YOUR SHIFT AT the long-term-care (LTC) facility where you work is done. As you begin to walk out of the building you hear a strange noise coming from Mr. G's room. You turn and enter his room on your way out to make sure everything is okay. What you find is a horrific scene: One of your technicians is sexually assaulting Mr. G. What do you do next?
While working in a hospital, you've just administered an opioid to a patient for postop pain. A little while later she wakes up to a stranger touching her breast. She screams and the stranger disappears into his relative's room, two doors down. Could this happen in your facility?
Nurses may come face-to-face with patients who've been sexually assaulted in any work environment. Studies have shown that sexual assault can happen anywhere: Police stations, day-care centers, group homes, churches, personal homes, hospitals, LTC facilities, and schools are just a few examples. According to the CDC, nearly 1 in 5 women and 1 in 71 men report experiencing rape at some time in their lives.1 (See Rape vs. sexual assault for definitions of these terms.) This article will review who's at risk for sexual assault and how to examine and care for adults who've been sexually assaulted.
Who's at risk?
Research has shown that sexual assault remains a risk throughout the lifespan. Unfortunately, people with cognitive and/or physical disabilities are at a higher risk for sexual assault compared with nondisabled people.2 Studies estimate that 80% of women with disabilities have been sexually assaulted. Women with disabilities are three times more likely to be sexually assaulted than women without disabilities.2
Certain circumstances may increase a patient's risk of being sexually assaulted. For example, those under the influence of alcohol or sedating medications are at an increased risk.
About 3% of LTC facilities and 0.7% of institutional care facilities for intellectually and physically vulnerable people have identified at least one sex offender living within their facilities.3 Many sexual assaults go unreported; reasons a victim may not report a sexual assault include personal beliefs, fear, embarrassment, mistrust of the justice system, or an inability to report due to a physical or cognitive disability. Only 10% to 15% of all sexual assaults will be reported to police, and victims who know their assailants are less likely to report the assault.4
One of the obstacles to identifying sexual assault is that nurses don't always recognize the signs and symptoms of an assault. (See Red flags for sexual assault.) Healthcare professionals often misinterpret or inadvertently overlook the physical signs of sexual assault in older and/or disabled patients because of complicated medical histories, diagnosed dementia, and prescribed medications. Also, healthcare professionals may not believe a patient's disclosure because of a lack of awareness of sexual violence affecting older adults.6
Physical and biological evidence
When sexual assault is suspected, any potential physical evidence must be collected and managed by a specially trained professional. DNA is found in almost every cell of the human body. Every person's DNA is individual to that person (with the exception of identical twins), so attempting to collect potential sources of DNA after a suspected assault is important. DNA can both identify and rule out a suspect. Sources of DNA include blood, hair roots, mucus, saliva, semen, skin cells, perspiration, tissue, and vaginal and rectal secretions.7
Potential DNA evidence can be found on anything that came in contact with the patient and/or suspected offender. This could include clothing, sheets, condoms, cigarettes, furniture, and anything else in the room or house that the suspected offender or patient may have come into physical contact with. Police or evidence detection personnel and Sexual Assault Nurse Examiners (SANEs) have had training on identifying and collecting such evidence found at the scene and/or on or around the patient or suspected offender. (For more information on SANEs, visit the International Association of Forensic Nurses at http://www.forensicnurses.org.)
Preservation of evidence
When a sexual assault occurs, the victim's body is considered part of the crime scene. This raises multiple challenges for evidence collection. Every patient who's been sexually assaulted has individual needs that need to be considered during evidence collection. For that reason, a professional with specific sexual assault training should examine and collect evidence from the victim.
As soon as an assault or possible assault is discovered, immediate actions should be taken by a facility or law enforcement agency to ensure safety, protect evidence, and initiate an exam by a trained sexual assault examiner. A medical screening is also indicated to evaluate the patient for acute injuries, which must be addressed before evidence collection. This would include, but isn't limited to, decreased level of consciousness, heavy bleeding, and fractures.
If serious injuries are suspected in a patient outside the hospital, 911 should be activated. It isn't in the patient's best interest for a healthcare professional without specific sexual assault training to examine the victim and "decide" whether the victim needs evidence collection. For example, a gynecologist shouldn't insert a speculum into a patient who's come to the office with a complaint of sexual assault. Inserting and removing the speculum risks the loss of potential evidence.
