HospitalInspections.org

Based on observation, medical record review, document review, and interview the Governing Body failed to:

1. ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to A0145

2. ensure a written nurse staffing plan with an approved matrix/grid was enforced to ensure an adequate number of Registered Nurses (RN) and Mental Health Techs (MHT) were available to meet the needs of all patients on 2 (BH4 and BH5) of 2 patient care units reviewed.

Refer to A0392

Based on medical chart reviews, interviews, and observations the facility failed to ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to A0145

Based on medical chart reviews, interviews, and observations the facility failed to ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings:
A review of patient #2's(alleged victim) medical record revealed he was a 15 y/o male admitted to the facility on 01/22/2025 with a diagnosis of SI and depression. A review of the nursing progress note dated 1/26/25 at 2118 stated, "Pt reported to RN at 1830 that another male pt (pt#1 alleged predator) forced him to "suck it" on January 25. ___ (pt #2) reported that he was alone in the room with ____ (pt #1) after taking a shower, and ____ (pt #1) threatened "You better suck it, or I'm going to beat your ass".___ (pt #2) reports that ____ (pt #1) has been threatening him with violence as well as "using a gun". ____ (pt #2) reported all that happened was oral sex to RN.

Pt #2 was interviewed in front of witness _____ (staff #18) MHT. When RN questioned pt if they reported the incident to any staff, pt verbally denied informing anyone. RN immediately reported to MD _____, House Supervisor, _____(therapist), and administration. Pt was offered PRNs but refused stating "I'll take them with my night medications". Pt receiving therapy with therapist for psychosocial needs. Administration and therapist are contacting parents at this time. Victim was moved to a separate unit with increased surveillance. RN will endorse to night shift."

A review of the nursing progress report dated 1/26/2025 @ 21:43 stated, "Mother came to STB to pick up patient #2 due to allegations. As per attending doctor on call patient to be discharge to mother. Attending psychiatrist spoke to mother regarding allegations and patient's discharge readiness. Mother stated she is patient's primary support and was able to identify ways to help patient when signs of crisis emerge. Patient's mother provided with discharge information and medication list. RN House Supervisor informed mother she will be called Monday Morning with follow up appointments. Mother was facilitated information by PD officer at scene so patient can have a sane exam as per mother's wishes. Patient denies SI, HI, depression, anxiety or hallucinations."

A review of patient #1's medical chart revealed he was a 13 y/o male admitted to the facility for suicidal Ideation (SI) with a plan. It was documented that the patient had no history of sexual abuse as a perpetrator or a victim. Pt. #1 was placed on Routine, Homicide/Assault/Aggression, and every 15-minute check (q15).

A review of patient #2's medical chart revealed he was a 15 y/o male admitted to the facility on 01/22/2025 per his mother, the patient is also being accused by her ex (not the father of the patient) of having sexually assaulted 9yr old stepsister and has open CPS case. He had been hallucinating along with paranoia and cybersex/watching pornography. During the intake process, it was recommended by the intake staff to place patient #2 on an SAO precaution. The patient had a physician order for SI and elopement precautions but did not have an order for Sexually Acting Out (SAO).

A review of patient #3's chart revealed he was a 13 y/o male admitted to the facility on 1/19/25 for Intermittent explosive disorder, Suicidal ideation, and Aggression. It was documented that the patient had no history of sexual abuse as a perpetrator or a victim. Pt. #3 was placed on Routine, Homicide/Assault/Aggression.

A review of patient # 4's chart revealed he was 16 y/o male. He was admitted on 1/17/25 for SI with a plan. Patient #4 has a history of sexual abuse by a cousin. He is an involuntary patient. He was placed on SI, Routine, At Risk for Victimization, and elopement precautions.

On the morning of 1/29/25, the survey team toured the facility with Staff # 5, Director of Nurses (DON). The DON took the team to Units 4 and 5, which are the patient rooms for adolescents and teens. Staff # 5 was asked about the process for showers and hygiene. Staff #5 stated that the patients share a room and one bath. The patients are in beds A and B. Between the hours of 9-10 pm, the patients assigned to bed A come to the room and take care of all their shower and hygiene needs while group B waits in the day room. At 9:30 pm, group B comes to the room for shower and hygiene time. Lights out at 10:00 pm. Staff #5 confirmed that the patients are never in the rooms together during shower and hygiene time.

