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Based on interview and record review, the facility failed to ensure the rights to a safe setting for 1 of 1 patient (Patient #7) on sexual victimization precautions, allowing the patient to be exposed to possible abuse as shown by:

-staff not appropriately monitoring the patient on sexual victimization precautions during a vulnerable time (shower time);

-not ensuring alarms were on per facility policy, and;

-not ensuring video cameras in the unit hallways were able to properly function and visualize alleged victim's room doorway in the unit's hallway.


Findings included:


Review of facility policy titled "Precautions", #PC 190, last revised 11/2022 showed that staff will be cognizant of patients' whereabouts at all times and staff will observe the patient as ascribed by the patient's risk precautions as ordered by the physician. Staff are also to be aware that the bedrooms and bathrooms are high risk areas, and, specifically listed under Sexual Precautions; staff will structure shower time with staff supervision.

Review of facility policy titled "Clinical Alarms", #PC 200, last reviewed 5/2023 showed that the alarms are to ensure monitoring for safe patient care, and motion sensor alarms in patient room are to be checked for proper functioning by nursing staff.

Review of policy titled "Youth Electronic Monitoring System", #PC 161, reviewed 5/2023 showed that the charge nurse is responsible for ensuring the motion alarm system in the hallways are functioning properly and if they fail, staff are still ultimately responsible for monitoring the hallways at all times.

Review of facility's self-report involving Patient #7 as alleged victim and Patient #8 as alleged perpetrator showed the following: On the night of 8/9/23 at approximately 6:00 pm, Patient #7 was taking a shower. A male peer, Patient #8 allegedly entered her room and had non-consensual intercourse with her. On 8/10/23, Patient #7 was sent to an emergency room where she had a medical work-up (a forensic assessment performed) and she also filed charges with police against Patient #8.

In interviews on 8/15/23 at 12:45 pm with Chief Nursing Officer (CNO)-Staff #C, Chief Executive Officer (CEO)-Staff #A, and Director of Performance Improvement/Risk Manager (DPRM)-Staff #B, they stated the following with regards to the sexual allegation incident involving Patients #7 & #8:

On the evening of 8/9/23 at around 8:00 pm, Patient #7 complained to the evening shift nurse on duty in unit 700, Staff #L, that at around 6:00 pm while taking a shower in her room, Patient #8 came into her bathroom and touched her inappropriately. The nurse then reported this to her House Supervisor-Staff #I and it was then reported to the facility's CNO, Risk Manager, and the attending physician, who ordered a medical consult to be performed. The following day on 8/10/23, Patient #7 met with the Director of Clinical Services (DCS)-Staff #H and reported that she was raped by Patient #8 and requested to go to the emergency room. The patient was sent to the ER, filed a police report while there, then returned back to the facility.

Record review at time of survey of Patient #7's clinical records showed the following: 26 year old married female admitted to facility involuntarily on 8/6/23, under Dr.-Staff #K, with an admitting diagnosis of Major Depressive disorder. The patient was placed on Sexual Victimization Precautions per doctor's order.

Further record review of clinical progress notes from nursing, nurse practitioner who performed a medical consult, and therapist who interviewed patient, showed that on 8/10/23, the patient was sent to HCA Houston Kingwood for a forensic exam due to the complaint that she was raped. Forensic exam results showed the patient was positive for vaginal and anal penetration with red linear abrasions to the fourchette (folds of the bottom posterior area of the vagina). The patient was prescribed several medications for the prevention of sexually transmitted infections and given emergency contraception medicine. She also had a pregnancy test performed. While still in the ER, she filed a police report with the Houston Police Department. The patient was then returned back to the facility.

Record review at time of survey of Patient #8's clinical records showed the following: 38 year old single male admitted to facility voluntarily on 8/8/23, under Dr.-Staff #N, with the admitting diagnosis of Schizoaffective disorder. The patient was on Assault Precautions per doctor's order.

Review of treatment records showed both Patients #A & #B resided in the facility's 700 unit, a mixed general adult unit.

In an interview on 8/15/23 at 1:00 pm, Staff #C stated that the nurses working the evening of 8/9/23 did not ensure the unit's motion alarms were activated at the time of the alleged incident occurred, and they should have been on.

In addition, there were no staff monitoring the hallways during vulnerable shower time that evening; the two staff present on the unit were at the nurse's station and did not walk the hallway or were present in the patient milieu, per facility policy.

