HospitalInspections.org

Based on staff interview, review of facility's policies allegations of sexual abuse was not reported as required.

Findings :

A. Interviews:
1. Interview with staff #1, Chief Nursing Officer at 1:15pm on September 19, 2023 in facility's conference room who admitted responsibility for not elevating and submitting a report of sexual harassment to to the appropriate state health care regulatory agency in accordance with HSC 161.132 (a) Department of State Health Services at (888) 973-0022 after a 14 year old female patient complained to staff about an incident of a male patient touching her inappropriately on her buttocks area as they were walking out of the gym. The facility did conduct an investigation of the allegation with review of surveillance video but did not witness male peer who was alleged to have touch the female patient conduct any physical inappropriateness with the female patient. Interviews with staff conducted. The two mental health technicians (MHT's) assigned and monitoring the patients during this recreation time frame did not witness this allegation. Staff #1 said she was waiting for the charge nurse to finish the incident report before reporting it further to the state regulatory agency. But became busy and forgot to send it to the state regulatory agency after internal investigation was concluded.

2. Interview with staff #2, Quality Director at 1:30pm on September 19, 2023 in facility's conference room. This staff was not familiar with this complaint/incident. It was not in the complaint/grievance logs. Later found out that the incident was in the systems patient event record but under the name of male peer who was allegedly accused of sexual inappropriateness and not the 14 y/o female patient who made the allegation. There was no evidence provided that allegation was reported to Department of State Health Services as was required.

B. In review of facility's policy "Child Abuse and Neglect " last revised August 2020 it states on page 7 of 9 under Paragraph B "Reporting abuse and neglect... section 1. How to Report: : "The Director of Risk Management, or designee , shall report the information as soon as possible to the Texas Department of State Health Services (DSHS) who oversees hospitals, psychiatric hospitals......1, Texas Department of State Health Services: 1-888-973-0022.."
It was evident that this allegation was not reported to Texas Department of State Health Services as per regulation and hospital policy.

C. Facility could not provide evidence that this requirement was met.