An interview was conducted with staff # 12 MHT and Staff # 11 RN on 1/29/25 in the afternoon. Staff #12 stated that he has worked at the facility for 2 1/2 years. Staff #12 stated a little before 9 pm one MHT watches the patients in the day room while the other MHT puts hygiene products and towels on the beds. All patients are brought back to their rooms to complete shower time and lights are out by 10:00 pm. Staff #12 confirmed that this had been the routine for the last 2 ½ years that he had worked at the facility. Staff #12 was asked if he was aware if any of the patients were on SAO precautions and how would they be monitored. Staff #12 stated he was not aware of any patient on SAO precautions and stated if they were on precautions they would be watched more carefully.

Staff #11 RN confirmed that the hygiene time was conducted with all patients together at the same time. Staff #11 stated that on 1/20/25 patient #1 had come to her and asked to be moved to another room. Patient #1 stated that patient # 3 was weird and he felt very uncomfortable. Staff #11 asked patient #1 what "weird" meant but he did not feel comfortable speaking with her.

Staff #12 stated that on 1/20/25 patient #1 stated that he had asked the nurse to move him because patient #3 was making sexual suggestions to him. He stated that patient #3 told patient #1 that "if he was hard right now, he would suck him off." Patient #1 had made the outcry.

Staff #11 stated that she called the house supervisor staff # 13. The house supervisor notified the physician moved patient #3 in with another boy and left patient #1 alone in his room. Staff #11 was asked why patient #3 was not left alone and patient #1 was moved in with another child since he made the outcry. Staff #11 stated she was not sure. Staff #11 was unable to verbally refer to the SAO policy and how the patients should be separated and monitored.
An interview was conducted with staff # 13 RN House Supervisor. Staff #13 stated that on 1/20/25 patients #1 and #3 were separated and placed in separate rooms. Staff #13 was unable to tell me what room and with what child patient #3 was placed with. Staff #13 stated that patient #1 was agitated earlier because his mother would not answer the phone. She stated that patient #1 liked a female patient on the unit and acted out in front of her regularly. Staff #13 stated patient #1 would curse at the staff and was very manipulative. Staff #13 stated that patients #2 and #4 identified as homosexual and had requested to room together. Staff #13 stated that she was trying to make sure that patients #2 and #4 were not placed together.

Staff #13 stated that she called the physician and moved them for the night to be addressed in the morning. Staff #13 was asked about patients on SAO or if she was aware any of the patients were past victims of sexual assault and she stated, "No." Staff #13 stated that bed boards decide if the patients need to go on an SAO, but she was "unsure" if anyone gets recognized as a predator or a victim.

A review of patient #1's chart and #3's chart revealed there was no documentation of the alleged incident when the physician was called, when and where patients were moved to other rooms, or what administrative personnel was notified of the incident.

During an interview with staff #1 and #2 on 1/29/25 revealed the following roommates and dates for patients #1-4.
1/18/25-1/19/25 Patient #1(alleged predator/victim) roomed with patient #3(alleged predator/victim).
1/20/25 Patient #1 was left in his room alone and patient #3 was placed in another room with another child after alleged sexually inappropriate behavior.
1/21/25-1/22/25 Patient #1 and patient #4 were roommates.
1/23/25 Patients #2 and #3 were roommates but Patient #2 wanted to be in the room with #4 because they "liked each other" according to staff #12 and #13. Patient #2 insisted he be moved out of patient #3's room. Patient #2 stated it was because he didn't like patient #3.
1/23/25 Patient #2 and patient #1 were placed in the room together even though patient #2 was on an SAO precaution and had an open case for alleged sexual assault.

Patient #3(alleged predator and victim) stated he was forced to give patient #1 oral sex in the shower on 1/19/25. Patient #4 stated he was forced to give oral sex in the shower with patient #1 on 1/23/25 however, they were not roommates on this date. Patient #2 stated he was forced to give oral sex and was penetrated rectally on 1/25/25 in the shower. Patient #2 was taken to the hospital for a sexual assault examination on 1/26/25. The test came back negative.

An interview was conducted with Staff #1, #2, #3, and #5 on 1/29/25 in the afternoon. Staff #1 confirmed the facility did not have a policy for showering or hygiene time. Staff #2 stated that he looked at videos and monitored different shifts but was not aware the adolescent patients were not following the rules for shower time.

Staff #1 stated that on the evening of 1/26/25, they were made aware of patients #2, #3, and #4's allegations of sexual assault. Staff #1 stated the police arrived with the parents and demanded their children be discharged. Staff #1 stated the psychiatrist spoke with the parents and patients. There was no documentation in the patient charts of any assessment by the psychiatrist before discharge. Patient #1 was not discharged until 1/29/25.

