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Based on observation of video surveillance, record reviews and interviews, it was determined the facility failed to ensure patients rights were protected and promoted for 2 of 2 patients reviewed (Patient #1 and #2) with an allegation of sexual assault against a facility staff member.

Specifically, the facility failed to ensure:

1.) staff followed the policy and staff training when conducting a contraband search of Patient #1's room without a second staff member as required; resulting in Patient #1 making an allegation of sexual assault against the mental health worker (MHW).

2.) administrative staff followed their established policies and procedures in response to the reported allegation of sexual assault by Patient #1 and #2 when the administrative staff failed to report the sexual assault allegation to the appropriate state health regulatory agency (Health and Human Services Commission); and in accordance with HSC, §161.132(a).

This deficient practice could compromise patient safety for all patients in the facility by failing to implement protections and further prevention of abuse, neglect and patient rights.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to A 0145 for evidence of specific findings.

Based on observation of video surveillance, record reviews and interviews, it was determined the facility failed to ensure patients were free from all forms of abuse or harassment for 2 of 2 patients reviewed (Patient #1 and #2) with an allegation of sexual assault against a facility staff member.

Specifically, the facility failed to ensure:

1.) staff followed the policy and staff training when conducting a contraband search of Patient #1's room without a second staff member as required; resulting in Patient #1 making an allegation of sexual assault against the mental health worker (MHW).

2.) administrative staff followed their established policies and procedures in response to the reported allegation of sexual assault by Patient #1 and #2 when the administrative staff failed to report the sexual assault allegation to the appropriate state health regulatory agency (Health and Human Services Commission); and in accordance with HSC, §161.132(a).

This deficient practice could compromise patient safety for all patients in the facility by failing to implement protections and further prevention of abuse and/or neglect.

Findings included:

Review of the Complaint Intake TX00411423 dated 3/6/22 revealed Patient #1, 15y/o Female and Patient #2 16 y/o female, reported to the facility on March 4, 2022 an allegation of sexual assault against a MHW (#10). Both patients (#1 and #2) were sent to another facility for a sexual assault nurse examiners (SANE) examination for evidence of sexual assault. Local law enforcement were contacted.

1.) a. Reviewed facility competencies training entitled "Patient Searches by Staff" signed by alleged employee on August 25, 2021 states:
"During room searches, a minimum of two staff members must conduct the searches.
During Unit searches, staff will gather all patient in a common area"

b. Interviewed staff #1, Quality/Risk Manager on March 9, 2022 at 12:45pm in conference room who confirmed policy and talked to mental health worker #10 during his internal investigation on going to conduct searches in patient room alone without a 2nd staff member present. Staff #1 further indicated on March 4, 2022 MHW (#10) accused of sexual allegations on the dayshift had conducted patient searches for contraband inside Patient #1's room alone with Patient #1 present inside the room and her roommate, Patient #2 in the hallway outside of the door. A minimum of two staff members were not present conducting a contraband search. The two patients were not gathered in a common area as per policy.

c. Interview staff #2, Director of Nursing on March 9, 2022 at 1:00pm in conference room who confirmed that alleged mental health worker (#10) conducted searches for contraband alone for Patients #1 and #2's room 508 on the adolescent unit. The search was conducted after it was reported to this mental health worker that a patient had staples in bed. During search one patient (Patient #1) stayed in the room with MHW #10 while second patient (Patient #2), the roommate remained in the hallway outside the doorway. The door to room 508 was opened during entire search.

d. Interviewed staff #8, Mental Health Worker on March 31, 2022 at 2:49pm via telephone who stated Patient #2, in room 508 told him that she reported to MHW (#10) on shift on March 4, 2022 about seeing staples in a Patient #1's bed. Patient #2 then reported that MHW #10 was in her room conducting a contraband search alone with Patient #1. She did not mention any type of sexual allegations to the mental health technician on the day shift. He did not hear about any sexual allegation against the staff who conducted the contraband search until the following day after it was reported to staff. "It is not protocol to conduct those searches alone. Patients should be placed in a central location. You need to have a second staff present."

e. Surveillance video reviewed (1:21pm to 1:48pm) showing the activities from hallway view confirming that mental health worker #10 was in patient room 508 conducting searches alone which included linen changes with Patient #1 in the room. The room door was open during period of surveillance reviewed on March 4, 2022. The staff was in an out of room and near doorway most of the time and his shadow could be seen on open door. Patient #1 was in the room with MHW #10 while the roommate, Patient #2 stood in the hallway of the open room door looking in the room most of the time. There was not a second staff member assisting in conducting the contraband search with the mental health worker #10. The patients were not in a common area as per training during this search.

f. During the dayshift of March 4, 2022 there were supervisory nursing staff oversight and 3 mental health technician on the Adolescent 500 unit. The census was 13 patients.

2.) Interview with staff #1, Risk Manager confirmed on March 21, 2022 at 11:58 am via telephone that the facility self- report of the sexual allegations made by Patient #1 and #2 against MHW #10 was initiated by filling out all the information on the Psychiatric Incident Report -6107 form and electronically signing, dating and time the paperwork on March 8, 2022, but never submitted it to the Department of State Health Services to receive a confirmation number that they received the case. The next day, March 9, 2022 health compliance surveyor from Health and Human Services reported onsite at facility to investigate the complaint of sexual assault allegation. Staff assumed obligation to submit report to Department of State Health Services as per policy was not needed since a representative was onsite.

Review of the hospital policy entitled, "Patient Abuse and Neglect," last reviewed/revised 2/11/2021 stated the following, in part:
Section 3 :
Anyone who receives or witnesses an incident of patient abuse or neglect ...."shall as soon as possible report the information supporting the belief to the department or to the appropriate state health care regulatory agency in accordance with ....Department of State Health Services (DSHS) at (888) 973-0022."

Section 4:
"It is the policy of Palms to Reporting illegal, unprofessional or unethical conduct. An employee of or other person associated with a facility including a health care professional, who reasonably believes or who knows of information that could reasonably cause a person to believe that the facility or an employee or health care professional associated with the 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, or chemical dependency services provided in the facility shall as soon as possible report the information supporting the belief to the appropriate state health care regulatory agency in accordance with HHSC 161.32(b) . Department of State Health Services (DSHS) at (888)973-0022."