HospitalInspections.org

Based on record review and interview, the facility failed to ensure patient's rights to be free from all forms of abuse, neglect, or harassment by failing to report/respond to an allegation of sexual assault in accordance with their policies and procedures, for 1 of 2 patients reviewed (Patient #2) with an allegation of sexual assault against another patient, [Patient #4].

Specifically, the facility did not have evidence an allegation of sexual assault was reported to the Department of Health and Human Services Commission (HHSC), Health Facility Compliance (the appropriate state health care regulatory agency with the authority over the facility) in accordance with their policy and procedures; and State Law.

This deficient practice could compromise patient safety by failing to implement protections and further prevention of abuse and/or neglect.

Findings Included:

Review of the Child Protective Services (CPS) Intake Report #75398019 dated 10/25/2021 and referred to HHSC- Health Facility Compliance (the appropriate state health care regulatory agency with the authority over the facility) for investigation under TX00398727 (State Complaint ID #311131) revealed on 10/24/21, Patient #2 alleged to her guardian that she was sexually assaulted on 10/20/21 and 10/21/21 by another patient (Patient #4) while a patient in the facility. The guardian then contacted the hospital staff who stated this allegation was under investigation. The local police department was notified by Patient #2's guardian. Patient #2 was scheduled to be taken to a local Hospital for a sexual assault nurse examiner (SANE) assessment by Patient #2's guardian. Patient #2's guardian noted the hospital had not seemed to have reported the allegations to any authority.

Review of Patient #2's nursing progress note dated 10/24/21 at 07:18 AM documented Patient #2 reported to Registered Nurse - A that a peer has been allegedly harassing her sexually, touching inappropriately, and making her feel uncomfortable and scared. The mother, attending physician, and supervisor were notified of allegations.

Review of Patient #2's Behavioral Health Progress Note dated 10/24/21 at 2:01AM by Medical Doctor -A documented that Patient #2 reported that on the second night that she was admitted in the hospital that the other patient approached her as she was her roommate and reported being sexually assaulted. The MD-A provided Patient #2 with education about the fact that her parents have decided to press charges. The Patient will most likely be sent to get a SANE exam as required by the investigator.

Review of the facility's Policy and Procedure titled, "Victims of Abuse, Policy Number: PC.3100" last revised 5/1/22 indicated in part; J. State Reporting
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

Who to report to:
The Patient Quality Care Unit of DSHS's [now HHSC] Division for Regulatory Services, 1-888-973-0022

Review of the facility's Sexual Allegation Response and Notification Checklist COPY, 2018 documented the following in part under Section 2: Investigation.
For Reporting: Notify assigned Regional Risk Manager
Notify the Corporate Clinical Director to determine regulatory reporting (child/adult protective services, state health services, etc.) Self-report is made to regulatory as directed.

On 09/14/2022 at 2:00 PM, this surveyor reviewed the Statewide Database Program [TULIP] to determine if the facility had reported this sexual assault incident to HHSC - Complaint and Incident Intake. Upon review, there was no evidence the facility had made an oral report, email, or facsimile report of the sexual assault allegation made by Patient #2 against Patient #4; and in accordance with their policies and procedures. The only report made was to CPS from the local mental health authority professional.

Interview on 9/14/22 at 1:00 PM with the facility's Chief Nursing Officer (CNO) stated when allegations of sexual assault are made, the risk manager is notified and gets involved. If there is a sexual allegation, the facility completes a self-report to the state (HHSC) Health Facility Compliance.

Interview on 9/14/22 at 4:00 PM with the facility's current Director of Risk Management (DRM)-A confirmed the allegations made by Patient #2 of sexual assault on 10/24/21 were not reported to HHSC- Health Facility Compliance as the facility was not able to provide evidence. The DRM-A stated the previous DRM-B must have not reported it as required.