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Based on record review and interview, the facility failed to ensure the process and procedures for prompt resolution of patient grievances in accordance with their Complaint/Grievance policy, for 1 of 1 complaint/grievance reviewed regarding Patient #1; who made an allegation of sexual assault while an inpatient at the facility.

Specifically, on 5/31/18 the facility's Patient Advocate was notified of Patient #1's sexual assault allegation against Patient #2 while an inpatient in the facility on 5/29/18.

The sexual assault allegation was reported to the facility's Chief Nursing Officer (CNO), Director of Clinical Services, and the Nursing Director of Adolescent services. There was not any evidence the facility addressed these allegations utilizing their grievance policy and procedures.

Findings Included:

Review of the Health and Human Services (HHSC) written complaint TX00295002 completed by the parents and signed by Patient #1 dated 6/7/18 documented the following allegations:

Patient #1 was an inpatient at the facility on 5/29/18. Patient #1 was sleeping when another; Patient (#2), woke her up from sleeping and asked, "top or bottom." Patient #1 did not know what that comment meant. Patient #1 indicated that Patient #2 "pulled her from her bed on to [Patient #2's] bed." Then Patient #2 grabbed Patient #1's head and started kissing her. Patient #1 was verbally threatened by Patient #2 if she told anyone. Patient #2 continued kissing Patient #1; "against her will, squeezed her left breast and then grabbed [Patient #1's] buttocks." Patient #1 then stated that Patient #2 "inserted her finger into [Patient #1's] rectum." The nursing staff walked into the room and saw Patient #1 on top of Patient #2 and separated the girls. Patient #1's parent contacted the director of clinical services at the facility and was told by the director that she was given a different account of the event. "As concerned parents we feel we are entitled to a clear explanation of what happened and if our daughter was sexually assaulted.

Review of Patient Advocacy/Complaint Form dated 5/31/18 completed by the facility's Patient Advocate documented a telephone complaint from the father of Patient #1 described as:

Patient #1 saw her outpatient psychiatrist and reported she was assaulted on 5/29/18. The psychiatrist has called Child Protective Services. Patient #1's father confirmed he was notified of the incident; but stated he was told his daughter (Patient #1) was found kissing another patient (#2) and they needed to be separated. He reported his daughter stated Patient #2 was reportedly aggressive and his daughter felt fear. Patient #1's father reported his daughter (Patient #1) is claiming the other Patient (#2) grabbed her breasts and stuck her finger in her rectum; Patient #1 used the word "raped". He said although the nurse stated they were found kissing, Patient #1 is reporting that the other girl threatened her and pulled her on top of her. Patient #1's father stated this is now a legal matter and wanted statements, incident report, etc. Patient #1's father asked the patient advocate to assist in providing information. Further review of this form documented the complaint was forwarded to the Director of Clinical Services and the Nursing Director of Adolescents.

Review of the 5/28/18 Nursing note/Progress Note at 23:45 documented Patient #1 was found on top of Patient #2 kissing each other. Doctor-A, and patient's family were notified about the event. Doctor-A ordered to separate each other. Patient #1 was moved to the day area for sleep; and Patient #2 remained in her room. No injury occurred in this event. The plan is to keep them separate to prevent further sexual misconduct.

Interview with the Director of Performance Improvement (DPI) on 10/30/18 at 1:30 PM stated this incident was "not a grievance" since it was a peer boundary incident of "kissing" while she was inpatient. The DPI stated there was an incident report completed.
In a follow up interview with the DPI, this surveyor explained the facility's policy definition for "patient grievance" did not compare with the federal regulations; CMS definition provided in the interpretive guidelines at CFR 482.13 (a)(2). The DPI confirmed this finding.

Interview on 10/30/18 at 1:50 PM with the Nursing Director of Adolescents stated she talked with Patient #1's father after he reported to the Patient Advocate on 5/31/18 the allegations of sexual assault. The Nursing Director stated she initially talked to all three girls when they were "caught making out in the room." Patient #1 was on top when found. The girls were separated. The Nursing Director stated Patient #1's father wanted to know "what we were doing about his daughter being raped." The Nursing Director stated she told Patient #1's father that at no time did his daughter report she was raped when she was at the facility.

During a phone Interview on 10/31/18 at 3:35 PM with the Patient Advocate stated she had just started her position at the facility on 5/21/18 when she had received this complaint. The Patient Advocate stated she notified the CNO, and "got everyone involved" due to the nature of the complaint. The Patient Advocate stated she received an email from Patient #1's father wanting a copy of the internal incident reported and wanted to know "what was done." The Patient Advocate stated she verbally responded to Patient #1's father by indicating that she could not provide that information to him due to confidentiality. The Patient Advocate confirmed she did not send anything in writing or any letters to Patient #1's father after she received his allegations that his daughter was sexually assaulted while in the facility. She responded that she requested for the Nursing Director to follow up. The Patient Advocate stated her correspondence with the family was by phone. The Patient Advocate stated she was new, and had not been directed to complete the formal grievance process or send anything in writing to the complainant. She further stated that once Patient #1's father stated this was a legal matter, she could not speak to him anymore. The Patient Advocate stated she did not feel this was a grievance since the patient had already been discharged from the facility.

Interview with Patient #1's parent on 11/1/18 at 11:11 AM, stated her husband called the facility immediately to report the allegations her daughter alleged once they were disclosed to her after following up with her physician- B; for outpatient care. Patient #1's parent stated contact was made with the facility's patient advocate and she responded by stating that since all the patients were minors; that there were laws to protect them and that this information could not be shared; including statements and facility incident reports. Patient #1's parent stated she has not received anything in writing from the facility regarding the allegations made to the patient advocate. Patient #1's parent stated her daughter has been "very scared, and traumatized after this event." Patient #1's parent confirmed her daughter did not indicate these same allegations while inpatient at the facility.

Review of the facility's policy and procedures titled, Patient Advocacy Conflict and Grievance Resolution last revised, July 2018 documented the following:

A grievance is defined as a "patient grievance" when:
-a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present).
-a complaint that is presented in writing, including via email or fax
-whenever the patient or patient's representative requests that the issue be handled as a grievance.

Further review under procedures indicates; 8. If the complaint cannot be satisfied during the initial conversation with the patient or family member, the complaint becomes categorized as a grievance and the Patient Advocate must be notified. 9. The Patient Advocate will then facilitate the investigation and resolution of the grievance through a complete investigation conducted by the Patient Advocate or by an appropriate member of the leadership team. 11. Once the issue has been resolved, the Patient Advocate shall provide a timely "written response to the patient and/or family member." The response shall include:
a. The name of the contact person
b. The steps taken to investigate the grievance
c. The results of the grievance process (i.e. how the grievance was resolved)
d. The date of completion.

16. The Governing Body shall have final authority and responsibility in resolving grievances.
17. Any grievance received after a patient is no longer in the hospital's system shall be forwarded to the Patient Advocate. The Patient Advocate shall ensure that the appropriate follow-up on the grievance is consistent with the procedures above.

Review of the CMS guidance and interpretive guidelines at 482.13(a)(2) for patient grievance states the following:
A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient 's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR §489.

o If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf.

o A written complaint is always considered a grievance. This includes written complaints from an inpatient, an outpatient, a released/discharged patient, or a representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs. For the purposes of this requirement, an email or fax is considered "written".

o Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements. Those post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance.

o All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are considered a grievance for the purposes of these requirements.

o Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply.