BalladHealth » Sc emcee Or Johnson Cty, TN 37608 lovernber fel 4233023422 November 7, 2022 fox 423.302.3447 balladheatth.org The Honorable Steve Finney, District Attorney General First Judicial District ‘Washington County Courthouse P.O. Box 38 Jonesborough, TN 37659 Dear General Finney: On October 11, you simultaneously delivered a letter to me, and to several media outlets, related to the care of an individual who was tragically abducted and raped, and who presented at Johnson City Medical Center for evaluation, care, and collection of forensic evidence. Upon receipt of your letter, | called you immediately, and we had the opportunity to speak about the situation. During our conversation, we both shared concemn first for the well-being of the victim and | committed that | would ensure the matters you raised in your letter would be investigated, and that would share my findings ‘with you. Ihave done so, and | am providing you with this response. More than anything else, we respect the rights and dignity of the person victimized by this horrible crime. | pray swift justice s brought to the vicious criminal who attacked this courageous young woman, and all of us stand side by side with you in that effort. Before I respond to the issues specifically In your October 11 letter, let me thank you for the extremely productive meeting we had last Thursday, November 3'°~ at which, you and District Attorney Staubus met with me, my senior clinical leadership, and a representative of the Branch House. We all agreed that, for reasons more fully explained below, the best care model for victims of sexual assautt is one that has coordinated points of entry outside of the emergency department setting. | pledge that Ballad Health will workwith you and District Attorney Staubus toward achieving this objective. Thursday's meeting was a major step in the right direction for our region and how to better serve the needs of victims of sexual assault. Regarding the issues raised in your letter in this specific case, we reviewed the facts related to this, patient's treatment at the hospital, our nursing leadership spoke with the patient and her family numerous times, we reviewed all patient records and documentation, interviewed everyone who was invoWed, and reviewed video and other available evidence (which monitors public waiting arees) to understand everything that occurred. Once the findings were presented to me, | personally met with the patient and her husband to share what we learned, and to receive their input directly. My most important goal was to listen to the patient; review the facts and ensure everything | represent to you is verified. The patient hos provided consent forus to respond ond has reviewed ths etter in advance of ny sharing fe with you, to ensure the accuracy of my statements, and to ensure we properly address any of her concerns. |.am happy to discuss more fully any ofthese issues with you, and, importantly, to continue our work together to improve the overall system of care for victims of sexual assaultNovember 7, 2022 Page 2 My takeaway from this review is two things are true. First, some of the information in your letter could not be verified or was stated in a way that could lead a reasonable person to some inaccurate conclusions. | will point to some specific examples. Second, there were some team members who either did not follow our policy or did not demonstrate the compassion we expect of our caregivers. will also be specific about this, ‘According to the patient, many people were extremely responsive, compassionate, and helpful, but there wes also some failure to show empathy by a nurse whose failure was meaningful to the patient. ‘As |will more fully describe below, our policy for forensic exams was not followed, and this nurse did ot adhere to our values of caring and respect. The result of the policy not being followed extended the “amount of time the patient had to remain in the ER, and it resulted in another nurse being called in from home to conduct the forensic exam, | want to thank you for going out of your way to personally thank ‘this nurse, who worked all day, and was willing to return to the hospital late at night after finding childcare for her own child, to conduct the forensic exam. While your letter referenced her by name, ‘unfortunately, many people drew the wrong conclusion about her involvement, As you stated in our ‘meeting, she was one of the people you, and the patient, pointed to as compassionate, helpful, professional and deserving of praise —so much so that you took the inltative to call her yourself to thank her. Again, | appreciate you doing that. | also want to thank you for your compliments Thursday about the other members of the team who did do all the right things. It can be true that most of the people involved represented the best of the hospital, but it can also be true that it can only takes one person to undermine the efforts of the entire team, assure you steps have been taken to address the failure of the evening shift nurse to adhere to our values, and our team is being reminded of their responsibility for conducting forensic testing in the absence of a SANE nurse. | believe the solutions we discussed this morning to create a regional partnership will actually be @ powerful improvement to this entire process and will be better for victims of sexual assault. | also want to say that nothing has been more helpful to me In determining the facts and a path forward than the potient and her husband taking the time to meet with me, answer my questions, and provide context to What she and they experienced. It is my goal to make sure her voice is heard, not just by me, but by our ‘entire Ballad Health team. The patient has already agreed to help us with this, and | know her contribution will be a powerful resource for all our caregivers. In September alone, Ballad Health's hospital ERs served 32,000 patients, 25 of whom suffered from sexual assaults. Given the magnitude of this issue, Its important we all get this right for the victims all ‘the time. In our meeting, you, District Attorney Staubus, and | reached an agreement in principle to move forward ereating a regional and coordinated system of entry for victims of sexual assault ‘anchored by the Branch House in Sullivan County, with additional work toward a similar Washington County entry point —an effort to divert from the ERs and to provide a more appropriate environment for people who suffered a sexual assault. | applaud you and District Attorney Staubus for your collaboration on this, and I could not be more enthusiastic in my support. There are decades of evidence and guidance from experts, including the Justice Department, which indicate that a busy ‘emergency department is not the bast place for a sexual assault victim as a point of entry, unless there is a medical condition which requires emergency treatment. The overwhelming majority of sexual aseault victims need services far different than what an ER provides, and which should be coordinated and provided ina more calm, secure, and settled location provided by people who specialize in sexual Sesault response, collection of forensic evidence and recovery. Men, women, and children will benefit throughout our region by the work we will do together in the coming months.November 7, 2022 Pages Here, | will address a few issues from your letter which hopefully will provide helpful information and background: Patient Arrival “The Ballad Health ER received notice from EMS at 5:48pm that the patient was being transported to the ER. The patient arrived in the Emergency Department through the ambulance entrance at 5:52pm. Your letter stated, “Once the victim arrived in the Emergency Room at Johnson City Medical Center, medical stoff demanded that she be taken to the ER waiting area rather than being taken back to the SANE room immediately. At that time, the victim and her family were forced to wait in the crowded emergency ‘room while the suspect was still outstonding.” This statement does not accurately portray what was ‘occurring at the time and could easily lead a reasonable person to conclude the ER staff made the patient wait in the ER waiting room for an extended period. This did not occur. Pursuant to our policy and best practice, the charge nurse was immediately notified of the patient's arrival, and she met the patient at the ambulance entrance. There, she immediately engaged with the patient, patient family, and police agent until 5:58pm. In accordance with our policy, the patient, family, land police agent were immediately directed to a private room adjacent to the Emergency Department Joby. This room Is referred to by ER staff as the Quiet Room. Unfortunately, the room was occupied by ‘another patient with COVID, so the charge nurse immediately went to secure another private room ‘within the Emergency Department. Atthis time of the evering, every roomin the emergency department was full with patients receiving emergency care and treatment. As you noted in your letter, the waiting room was also busy. During this period, the patient, her husband, and the police investigator were standing by the registration desk, where the patient’s husband understandably was advocating forthe patient to have a private room away from any public area. At the same time this was occurring, the charge nurse was rally moving another active ER patient from a private room in the ER to secure the private room for the sexual assault victim. This process took 2 minutes. The charge nurse did exactly as we would want her to do, understanding the importance of getting the sexual assautt victim to a private and secure area as quickly as possible. ‘At 6:00pm, eight minutes after the patient's arrival to the ER, the patient, family, and police agent were escorted to a private examination room inside the ER. Atno time did the patient sit in in the waiting oom, and the patient was in the company of a police agent and family member the entire time, Your letter further references that the patient was “placed in a room next to the psyoh ward.” This is not accurate, The patient was in a private exam room inside the emergency department. ‘The public areas of our emergency departments are under constant surveillance by multiple security cameras, and we reviewed the footage to determine and confirm the timing of activities. The patient ies prioritized immediately ahead of the other patients present, which is consistent with ovr policy. Having spoken to the patient about this, itis clear to me the patient was not aware of the efforts ofthe charge nurse to secure the room during that 2-minute period, and! believe better communication with the patient during this period could have reduced the anxiety experienced by the patient and her husband. Our team will benefit from being reminded of the importance of ongoing communication.November 7, 2022 Page 4 Medical Evaluation and Treatment Issues: ‘The patient immediately received a medical screening exam and was triaged for any medical conditions. ‘A physician saw the patient at 6:08pm ~ 8 minutes after being brought to the private room. The triage purse was with the patient at 6:09pm. At 6:21pm the triage was complete. ‘The patient shared with me that she was very pleased with the care she received from the nurse and physician who provided this During the 7 o'clock hour, the nursing staff had shift change. Based upon my conversation with the patient, and with the Chief Nursing leadership of JCMG, itis clear the nurse who came on shift failed ‘erribly in her interactions with the patient. The nurse lacked empathy, failed to be proactive in determining what needs the patient might have had, and missed several opportunities to provide compassion where it was needed. | have personally apologized to the patient for this, and appropriate ‘actions have been taken which reflect my disappointment in this professional's lack of adherence to our values. During my conversation with the patient, she graciously offered, and | have accepted, her help) in sharing her experience with all our caregivers so they can learn how she felt about the way she was treated by this caregiver. Much can be learned ~ and | suspect our caregivers throughout Ballad Health willgain enormously from hearing the patient's story first-hand. | am extremely grateful for the patient’s passion for helping the hospital and our caregivers throughout Ballad Health as they seek to learn from this. The patient's interest in helping our caregivers learn from her experience is inspirational to me, and her effort will benefit many caregivers and patients throughout our region. In your letter, you refer toa discussion regarding the patient needing to use the bathroom, stating, “The only thing the nurses did was to bring the victim a cup.” This comment leaves out extremely relevant context which leads the reader to an inaccurate conclusion. Once a medical screening exa complete, which was done at 6:21pm, and it was determined the patient did not require medical care, the remaining time in the Emergency Department is dedicated to the collection of evidence required by Jaw enforcement and your office for the prosecution. As you certainly must be aware, urine specimens are a component of the evidence collected. Therefore, a specimen cup was provided to the patient, which is the appropriate standard, In my discussion with the patient, she expressed no concerns with respect to the medical screening exam or the collection of the necessary evidence. Your letter stated that “the victim asked if she could speck with a lactotion consultant” related to breastfeeding her baby, and that “this request was denied.” ‘The request was not denied. The issue here is that Lactation consultants work during daytime hours, and not at night. The record reflects that when the patient requested a lactation consultant, since one was not on-site, the emergency department physician himself met with the patient at 7:13pm to discuss breastfeeding questions, and to provide guidance. Importantly, very few victims of sexual assault present with an infant, or, after daytime hours with an infant. So, there are few, if any, requests fora lactation consultant after hours for sexual assault victims. This explains why the lactation consultant was not readily available. Because of this this became a unique situation where the staff attempted to respond to the patient but did not have al the requisite experience to do so. So, the patient expressed to me that she felt the ER Physician ‘thought he was acting n the best interest of the patient by attempting to answer her questions, and he ‘showed compassion, but he should have taken the extra step of calling a lactation consultant to ensure he was providing all the relevant information to the patient's satisfaction. | agree with the patient about this, My clarification of this issue ts intended to draw an important distinction between the hospital simply denying the patient the consultant (which did not happen) versus the consultant not being available, and the staff attempting to be helpful. They may have failed to satisfactorily answer the patient's questions, which isa legitimate concern we will share with the physician, but the language ofNovernber 7, 2022 Page 5 your letter might lead a reasonable person to conclude the staff dispassionately showed no interest it responding to the patient's request. That would not be a fair conclusion. They were trying to be helpful Forensic Evidence Collection: Your letter indicates that the SANE nurses did not respond to repeated calls. On September-19” and again on September 24", the supervisor of the SANE nurses shared with all Emergency Department leaders via email that the SANE nurses would not be available from September 27" through October 2", ‘as they were attending SANE continuing education training from the international Association of Forersic Nurses in Dallas. During the time when attempts were made to contact them, they were on 2 flight enroute to their training. One of the nurses did receive a text message when the airplane landed, and we confirmed that she responded immediately at 8:01pm that they were out of town at the national training. While the leader of the SANE nurses did notify the Emergency Departments of their absence, she did not notify our outside community partner, Branch House. This should have occurred. While the coordinator of the SANE nurses did communicate the planned absence to the ERs, ! do not believe this was effective communication, and it contributed to some confusion. However, as | now describe, had our policy been followed, this would not have negatively impacted the patient and her length of stay in the ER, Ballad Health policy accounts for the unavailability of a SANE nurse by stipulating that ER physicians and hurses are to conduct the forensic evidence collection in accordance with the very precise instructions contained on the kits. And in fact, in several instances in September, the forensic evidence collection was conducted by ER physicians and nurses without incident. In this instance, the staff did not follow our established policy. In speaking with the staf, there is an explanationas to why, which I will elaborate on below. However, the result was that it extended the ‘amount of time the patient had to spend waiting for the exam. | want to be clear, however, that with respect to the collection of the evidence, it was conducted by a trained nurse with experience, and it was done well within the preferred window of time for the use of forensic evidence. In reviewing the 25 ‘sexual assault cases Ballad served in September, all but one was done within 3 hours. In this particular ‘case, the patient’s stay was 7 hours. And | attribute 100% of the delay to the fact the policy for the administration of the forensic exam was not followed, In your letter, you assert that the doctor “could not find a single nurse that was willing to be in the room while he performed the kit”, Here, | agree with you, but also fee! the use of the words “willing to" are not entirely accurate. Based on our investigation, it was not that the nurses were “not willing to” assist with the forensic exam. According to them, it was that they were not comfortable doing s0 until such time as they exhausted their effort to call someone in who had specific training. Their concern was that, because we typically use Sexual Assault Nurse Examiners who are specially trained, the ER nurses who were present rarely participate in performing the forensic exam kit. Given their ack of comfort, they |were attempting to get the most qualified person to come in. They succeeded, in that they called one of their colleagues, who had worked all day, and was not on call—yet nevertheless, in the interest of the patient, agreed to retum to the hospital to administer the forensic exam kit. This person had to secure childcare