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Based on interview and record review, the facility failed to ensure patients' right to make informed decisions about his or her care. Five (5) of six "Consents for Treatment " were incomplete; and one 1) consent for blood was incomplete [Patient ID #1, 2, 3, 4, 6].

Findings included:

Record review of facility "Patient Rights and Responsibilities," undated, showed:".... the patient has the right, in collaboration with the physician , to be informed about and make informed decisions involving his / her health care, including the right of the patient to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal..."

Record review of facility policy titled " Medical Record Content,"dated 02/28/2020, showed:"...6. Every entry in the medical record is timed, dated, and signed."

Record review on 9/21/2022 with Staff N, RN , of six (6) current patient medical records " Consent To Treatment" showed the following:

- 5 of 6 consents lacked indication ( check mark) of the presence of an Advanced Directive and / or Medical Power of Attorney [ Patients IDs #1, 2, 3, 4, 6).

- 1 of 6 consents lacked date, time, and witness signature ( Patient ID # 4).

- 2 of 6 consents were not timed (Patient ID# 4, 6).

-1 consent for a blood transfusion lacked a date, time, and physician signature ( Patient ID # 2)

During an interview with Staff N, RN at the time of review, she acknowledged the findings and verified the consents were not complete.

Based on interview and record review, the facility failed to report a patient allegation of sexual assault to the appropriate authorities and regulatory agency per facility policy.

Findings included:

TX00429169

Record review of facility policy titled: "Response to Family Violence, Abuse, Neglect, Human Trafficking or Exploitation of Children, The Elderly, and /or Disabled," dated 10/15/2019 showed the following :

-"Purpose: To provide general guidelines to all hospital staff for responding to suspected or identified family violence and abuse, neglect, or exploitation of a patient.
-Definitions:...Elderly person: a person sixty-five (65) years of age or older.

Attachment B: "Types of Abuse / Neglect Reportable to Law Enforcement and Other Agencies":

Reportable Condition: Elder Abuse (physical, sexual, exploitation, neglect)
Description: Age 65 and older : Nursing Home, Adult Daycare, Assisted living facility. Suspected abuser may be a staff member.
Reportable to Whom: 1. Law Enforcement 2. Texas Department of Aging and Disability Services (DADS). Report immediately.
Contact Information: Law Enforcement Agency in area where incident occurred. DADS: 1-800-458-9858."
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Record review of Patient ID # 7's medical record showed she was a 65 year old female admitted to the facility on 07/08/2022 for "chest pain on breathing."

Review of the patient's "History & Physical" exam," dated 07/09/2022 , showed: "... The patient had been recently discharged from Park Manor and says she will not go back to another facility because she reports she was sexually assaulted there. The patient is very anxious and we will continue to monitor the patient's response ..."

Review of Patient # 7's "Discharge Summary," dated 7/12/2022 recapped the hospital course : problems and treatments. This Discharge Summary included the same sentence as the History & Physical exam above :"The patient had been recently discharged from Park Manor and says she will not go back to another facility because she reports she was sexually assaulted there... " In addition, it was documented " On the day of discharge, the patient felt well and was without any acute complaints. She stated that she wanted to go home with home health and not back to the nursing home."

During an interview with Staff I, Medical Social Worker, on 9/21/2022 at 1:40 PM he stated if a patient reported an allegation of a sexual assault that occurred at another facility, a referral would be made to adult protective services (APS).

Review of all discipline's progress notes ( physician /NP, nursing, social services, case management) failed to reveal documentation of the "allegation of sexual assault," including any referrals for an official investigation.

Hospital nursing leadership was unable to provide documentation that any staff member made a referral to law enforcement or to DADS per the facility policy.