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Based on review of patient records, policies and procedures, and interview, the facility failed to ensure that 18 patients (Patient #1, #2, #4, and #6 through #20) of 18 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault.

Refer to Tag A0117

Based on review of patient records, policies and procedures, and interview, the facility failed to ensure that 18 patients (Patient #1, #2, #4, and #6 through #20) of 18 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault.

Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subchapter (b) requires:
(b) A health care facility providing care to a sexual assault survivor shall provide the survivor with:
...
(3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure;
(4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...)
...
(7) the name and telephone number of the nearest sexual assault crisis center; and
...

Findings included the following:

On 6-18-2025, review of the Table of Contents for Christus Trinity Mother Frances Tyler Emergency Care Center (ECC) was reviewed. It contained 15 policies with only one pertaining to "Treatment of Sexual Abuse or Assault".
Review was made on 06-18-2025 of the Policy Title: Treatment of Sexual Assault Survivors in the Emergency Care Center (ECC), Approved by: Chief Nursing Officer (no name or signature), Created: 08/2023, no policy number, no reviewed date.

The policy did not contain information or procedures for ensuring patients were provided the following rights as required by state law. The right to:

access to a sexual assault program advocate, if available;

the information form required by the commission detailing survivor rights and required information; or

the name and telephone number of the nearest sexual assault crisis center.

Review of patient charts on 06-19-2025 revealed that Patient #1, #2, #4, and #6 through #20 did not contain evidence that the required information form or information on the nearest sexual assault crisis center had been provided.

Interview was conducted with Staff Member #8 in her office. Staff Member #8 provided a copy of the information packed that Advocacy Center handed out when they came. Review of packet content showed that while the packet contained local resources, there was no record that the Advocacy Center ever gave the packets to the patients.

Review of patient records showed that 6 patients (Patients #2, #4, #6, #10, #14, and #20) did not have evidence of access to an advocate as required. Since they did not have access to an advocate, no packet of local resources was given.

The Advocacy Center packet did not contain the state required information form. Staff Member #8 stated that the hospital had just become aware of state required information form last week. She stated that they were going to start giving the form out but hadn't had any SANE cases since they had become aware.

When patients declined the SANE exam or were not provided a SANE exam, the state required information form and the name and telephone number of the nearest sexual assault crisis center was not being given by nursing staff. This information was expected to be given by the SANE nurse. If the patient never saw the SANE nurse, the information was not given. This was confirmed during interview with Staff #4 and Staff #7 during interview on 06-19-2025 in the conference room during record reviews.