Evidence is time-sensitive. Every hour a patient goes without proper evidence collection increases the chance that evidence will be lost. Because of the time sensitivity, most jurisdictions limit evidence collection based on time, which is dependent on the jurisdiction. The typical time limit on evidence collection was once 72 hours; however, with advanced techniques and current technology, some jurisdictions have increased collection times up to 7 days.8 Some circumstances could extend the time limits for evidence collection; for example, if a patient hasn't showered since the assault. However, one shouldn't assume that waiting hours or days is acceptable.
Scene evidence must be collected, preserved, labeled, and packaged according to the jurisdictional or institutional policy of the facility where the assault took place. Chain of custody must be maintained, including documentation of all handling, transfer, and storage of evidence.8 If policies aren't followed and chain of custody has been broken, the evidence may not be admitted in a legal proceeding.
The sexual assault physical exam
Due to the complex care needs of patients who've been sexually assaulted, many jurisdictions use a SANE for these exams. A SANE is an RN who's specifically trained to provide all-inclusive care to a patient who's been sexually assaulted. SANEs provide victim-centered care while remaining objective during the exam. A SANE may be an employee of a healthcare facility, police department, or other victim advocacy program. SANEs are prepared to testify about their findings from the forensic exam in a court of law.8
A sexual assault response team consists of hospital-based staff, law enforcement officers, sexual assault victim advocates, prosecutors, judges, and any other professional who assists the patient who's been sexually assaulted. The team's constituents may differ from jurisdiction to jurisdiction. (For more information on sexual assault response teams, visit the National Sexual Violence Resource Center at http://www.nsvrc.org/projects/sexual-assault-response-teams-sart-0.) A forensic medical exam may be performed at a hospital or other healthcare facility by a SANE, sexual assault forensic examiner, or if necessary, another medical professional. This exam is complex and on average takes about 3 to 4 hours. While this may seem lengthy, medical and forensic exams are comprehensive because the patients need and deserve special attention to ensure they're medically safe and protected. In addition, evidence must be collected so if the patient chooses to report the crime to the police, the stored evidence is available.1 With the exception of situations covered by mandatory reporting laws, adult victims of sexual assault, not healthcare workers, make the decision to have evidence collected and to report a sexual assault to law enforcement.8 (See When is reporting mandatory?)
Consenting to a SANE exam doesn't mean that the individual has to press charges. The decision to involve law enforcement can be made at a later date. It's also important to inform patients who've been sexually assaulted that they aren't responsible for paying for evidence exams. Special billing procedures should be implemented and explained to the patient by the facility providing the services.
The purpose of the forensic medical exam is to:
* assess the patient.
* document threat and force.
* document any recent sexual contact apart from the assault.
* identify a suspect.
* corroborate the facts of the assault.8
It also includes preventing further injury by screening and treating for sexually transmitted infections (STIs) while attempting to maintain the patient's dignity and personal control over the exam process.
The SANE will inquire about the sexual assault in order to assess what types of medical care the patient may need. For example, if the patient describes any kind of physical restraint to the wrists, the SANE will look for potential evidence that may be collected from the hands and arms. It would also trigger the healthcare provider to consider if X-rays or skin/wound care are needed. It's important for the SANE to obtain a history from the patient and any witnesses if the patient is unable to communicate.
Evidence may be collected in many different forms during the SANE exam. A specifically designed sexual assault kit is used to collect evidence found on the patient, including hair, skin, blood, and fibers. Photographs may be taken and blood specimens may be obtained to assess for STIs. Clothing may be collected for evidence in the form of stains, debris, hair, and fibers. Hair combings and oral swabs may be helpful in evidence collection. Other areas of the body that may be swabbed are the vagina, penis, anus, rectum, and any areas of skin-to-skin and/or mouth-to-skin contact. Fingernail scrapings/clippings may also be taken.