An interview was conducted with staff # 15 police investigator on 1/29/25 in the afternoon. Staff # 15 stated that he had interviewed staff and patients #1-4's allegations of sexual assault. Staff #15 had two case numbers for patients #2 and #3 but was not opening any other cases. Staff #15 stated he would have his investigation completed in a couple of weeks but at this time had no further information to share. Staff #15 did confirm that the SANE exam was negative for patient #2.

According to the facility policy "Title: PC.3100 Victims of Abuse "the facility failed to report the abuse to the state immediately. The policy stated, "Immediately report abuse, illegal conduct, neglect, unethical conduct, and unprofessional conduct as required by 25 TAC §133.47 & 134.46, Abuse and Neglect Issues:
What to report:
1) Abuse/Neglect/Exploitation of a child
2) Abuse, neglect or exploitation of an elderly or disabled person
3) Abuse and neglect of individuals with mental illness
4) Illegal, unethical, and unprofessional conduct

Immediate reporting of a specific related to abuse and neglect is required by 25 TAC §133.47 & 134.46, Abuse and Neglect Issues. The definitions of abuse, illegal conduct, neglect, unethical conduct, and unprofessional conduct are defined under §133.47 & 134.46." Staff #1 confirmed the facility had failed to immediately inform the state.
A review of the policy and procedure Title: BHC.2750 Sexually Acting Out and Victimization stated, "12. Response to alleged sexual familiarity occurrences: Facility staff and physicians should take all reports of sexual familiarity between patients seriously and respond accordingly. Sexually Acting Out Protocol will be completed by the Supervisor/Designee. Designated staff will follow the protocol instructions in the event of sexual acting out between patients and/or allegations against staff to
include the following:
a. All patients who allege sexual assault will be placed on 1: 1 observations or as ordered by a physician. 1 :1 observations will be discontinued upon the written order of a physician only.
b. Attending physician will be contacted for any patient involved in sexual, misconduct (i.e., inappropriate touching, gestures, or comments) to determine level of observation orders
c. Separate the parties involved. Reassign patients to separate care areas. Explain intervention. Add red dot to observation record to identify high risk monitoring of SAOA patients boarding from other care areas. Use high risk notification form to provide SBAR to transferring staff.
d. Notify Administration/Designee.
e. Administration/designee will notify state agencies (as applicable).
f. Notify each patient's attending physician immediately.
g. Chain of command: reporting unsafe conditions, staff behaviors.
h. In the case of a minor or patient declared legally incompetent, the patient's parent or legal guardian should be notified of the incident by the appropriate personnel.
1. Staff will interview involved parties separately to determine exact nature of the alleged occurrence and complete a nursing assessment/reassessment.
J. The physician along with Administration/Designee will determine whether evaluation in an emergency room is needed (i.e., allegation of rape). If deemed appropriate, nursing staff will transfer the patient to the emergency room for evaluation as soon as possible upon written order of a physician. If for any reason a delay in treatment occurs, the Administrator on Call will be contacted for further recommendations with subsequent documentation placed within the medical record. In order to preserve evidence, patient should not be allowed to change clothes or shower prior to transfer.
k. Examination requirements:
a. the physician, in collaboration with the nursing staff, will determine the potential risk of sexually transmitted diseases (SID).
b. the physician and/or designee will complete a mental status examination and incident review and determine whether a rape kit, and/or testing should be done for HIV, Hepatitis B, Hepatitis C,
and/or any SID and order as appropriate. Pregnancy testing may also be considered. Plan B reviewed/offered as appropriate. The physician should discuss these issues and concerns (potential risks and testing) with the patient or guardian and off er and discuss medical options as appropriate.
1. Designated staff should notify appropriate state or local authorities as required by State statutes. If uncertain, consult with the corporate Legal Department. Discuss with alleged victim, parent/guardian regarding patient rights to initiate criminal proceedings/press charges.
13. Documentation and evidence retention: Staff will complete documentation of any incidents of sexual familiarity in the patient's medical record; the documentation will include the following:
a. Document clearly that this is an allegation, unless witnessed by staff, using words like allegation, alleged or possible.
b. Do NOT use names of the other patient(s) allegedly involved; use peer (For example, use male peer or female peer).
c. Give basic, concise, objective information about the incident. Document only what was observed or reported by the patient and document it as such.
d. Document your interventions separately according to events that transpired with each patient (ie. talked with patient, supported, processed, etc.). Follow up at a later time with the patient who has made allegations and document the interaction.
e. Document behavior immediately following disclosure and soon after (ie. Is the patient upset, tearful, withdrawn or talking, laughing with peers, jovial, etc.?).
f. Evidence retention: written statements, surveillance/security tape, copies of external reports. Secure crime scene if applicable. Room or area where event took place should be taken out of service and not cleaned until cleared by law enforcement.
14. When an occurrence of sexual familiarity is discovered, steps should be taken to prevent recurrence. A preventative approach should be instituted as part of the patient's treatment plan.
15. Staff Development- Clinical orientation and annual updates include:
a. Review of SAOV and SAOA Policy,
b. monitoring and patient observation,
c. review of patient boundary violations, early identification of SAOV and/or SAOA behaviors(s) and intervention, and
d. effective communication among caregivers."

