HospitalInspections.org

Based on interviews and record reviews, the facility failed to guarantee incidents of abuse and neglect were reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred. This was evidenced by the facility's failure to ensure that:
The disclosure of recent allegations of sexual abuse and neglect by 1 of 3 patients (Patient #1) were fully assessed and then reported to the appropriate agencies or authorities by an Intake RN, Charge and Staff RNs, Attending Physician's Nurse Practitioners, and the Attending Physician.

Findings were:

Record review of Policy 16799145, "Identifying and Reporting Abuse, Neglect, and Sexual Exploitation, PR-102" last approved 10/2024 by Staff D (Chief Nursing Officer), showed:
"Purpose ...
To establish guidelines for identifying and assessing possible victims of abuse, neglect, or sexual exploitation, whether occurring outside the hospital or in the hospital ...
To establish procedures for reporting suspected abuse, neglect, or sexual exploitation to Children's Protective Services ... of the Department of Family and Protective Services, and Texas Health and Human Services ...
Staff shall be alert to physical, behavioral, or other evidence of abuse, neglect, or sexual exploitation at each stage of the admission process ...
Members of patient's treatment teams and other hospital staff members shall be alert to physical, behavioral, or other evidence of abuse, neglect, or sexual exploitation of patients that occurred outside the hospital ...
Behavioral evidence of abuse, neglect, or sexual exploitation ... Inadequate ... supervision of a child, adolescent ...
Action by staff suspecting abuse, neglect, or sexual exploitation of patients that occurred outside the hospital ... the staff member shall promptly notify the Chief Nursing Officer, and, in the case of admissions staff members, the Director of Admissions. The staff member shall report the suspected abuse, neglect, or sexual exploitation to the Child Protective Services ... or Department of Family and protective Services ..."

Patient #1.
Record review of the "Intake Assessment Tool" by Staff R, an RN in the Intake Department, dated 12/2/2024 at 6:35 pm, showed a 16-year-old female voluntarily admitted into the hospital with suicidal ideation and a plan to ingest methamphetamines laced with poison or to cut her wrist. During the assessment, the patient, accompanied by her mother, stated:
(a) She had a history of sexual victimization within the previous 6 months as indicated by having sex with multiple people for drugs.
(b) She tried to kill her sister with [a piece of] glass 2 to 3 weeks earlier.
(c) She ran away from home 3 months earlier.
(d) She had irritability, poor impulse control, physical and verbal aggression, and difficulty with sleep.
(e) She had a history of sexual trauma, sexual assault, sexual victimization.
(f) She was smoking 1 gram of methamphetamines daily since age 14 with the last use on the morning of admission.
(g) She used marijuana daily with the last use on the morning of admission.
(h) Her mother had a history of depression suicide attempt, intense mood swings, hallucinations, delusions, and prior psychiatric hospitalization.

Further review of the "Intake Assessment Tool" showed that Staff R did not further investigate the allegations of sexual trauma, sexual assault, sexual victimization. Staff R did not report the recent sexual assault and victimization (engagement in sex for drugs) to the Department of Family and Protective Services. Additionally, Staff R documented on the form that the abuse and neglect (engagement in sex for drugs) was NOT reported to the Department of Family and Protective Services.

In an interview with Staff R on 1/8/2025 at 12:05 pm, she stated that the allegations of abuse and neglect made by Patient #1 should be reported to the Children's Protective Services. She also stated that even though she documented the abuse and neglect had NOT been reported to the Department of Family and Protective Services, she DID report it. Shortly thereafter following considerable time trying to locate the report, she stated she was not able to find the report in her files.

Record review of the SBAR (Situation, Background, Assessment, Recommendation) form by Staff V (RN) dated 12/2/2024 at 8:35 pm (completed 2 hours after the Intake Assessment) showed:
High risk areas - suicide, assault, elopement ... sexual acting out (victim) ... self-harm ... Client endorses sexual abuse by several people 'in trade for drugs' ... Has been coerced into sex with multiple people in trade for drugs." Staff V did not document that the allegations of sexual abuse in trade for drugs were reported to Child Protective Services.