In an interview on 8/15/23 at 1:10 pm, Staff #A, #B, and #C stated that the video footage in the hallway where Patient #7 resided was reviewed and it showed the following: while the patient was in her room, the camera footage by the patient's bedroom doorway showed a figure identified as Patient #8 present in and around the doorway. There were then four to five minutes that the video could not be visualized. Staff #'s A, B, and C acknowledged that Patient #8 could have gone into Patient #7's room during that time. Staff #C then stated that the Mental Health Technician (MHT)-Staff #M, who should have been present on the unit, was not there monitoring the hallway and the unit schedule was not maintained. Staff #C added that there were only two staff present in the unit (RN-Staff #F & #G) but they remained in the nurse's station, not in the milieu monitoring the hallway where they should have been.

Based on record review and interview, the facility failed to ensure an accurate visitation schedule was provided to patients as shown by the visitation schedule in the facility's patient rights handbook conflicting with the actual visitation schedule.


Findings included:


Review of facility policy titled "Patient Visitation Rights", #PR-100, last reviewed 5/2023 showed that all patients will be informed of their visitation rights.

Review of facility's current patient handbook showed that visitation hours for adults are the following:

Monday 6:16 pm-7:15 pm,
Wednesday 6:15 pm-7:15 pm, and
Sunday 1:00 pm-2:00 pm.

This schedule showed that adult patients and their visitors were allowed to have three days for visiting.

Review of facility's patient activity schedules per unit, however, showed the following visitation times for adults:

Unit 100; Monday only, 6:15 pm-7:15 pm;
Unit 300; Tuesday only, 6:15 pm- 7:15 pm;
Unit 500; Wednesday only, 6:15 pm -7:15 pm, and;
Unit 700; Thursday only, 6:1 5pm-7:15 pm.

The actual visitation times were only one day a week for adults, not three as shown in the current patient handbook, which was given to all patients upon their admission to the facility.

In an interview on 8/15/23 at 3:15 pm, Staff #B and #C stated the actual visitation schedules are in the unit-specific itinerary schedules and also posted in the facility lobby, and were different than the ones in the patient handbook.

Based on observation and interview, the facility failed to maintain their physical plant to assure the safety of patients in 3 of 3 units observed, as shown by the presence of various patient safety hazards which included rusty bases of doorways in patient's bathrooms, exposed rusty protruding toilet bolts in patient's bathrooms, and unsecured rusty nails and screws in patient bedrooms.


Findings included:


Review of facility policy titled "Maintenance Services", # M105, last reviewed 5/2023 showed that maintenance services will ensure the facility building is maintained to provide patient safety, and corrective maintenance and repairs will be done in a timely fashion.

Observation of three facility units (Units 100-PICU, Unit 200-General Adult, & Unit 500-Woman's Program) on 8/8/23, starting at 10:45 am, led by Staff #C, showed the following:

Observation inside patient bedrooms showed there were metal bathroom door frames separating the bedroom from the patient bathroom. Several of these areas had rusty portions near the bases in various stages of corrosion, most already to the point of hole formation which exposed sharp, rusty edges. These were present in room numbers: 207, 209, 210, 211, 212, 213, and 214. Room 214 had a larger hole approximately 2" x 1" corroded by rust at the bottom of the doorframe, exposing a sharp rusty edge, which was possible to bend and break-off from the frame. All of these areas posed a risk of abrasion from accidental or intentional self-harm by patients. These were also infection control issues, as these areas were part of the patient bathrooms touching the floors (tetanus bacteria, fecal bacteria, etc.).

Observation inside patient bathrooms revealed there were two bolts present on each of the toilets securing them to the floor. These toilet bolts were sharp, rusty, and protruded approximately 1"- 1.5" above the toilet bases, posing a safety hazard for accidental or intentional patient injury/self-harm (puncture, cutting, infection). These findings were in rooms 107, 114, 214, 509, 511, & 512.

Observation of window frames in patient bedrooms showed the following: Room #113's window frame had an area of cracked and crumbled, sheetrock, some of which was missing which exposed a hole approximately 2" x 3". The wooden frame underneath the sheetrock was visible and a rusty nail approximately 1.5" was protruding out of the wood, available for patients to remove and posing a safety hazard.

Observation of Room #111 showed it had large screws securing an air conditioning unit to the wall. The unit had been pulled away from the wall exposing three screws which could have been unscrewed by patients, despite being safety screws, and posed a safety hazard.

Observation of Room #107 showed it had a wooden window frame with a rotted base on one side, exposing a rusty nail approximately 1.5" that was able to be removed by hand while in room. This nail posed safety hazards to patients.

In an interview at the time of all findings, Staff #C acknowledged they were all safety hazards and would be fixed promptly, along with any other problems in patient rooms.