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Based on record review and interview, the facility failed to ensure their policies and procedures protected a patient's rights to be free from all forms of abuse or harassment while a patient in the facility.

Specifically, the facility failed to report an allegation of sexual abuse/assault to the state health care regulatory agency for one of one patients reviewed (Patient #1) with a complaint of sexual abuse by another patient (Patient #2) while receiving mental health services at the facility. Both patients were under the age of eighteen years with parents serving as their legal guardians.

Specifically, the facility's procedure for how to report abuse/neglect/exploitation were not specific for reporting allegations of abuse/neglect against the facility and/or facility employees to the appropriate state health care regulatory agency that authority and licenses the facility, Department of State Health Services (DSHS at 888-973-0022) and in accordance with the Health and Safety Code 161.132 (b).

The deficient practice could affect the prevention of possible unidentified abuse/neglect or mistreatment for all patients in the facility by compromising their safety.

Findings included:

Review of Patient #1's Complaint Intake Form, dated 02/08/2018, revealed that a rape crisis counselor at a rape crisis counseling center reported Patient #1's allegation of sexual abuse by her facility roommate, Patient #2, to the Department of Family and Protective Services (DFPS) on or about 11/12/2017. Patient #1 alleged to the rape crisis counselor that Patient #2 "kissed her on the mouth, inserted a finger into her vagina and performed oral sex on her" during a therapy session with the rape crisis therapist.

Review of Patient #1's Group Note, dated 10/19/017 at 3:41 PM and completed by Therapist #1, revealed the following: "Patient reported feeling not safe. Patient verbalized increased concern with ex-roommate and stated that her peer was sexually inappropriate with her. Therapist informed staff and mother and filed CPS (DFPS) report."

Review of facility investigation, not dated but signed by facility risk manager, revealed but was not limited to the following: " Patient reported to registered nurse (RN) and therapist on 10/17/017 that her ex-roommate had touched her inappropriately and then penetrated her with her finger. Interviews were conducted with Patient #1 and Patient #2's psychiatrist. He indicated that he did not believe force was involved by either patient. Interview was conducted with Patient #1's therapist who reported she spoke at length with Patient #1 regarding the interaction. Patient #1 reported that she was approached by Patient #2 who started kissing her. She reported that she was afraid to move and did not tell Patient #2 to stop. She stated that she (Patient #2) kissed her, penetrated her with her finger and grabbed her breast. She did not report it sooner because she was not comfortable doing so. The therapist stated she spoke with both parents, neither of whom were concerned. Findings: The allegation is substantiated. Incident was reported to regulatory agency." There was no documentation as to the name of the regulatory agency.

Review of Abuse, Neglect and Exploitation Reporting, Investigation and Response Policy and Procedure, last revised 01/25/2017, revealed but was not limited to the following: "The Director of Risk Management shall report allegations of abuse, neglect or exploitation to the Texas Department of State Health Services and the Corporate Office as required. The CEO that investigations are completed in a timely manner and that the required agencies, departments and committees are notified." The phone number for the Texas Department of State Health Services was not listed.

Interview on 03/15/2018 and again on 03/16/2018 with Patient #1's therapist (Therapist #1) confirmed she reported the sexual allegation to a regulatory agency. She was unable to identify the name of the regulatory agency where she reported the allegation. When surveyor informed her she made the allegation to DFPS, she confirmed that was the agency that her supervisor (no longer with the facility ) instructed her to report to. She confirmed that she was not aware that DSHS was the appropriate reporting agency for this allegation of sexual abuse. Patient #1's therapist (Therapist #1) revealed she has worked at the facility for approximately two years.

Interview on 03/16/2018 with the current Director of Risk Management and soon to be acting Director of Risk Management confirmed the allegation of sexual abuse made by Patient #1 towards Patient #2 should have been reported to the DSHS because Patient #1 or Patient #2 were not old enough to consent to a sexual relationship.

Health and Safety Code 161.132 (b) indicates an employee of or other person associated with an inpatient mental health facility, a treatment facility, or a hospital that provides comprehensive medical rehabilitation services, including a health care professional, who reasonably believe or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care facility professional associated with that facility has, is, or will be engaged in conduct that is or might be illegal, unprofessional or unethical and that relates to the operation of the facility or mental health, chemical dependency or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the agency that licenses the facility (DSHS) or to the appropriate state health care regulatory agency (DSHS).