for her own child, and came ia, The feedback from the patient was that this individual was professional and did a good job. And you very graciously called this team member personally to thank her, which | applaud you for.November 7, 2022 Page 6 While { do not think it was a good idea for all three of our SANE nurses to be at 2 training out of state at the same time, this is irrelevant. When a SANE nurse is not available, itis our policy for the ER physician and nurse to administer the forensic exam kit, which they are qualified to do and itis within their scope of practice to do so -s0 long as they follow the precise instructions on the kit. The policy was not followed, and it resulted in an extended amount of time the patient had to spend in the ER. lagree with you this should not have happened. Conclusion: Ihave reached several conclusions resulting from the facts and my review: L “There is an opportunity for our caregiving team to hear first-hand from the patient (who's ‘anonymity can be maintained) about her experience. She has graciously offered to do so, and | ‘am inspired by her courage in doing so. There were many heroes who cared for this patient, ‘and the patient expressed her genuine appreciation for their care. But there were also some ‘opportunities for at least one person to better display our values. Four of our values are Caring, Honesty, Respect and Faith. And our mission statement expressly says we will “honor those we serve”, It only takes one individual to undermine the efforts of an entire team, and we do not wish to tolerate it when this occurs. Appropriate steps have been taken to address this. Also, ‘we will be conducting a required continuing education program for our caregivers throughout all of Ballad Health so they can benefit from hearing our patient's story and hhow the patient felt. | believe our caregiving team will be inspired by this and will appreciate the education. “The underiying problem, which you and 1 agree on, is that when we expose sexvel assault victims to busy ERs, the environment is unpredictable in terms of volume and patient severity Often, when an ER is busy with high acuity patients, as is typically the case at JCMC, the staff face significant competition for their time based on the severity of the patients at any given moment. If we had 25 sexual assaults In September throughout Ballad Health’s footprint, this amounts to an average of one-per-day seen in any one of our nearly 2 dozen hospitals. W hospital and when that patient will come into the ER is not predictable, and that patient may come into a situation where there are multiple life-threatening events happening. A sexual ‘assault victim does not need to be put in the middle of this environment unless they have a heed for medical treatment. The overwhelming majority of sexual assault victims do not need medical treatment, but rather, a single point of entry which is secure, provides for a medical screening exam, quiet and comfort, and which can, based on their individual needs, bring services to them. I was extremely pleased today during our meeting when you and District ‘Attorney Staubus agreed with this assessment, and proposed a different model, My team is ‘committed to working with you and ather community partners to implement it. Your proposal has the capacity to materially improve our region’s response to sexual assault, and to make the process much more focused on the needs of the victim. | applaud you for taking this step, and you can absolutely count on Ballad Health to be supportive of the model. ‘The primary reason Ballad Health employs SANE nurses is because, historically, victims of sexual assault have been directed to the emergency departments, and it was our effort to help law enforcement with reliable collection of evidence. That said, no matter the certification or training of the SANE nurses, when there are 21 unique ERs where the sexual assault victims are presenting, itis just not possible to have a standardized and accountable process. This has led to significant variation In the type of post-assault care the victims receive, and has led to {frustration amongst all the partners related to the response to sexual assault, includingNovember 7, 2022 Page 7 frustration on our own team. | believe, given the conversation we had Thursday, it wll be bboneficial for Ballad Health to cooperatively and responsibly transition the SANE nurse program to the Branch House and/or our new partnership model. Combined with creating a common entry pointoutsidethe ER, this will provide for standardization in response, and a proper focus ‘on the unique needs of each sexual assault victim, | am thankful this willbe a result of our discussion, as itis the right thing todo. 4. Wewill be reminding our team that our policies are not merely suggestions but represent our expectations. The failure of a few people to follow our policy resulted in this patient waiting much longer than he should have, and potentially undermined confidence in the entire team This important that everyone understands there are reasons why our policies exist, and why they must follow the policy. 5. | applaud your advocacy and passion for the victims of sexual assault, and certainly respect your position as the District Attomey General. We will always be cooperative with you and your Office, most importantly, so we can always have the same understanding ofthe facts and circumstances before conclusions are reached. | respectfully ask that the names of individual caregivers not be included in communications that you intend to make public through the ‘medio, particularly i they are not being accused of a crime. Some of the team members mentionedin yourletter recelved unfai attacks through social media, including the very person ‘you called to thankfor her outstanding service. 1 am concerned about the increase in the yhumber of assaults on health care workers, and care must be taken to ensure their safety. Thank you for your service to our communities. | am committed to our mutual goal of making this system of service for people victimized by vicious criminals more reliable and focused on the needs of Vetims, and applaud you and District Attorney Staubus for proposing positive solutions which we all an get behind. Ce: Ballad Health Board of Directors