Record review of the Staffing Schedule for 12/2/2024 showed that Staff Q was the RN on Unit 600.

Record review of the "Nursing Admission History" by Staff Q (Unit 600 RN) dated 12/2/2024 at 11:00 pm (completed 4½ hours after the "Intake Assessment Tool") showed NO history of sexual victimization within the previous 6 months. This documentation was not congruent with the documentation on the "Intake Assessment Tool," which affirmed a history of sexual victimization within the previous 6 months. Staff Q did not document that there was further investigation of this incongruent information. Staff Q also documented a history of sexual aggression over the lifetime of Patient #1 but did not document the name of the victim as was prompted by the form. And lastly, Staff Q documented psychological trauma but failed to provide additional information even though the form prompted the nurse to do so.

In an interview with Staff C (Assistant Chief Nursing Officer) on 1/8/2025 at 11:38 am, she stated that if a patient tells the nurse that there's a history of sexual abuse, the nurse should further assess this by asking more questions and documenting the history. She also stated that other staff should be updated as new information is obtained about sexual abuse. She also stated:
1) Staff R (Intake RN), who documented that Patient #1 was a sexual victim, should have assessed further and documented that information.
2) Staff Q (Unit 600 RN), who documented a history of sexual aggression and a history psychological trauma - sexual abuse, should have "asked more questions. The nurse didn't do a thorough assessment."
3) Staff N (Attending Physician) "didn't catch it either."
She concluded the interview by saying, "It was missed by 3 people. Allegations of sexual abuse by a child must be reported to the State."

Record review of the "Psychiatric Evaluation" by Staff N (Attending Psychiatrist) dated 12/3/2024 at 9:40 pm showed, "She [Patient #1] said that she feels despondent because of escalation of her methamphetamine use and has been self-harming and quite desperate to get a hold of her substance use, which she thinks is getting out of hand." He noted that the patient lives with her mother and will "discharge home to her family upon resolution of her symptoms." Further review of the "Psychiatric Evaluation" showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people "in trade for drugs."

Record review of the Psychiatric Progress Notes by Staff W or Staff X, both Nurse Practitioners, dated 12/4/2024 at 11:44 pm,
12/5/2024 at 11:47 pm,
12/6/2024 at 11:02 pm,
12/7/2024 at 9:38 pm,
12/8/2024 at 12:02,
12/9/2024 at 11:14 pm, and
12/10/2024 at 11:56 pm showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people "in trade for drugs."
The supervising psychiatrist on each Progress Note was identified as Staff N.

In an interview with Staff E (RN on Unit 600) on 1/7/2025 at 9:59 am, she stated that if a patient reported sexual abuse, she would "send it up the chain" by reaching out to the charge nurse.

Record review of the Discharge Summary by Staff W (NP) and co-signed by Staff N (Attending Psychiatrist) dated 12/10/2024 at 11:42 pm showed that there was no documentation of a history of sexual victimization, sex with multiple people for drugs, sexual acting out (victim), or sexual abuse / coercion for sex by several people "in trade for drugs." Discharge Disposition: Discharged to home.

Record review of the "Discharge Summary Plan" by Staff Y (LMSW) dated 12/10/2024 at 1:46 pm showed:
Discharge Disposition - Home with mother.

Record review of the E-Report to the Texas Department of Family and Protective Services, authored and submitted by Staff S (Licensed Master Social Worker) dated 12/4/2024 at 3:21 pm, showed two alleged perpetrators:
1) Patient #1's mother
2) The man who allegedly gave Patient #1 substances for sexual favors. The man was identified by name.
Patient #1 stated she "had access to go to his home when she wanted," adding he is "currently booked in jail." Staff S also wrote, "Child has multiple substances (reported meth, marijuana, alcohol) and engaged in sexual acts with male perpetrator."
Staff S stated the mother provided "neglectful supervision," adding, "Patient was left unattended to go to sexual perpetrator's house and was not properly supervised by her mother."