After the patient (or a guardian if the patient isn't competent to give consent) provides informed consent, the examiner takes a thorough health history including any allergies, preexisting diagnoses, recent procedures, and medications that may influence the exam. This health history should also include last consensual sexual intercourse if the patient is sexually active. Obtaining information regarding complaints of pain, tenderness, or bleeding since the assault helps to guide the exam. The history should also include the time of the assault, details of the assault, and any activities that took place after the assault that could affect interpretation of findings and evidence collection. The examiner asks patients if they've wiped, showered, or bathed; changed their clothes; eaten; used toothpaste or mouthwash; used an enema; or changed or removed a tampon, sanitary pad, or barrier contraceptive.4
After obtaining the health history, clothing is collected carefully to prevent loss of potential trace evidence, such as hair or fibers. Next, the examiner conducts a head-to-toe external exam, swabs potential areas of evidence, and documents and treats any minor injuries. Documentation usually includes written notes as well as photographs.
The external exam is followed by an internal exam. Swab specimens may be collected as evidence and any internal injury documented. If use of drugs or alcohol is suspected, the SANE needs to be informed and will obtain urine and/or blood samples for toxicology.
All patients who've been sexually assaulted should be offered prophylaxis for STIs and hepatitis B infection. Pregnancy prophylaxis should also be offered when the patient is of childbearing potential. In 2010, the CDC published recommendations for the prevention of STIs and pregnancy following a sexual assault.9
Crisis intervention should be offered during and after the exam. For patients with significant cognitive disabilities, such as dementia, standard counseling won't be effective. In these cases, the presence of an advocate who continually reassures the patient may be helpful.10
Another consideration for the advocate is to educate the patient's caregivers on how assaults and trauma affect individuals. Studies have shown that when an assault takes place at a patient's care facility, the patient may feel unsafe and may benefit from being moved to another facility.10 (See When a patient is sexually assaulted in your facility.)
Upon receiving a patient after the completion of the SANE exam, expect discharge instructions that include any medications given, any follow-up and treatment for injuries, a safety plan, and information for psychological counseling.
Psychological follow-up should be included, ensuring the best recovery possible. Older adult victims with dementia have shown the same postassault trauma behaviors as those without dementia.11 When the patient is disabled, caregivers need to learn how to assist with decreasing the triggers and/or respond to trauma behaviors.
Scenario summaries
Looking back at the two scenarios at the beginning of the article, what are the best ways to handle them?
For Mr. G, the patient in the LTC facility, first and foremost is to ensure your safety. Intervene only if you can do so without having your safety compromised. Call for help and refer to your facility's policies and protocols. Assign a provider to stay with Mr. G. Call police and confirm that he receives a SANE examination. Make sure Mr. G doesn't bathe and confirm that potential evidence (such as bed linens and clothing) isn't tampered with. Notify the appropriate agencies in your area, such as Adult Protective Services. After Mr. G returns to the LTC facility, ensure he receives proper psychological care.
In the second scenario, again, first ensure your safety and the safety of the patient and other patients in the facility. Call for help and follow facility policies and protocols. Reassure the patient and assign a provider to stay with her. Involve police if the patient chooses, and notify your SANE team (if your facility has one). Notify the appropriate agencies and provide psychological counseling if needed.
Providing the best care
When a patient's disclosure of sexual assault is ignored by healthcare providers, the patient's basic right to have a complaint believed and investigated is denied and the patient won't get proper medical treatment and supportive care. Healthcare providers can also put their licenses on the line and possibly open themselves up to a civil lawsuit and/or criminal charges by failing to protect a patient who's disclosed a sexual assault. Take any suggestion of sexual assault by a patient seriously and make sure proper protocols are followed to ensure the best outcome.
Rape vs. sexual assault
The definition of rape and sexual assault varies from state to state and is law-dependent. Generally speaking, sexual assault is nonconsensual sexual contact. Rape is a form of sexual assault. However, the definitions may vary in that rape is typically considered nonconsensual physical contact involving the penetration of the vagina, anus, or mouth of another person by a sex organ, other body part, or foreign object. In both sexual assault and rape, force doesn't necessarily need to be used.
Red flags for sexual assault5
* unexplained injuries
* delay in seeking treatment for injuries
* history given by a caregiver that isn't consistent with the patient's injury
* anal, genital, and oral injuries
* bruising involving inner thighs, genitalia, breasts, or anus
* "suck" or bite marks
* STIs
* fear of a specific caregiver, family member, or visitor
* changes in behavior including fearfulness and depression
* loss of sleep.
When is reporting mandatory?
Although many states don't participate in mandatory reporting when a victim is a competent adult, this isn't true when medical personnel treat a child, older adult, or vulnerable adult who was the victim of a crime. Although states use different legal languages, nurses may be required to report abuse, suspected abuse, neglect, and sexual assault involving the dependent adult, older adult, and the vulnerable adult to adult protective services and/or police. Healthcare professionals who don't meet their mandatory reporting requirements can be exposing themselves to fines, loss of license, and possible jail time.
Refer to individual employer and institutional policies at your facility to ensure proper activation of policies regarding mandatory reporting. Although you may not be directly responsible for reporting to governing bodies, you should be aware that employers have other requirements placed on them by agencies such as Medicaid and Medicare.
When a patient is sexually assaulted in your facility
Follow these steps to ensure you're providing the best care possible for patients who've been sexually assaulted in your facility.
1. Ensure safety for yourself and the patient. If you come upon an assault in progress, call for help. If it's something you can physically stop without endangering yourself, stop the assault and remove the offender from the room. Have someone stay with the patient who's been assaulted so he or she feels safe.6
2. Notify your immediate supervisor and activate protocols related to violent crimes or abuse on the premises. Some facilities have protocols specific to sexual assault.
3. To preserve evidence, ask the patient not to eat, smoke, drink, wash, or use the bathroom if possible. Don't wash or bathe the patient. Don't change clothing or incontinence pads, disposable underwear, or other clothing. Don't comb the patient's hair or brush teeth. By performing any of the above, you may lose or compromise physical evidence. In most circumstances, physical evidence may be collected from 72 up to 120 hours, depending on the specific forensic program guidelines. Keep in mind that the chances of finding usable evidence decrease as time passes.12
4. Don't clean up the crime scene and don't remove anything. This includes sheets from the bed if the patient was assaulted on the bed or bedding/belongings that were on the bed after the assault. Don't move anything the offender may have touched. Once the patient has been removed from the room, close the door and don't allow anyone in the room until the police say they've processed the room and it can be returned to normal usage.12
5. Initiate and prepare the patient for transfer to a facility that's equipped to provide sexual assault exams with evidence collection. To obtain the name of your local facility contact, call the National Sexual Assault Hotline at 800-656-HOPE. This hotline will connect you with personnel at your local crisis center who can answer questions. If the patient who's been sexually assaulted is a competent adult, he or she can talk to someone at the crisis center to find out local resources and options for reporting or not reporting. Some crisis centers provide an advocate to accompany the patient at the hospital. This is also a good resource for families and caregivers.
6. Clearly communicate to the examiner or receiving hospital the patient's medical history, including medications and cognitive difficulties. They'll need to know about any consent issues; for example, if the patient isn't competent and has a legal guardian. If this is the case, make sure the guardian will be available by phone or in person to give consent for the evidence collection exam.6
7. Document everything; if you were a witness, document what you saw. If the patient disclosed information to you, document what was said using as many quotes as possible. Don't write down your opinions; document only the facts.8
8. If a patient is disclosing to you after the fact, listen and validate that you'll notify proper authorities.
9. If the patient who discloses is a competent adult and doesn't fall under any mandatory reporting laws, he or she may choose not to report the assault to the police. Maintain confidentiality and help the patient make an informed decision about whether to have an evidence exam or not.6
10. Believe and address all concerns that a patient verbalizes. Address patients who appear to be fearful of something or someone. Get the patient proper help to meet medical needs related to the assault.
11. Encourage all nurses at your facility or place of employment to recognize the signs and symptoms of abuse and sexual assault.5 Review your policies related to victims of crimes and know your mandatory reporting requirements.
12. If you work at an LTC facility, encourage management to do background checks on all residents. Staff should be aware if a patient has a history of assaults, and safety measures should be employed with that patient. An example would be to place that patient in a single room and make sure he or she is never alone with any other patient. Removing the patient from the facility is another option.
13. Be alert for trouble. Question anyone in the hallways of hospitals or healthcare facilities who doesn't look familiar, isn't displaying identification, or appears to be loitering.
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