HospitalInspections.org

Based on record review and interview, the facility failed to ensure each patient had the right to receive care in a safe setting when staff failed to report internally and investigate an allegation of abuse that was observed by nursing staff (Patient #3).

Findings were:

Review of Clinical Record for Patient #3 reflected in part "Chief Complaint: Transfer from Starr County, status epilepticus @0300, 0800, needs neuro (neurological) consult, dx (diagnosis) uti (urinary tract infection), hx (history of) seizures, htn (hypertension), pneumonia, developmental delay. 27-year-old female with developmental delay and history of difficult to control seizures transferred from Star County because of status epilepticus..."
Nurses Note 11/8/21 at 23:00:00 documented by Staff #20 reflected: "Father in room next to patient. Observed father continuously slapping and knocking his knuckles on patient's head. Patient agitated and crying as father continues. Primary RN notified and both approached father to stop unless (sic) security will be called. Father acknowledges but states 'I am only doing it to calm her down.' Providers to be notified to escalate incident to be further investigated".
Case Management note 11/9/21 at 16:12 CST (Central Standard Time) reflected "CM (case manager) received call from nurse Manny in NSICU, states the Night Nurse the patient was agitated last night and nurse observed the patient's father squeezed her leg and then hit patient on head. CM notified nurse (staff #19) there is no documentation of abuse. CM filed APS referral online. CM received email confirmation that report has been submitted."
Case Management note 11/10/21 at 15:56 CST reflected "CM (case manager) received a call from APS (adult protective services) intake coordinator to follow up with aps referral submitted yesterday, states she will send this to case worker and that person will follow up, states she does not have a time frame of when this will occur."
Case Management note 11/12/21 at 12:01 CST reflected "CM received call from APS, states will be visiting patient today."
Case Management note 11/16/21 11:34 CST reflected "CM spoke with (APS) following the case. As per (APS) visited with the patient last Friday but the patient was sleeping, also mentioned received report from CNA (certified nurse aide) and nurse who communicated that while the patient was watching a movie on television which had a sexually oriented scene the patient began to touch herself in a sexual manner, the CNA then changed the channel and the patient got a little upset voicing out "apa, apa" and displaying oral sexual gestures, concerning the CNA that she might be being sexually abused at home..."
Nurses Note 11/16/21 at 10:36:00 reflected " ...Father continues at bedside. No incidents reported by primary nurse."
Nurses Note 11/17/21 at 18:00:00 reflected " ...pts (patient's) dad at bedside ..."
Nurses Note 11/17/21 21:26:00 reflected " ...pt (patient) picked up by ambulance. Dad at bedside, agreed for pt to be taken by ambulance ..."

In an interview during the afternoon of 8/2/2022, Staff #3 stated "we reviewed all of our records and logs and law enforcement was not called. We did not call security or our code strong team during or after this incident. An incident report was not completed, and investigation was not completed. We called APS."

In an interview during the afternoon of 8/2/22, Staff #18 stated "we did not respond to a call related to this incident. I reviewed all the incident reports and security logs. Review of the logs did not reflect a security incident for this date. There was not a security incident report filed. The expectation is that security is contacted if someone is harming a patient in any way. We separate, and de-escalate the incident, and contact the police department. An in-house report and a police report are made. We have 2 (security) rovers and a supervisor in the main building at all times, 24 hours a day. We also have a security patrolling the parameters who can also assist and support the officers inside. There are two ways the nurses or staff can contact us. Dialing 7911 (direct number) or can call PBX (Private branch exchange) by dialing 0".

In a telephone interview during the afternoon of 8/2/22, Staff #19 stated "I did not witness this incident. The evening shift mentioned it to me. I never saw the father being aggressive, I would have protected the patient and called man-power security to de-escalate the situation. My priority is to make sure the patient is not harmed."

In a telephone interview 8/3/22 at 7:21 am, Staff #20 stated "I wasn't the primary nurse, but I was sitting nearby. She (the patient) wasn't actually having a seizure. She would just start acting out. We told the stepfather to stop. He told us this is what he would do to calm her down. I reported it to the nurse taking over the next morning. We thought she (the patient) was being abused. The following night I was told the facility contacted APS. I am not sure why the primary nurse didn't put a note in. He (stepfather) did stop when we told him we would call security if he didn't stop. He stopped. The primary nurse addressed it the next morning with the doctor and someone made a call to APS. We were told the next morning to put our notes in and I think I'm the only one that put a note in. The primary nurse didn't write a nurses' note."

Surveyor was unable to interview the primary nurse. The facility reported the nurse no longer works for the facility and did not provide a phone number.

Review of the facility provided Statement of Patient Bill of Rights and Responsibilities dated 07/12 stated in part "The patient has a right to: ...Considerate and respectful care, provided in a safe environment, free from all forms of abuse or harassment ..."

Review of the facility provided policy and procedure titled "Suspected Child, Disabled Person or Elderly Abuse/Neglect" effective 07/03, last revised 07/21 reflected in part: "...It is the policy of DHR Health, under the guidance of applicable laws, that any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect, shall report the information to DHR management and to the appropriate regulatory agency. This report or communication is incumbent on the person who suspects..."