going to occur. You understand about the court process and the criminal justice process. And so, you can be that conduit between the hospital and the outside folks, the law enforcement and the DA's office. You can help interpret. You can help make sure that things are released that need to be released. And you can, you know, provide those introductions. And so, you have, again, are in a really unique opportunity to kind of expand your role, expand what you're doing to really impact your hospital and the response that it has when someone is sexually assaulted. So, in conclusion, I hope you enjoyed this presentation. I hope you have a little bit better understanding of the different roles and the different individuals and departments that will be involved in an in-house investigation should a sexual assault occur in your facility. We know that sexual assault in a facility, healthcare facility, is very challenging. And as you can see, there's a lot of moving parts. There are so many different departments and they have all conflicting perspectives that seem to be conflicting, I guess. That gives the illusion. But they all are there for the patient. They're there to take care of the patient. That's why they're all in healthcare, is to provide care to patients. And so, we have to keep that in mind when we are responding to an event that occurs on a hospital campus. And just know that there's going to be a lot of people involved. Information sharing can become very challenging because there's different privacy laws and rules and regulations about sharing information. And so, I tend to stay out of that piece and let everyone else, the experts in that area, kind of address those issues with law enforcement. And then finally, the forensic nurse, again, has an opportunity. You really can, again, impact outcome and system response. And I really hope that you're able to take a little bit of this information and take it back to your facility and to make an impact and hopefully prevent a sexual assault in your facility. So, that's the end of my presentation. I want to thank you for taking time to sit here and listen. I appreciate it. I hope you were able to glean a little bit of information. If you have any questions, please feel free to shoot me an email. Here is my email here on the slide. And again, thank you so much. And I would also like to thank IAFN for inviting me to present this information to you today.

sexual assault

healthcare institutions

internal stakeholders

external stakeholders

investigation process

patient care

law enforcement

violence in healthcare facilities

systemic issues

forensic nurses

evidence documentation

culture of safety