Staff #1 confirmed on 1/29/25 in the afternoon that she did not know what was in the SAO policy and wasn't familiar with it. Staff #1 confirmed that patients were not being monitored or identified properly while on SOA or Victim precautions.

Staff #1 confirmed that patient #1 was not placed on an SAO or placed on a 1:1 observation on 1/20/25 when he made an outcry of sexual assault. Patient #3 did have an order for SAO and was placed in a room with another patient without consideration of the SAO and a current sexual assault claim.

Staff #1 confirmed that there was no documentation on patient #1 or patient #3 on 1/20/25 concerning sexual allegations, the patients moved to other rooms, or that the administration or parents were notified. There was no reassessment of the patients to ensure there was no sexual misconduct on that shift.

Staff #1 confirmed that the patients were not being separated or monitored in their rooms during shower time which allowed the patients to have an opportunity for sexual misconduct and potentially for sexual abuse.

A review of the employee files #16 RN, #12, #13 RN HS, and #14 RN HS revealed they had not received 8 hours of Abuse, Neglect, and Exploitation (ANE) training.

Based on document review and interview the hospital failed to have an organized nursing service that ensured safe staffing levels for patient care on 2 (BH4 and BH5) of 2 patient care units reviewed. The facility failed to have a safe staffing matrix that clearly delineated the Licensed Vocational Nurse (LVN) and the Mental Health Tech (MHT) from the Registered Nurse (RN). Also, the facility failed to follow the hospital policy titled, "Appropriate Staffing Levels", Policy Number: BHC.CE 0003c".


Refer to Tag A0392

Based on document review and interview the hospital failed to have an organized nursing service that ensured safe staffing levels for patient care on 2 (BH4 and BH5) of 2 patient care units reviewed. The facility failed to have a safe staffing matrix/grid that clearly delineated the Licensed Vocational Nurse (LVN) and the Mental Health Tech (MHT) from the Registered Nurse (RN). Also, the facility failed to follow the hospital policy titled, "Appropriate Staffing Levels, Policy Number: BHC.CE 0003c".


Findings:

An observation tour of the Behavioral Health Unit was conducted on 1/29/2025 after 9:00 AM
with Director of Nurses (DON) Staff #5 on 1/29/2025. The Behavioral Health Unit had 6 separate units. 4 units were for adult patients and 2 units were for pediatric patients, ages 7-17. BH4 was the primary pediatric unit and BH5 was an additional unit for pediatric patients and was only used as a swing unit when patient census and patient care required additional rooms. BH4 and BH5 shared one nursing station and the two units were separated by a locked door.




A review of the staffing sheets dated 1/15/2025-1/28/2025 was completed with Director of Nurses (DON) Staff #5 on 1/29/2025 after 2:00 PM. The staffing sheets indicated the staff name and their discipline assigned to each unit for AM shift and PM shift. The staff scheduled for the AM shift worked from 7:00 AM-7:00 PM. The staff scheduled for the PM shift worked from 7:00 PM-7:00 AM.

A review of the staffing matrix/grid for BH4 and BH5 (Pediatric) units revealed the unit was staffed according to a 3-shift schedule. The 3 shifts included a day shift, an evening shift, and a night shift. The BH4 Unit matrix/grid revealed the Licensed Practical Nurse (LPN) and the Mental Health Tech (MHT) were counted as one. There was no way to determine the staffing needs of each discipline to ensure patient and staff safety. The BH5 Unit matrix/grid revealed the Registered Nurse (RN), LPN, and MHT were counted as one and there was no way to determine the staffing needs of each discipline to ensure patient and staff safety.

Further review revealed the staffing matrix/grid did not match the actual working shifts for the BH4 or BH5 Units. This surveyor could not determine if the BH4 or BH5 Pediatric units were staffed appropriately to ensure patient and staff safety.

An interview was conducted with DON Staff #5 on 1/29/2025 at 5:35 PM. DON Staff #5 was asked how he staffed the units according to the staffing matrix/grid. DON Staff #5 stated, "I don't use that grid. That grid is for 3 separate shifts. I use this grid that was shared from one of our other UHS facilities to staff the units". DON Staff #5 was asked if the staffing matrix/grid that was being used was sent through the staffing committee for approval. DON Staff #5 confirmed the staffing matrix/grid had not been approved by the Chief Nursing Officer (CNO) or the Staffing Committee for use at the facility. DON Staff #5 was asked who relieved the RNs for a lunch break if there was only one RN scheduled. DON Staff #5 stated, "The RNs get the nurse that's working the other unit to relieve them". DON Staff #5 confirmed that 3 separately locked units for adult patients share one nursing station and two separately locked pediatric patient units share a nursing station.

DON Staff #5 was asked to review the staffing schedule for 1/15/2025 on BH4. The staffing schedule revealed that a Licensed Vocational Nurse (LVN) was scheduled on BH4 with the word (split) beside the employee's name. DON Staff #5 was asked to clarify what the word "split" meant. DON Staff #5 stated, "That means the employee administered all medications to patients on both BH4 and BH5 pediatric units". DON Staff #5 was asked if the LVN was scheduled to work on B. DON Staff #5 stated yes. DON Staff #5 was asked who covered for the LVN while they passed medications on the other unit. DON Staff #5 stated, "The RN was still on the unit and there was a Mental Health Tech (MHT) there also but, no one took her place while she was on the other unit". DON Staff #5 was asked if the LVN was scheduled to work both pediatric units for the day. DON Staff #5 confirmed the LVN was scheduled to work two separate locked units and administer medications to all patients on both BH4 and BH5 pediatric units on 1/15/2025.

An interview was conducted with RN Staff #13 on 1/29/2025 at 2:03 PM. RN Staff #13 was asked how lunch breaks were managed on the night shift. RN Staff #13 stated, "The nurses will give each other lunch breaks. I work with adolescents mostly. Sometimes we only have one unit open for pediatric patients. So, there were not always 2 RNs on the unit. At times we would have an LVN, and we would just relieve each other for a lunch break. Both of the pediatric units share a nursing station, but they are 2 separately locked units". RN Staff #13 was asked if she had to clock out for lunch. RN Staff #13 stated, "Yes, we have to clock out for lunch but sometimes we just eat at the desk in the nurse's station or go to the nutrition room to eat quickly". Does the House Supervisor come and give lunch breaks? RN Staff #13 replied, "Not usually".


A review of the facility policy titled, "Appropriate Staffing Levels", Policy Number BHC.CE 0003c, with a last review date of 9/01/2023 was as follows:

"Scope
All operating inpatient facilities that are Behavioral Health Division subsidiaries of Universal Health Services, Inc. that participate in Medicare and Medicaid programs and UHS of Delaware Inc. and their personnel who support the Behavioral Health Division operations.

Purpose
To assure compliance with all laws, rules and regulations relating to federal and state health care programs.

Policy
It is the policy of South Texas Health System Behavioral to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and is
reviewed annually.

Procedure
I. The Chief Nursing Officer is responsible for developing a core staffing plan for each patient care unit based upon population served. The staffing will include Registered Nurses (RNs) and Mental Health Technicians (MHT)

2. In development of the core staffing plan, each CNO shall consider the following:
a. Each patient care unit will have a minimum of one RN at all times. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented ..."

A telephone interview was conducted with DON Staff #5 on 1/30/2025 at 10:24 AM. DON Staff #5 was asked if the Chief Nursing Officer (CNO) developed the staffing plan and staffing matrix for the behavioral health unit. DON Staff #5 stated the staffing matrix was part of the hospital staffing plan. DON Staff #5 confirmed the facility did not have a CNO at the time and he was unsure if an interim had been placed in that position. DON Staff #5 confirmed the staffing plan that was in use at the time of the survey came from another UHS facility as a guide/tool. DON Staff #5 was asked if there was documented relief for the RNs during their scheduled lunch breaks. DON Staff #5 confirmed there was no documented relief for the RNs. DON Staff #5 also confirmed the facility policy titled; "Appropriate Staffing Levels" had not been reviewed annually as required by the facility policy.