HospitalInspections.org

Based on record review and staff interviews, the hospital staff failed to ensure that:

A. two (Patient # 1 and 10) of 2 patients were informed of the patient's rights, in advance of furnishing patient care. The hospital staff failed to follow the "Patient Rights and Responsibilities" policy.

(Cross Refer to Tag A0117)

B. one (Patient # 1) of 1 patient remained free from all forms of abuse, neglect, and/or harassment when Patient # 1 was physically assaulted by Staff # 7 (Hospital # 1 Security Officer) while receiving outpatient radiology services at the hospital. The hospital staff failed to follow the hospital's "Use of Force, Patient Rights and Responsibilities, and Abuse Identification and Reporting" policies.

(Cross Refer to Tag A0145)

Based on record review and staff interviews, the hospital staff failed to ensure that 2 (Patient # 1 and 10) of 2 patients were informed of the patient's rights, in advance of furnishing patient care. The hospital staff failed to follow the "Patient Rights and Responsibilities" policy.

Findings include:

Patient # 1

A review of Patient # 1's medical records revealed that Patient # 1 arrived at the hospital on 11/24/2025 at 3:00 PM for outpatient radiology testing. Patient # 1 was also treated in the hospital's emergency room on 11/24/2025 at 3:44 PM after completion of outpatient radiology testing.

A review of Staff # 14's (Emergency Room Physician) Provider Note dated 11/24/2025 at 4:48 PM revealed the following,

"77-year-old male coming from (Hospital #2) for 2 open wounds on his forehead. Patient has a history of a carcinoma, had biopsies done 10 days ago in Tyler from his dermatologist. Today he was coming to Jacksonville hospital for imaging when he got into an altercation with a security officer who then subsequently threw him down to the ground. Sutures from the 2 wounds broke and with subsequent bleeding. He was then brought into the emergency department for evaluation. He is not on anticoagulation. Denies headache. No loss of consciousness. Review of systems: Skin: Positive for wound. All other systems reviewed and are negative ...PMH: no past medical history on file ..."

There was no documentation in the patient's medical record to provide proof that Patient # 1 or the patient's surrogate received a "Notice of Patient Rights and Responsibilities" before being provided care and treatment by hospital staff.

Patient # 10

A review of Patient # 10's medical records revealed that Patient # 10 arrived at the hospital's emergency room on 11/23/2025 at 3:10 AM for lower extremity swelling. A review of the emergency room physician's note documented on 11/23/2025 at 3:24 AM revealed,

"Patient is a 65-year-old from the Russell County jail who supposedly had some seizure-like activity at the jail. He complains of bilateral leg swelling ..."

There was no documentation in the patient's medical record to provide proof that Patient # 10 or the patient's surrogate received a "Notice of Patient Rights and Responsibilities" before being provided care and treatment by hospital staff.

A review of the hospital's "Patient Rights and Responsibilities" policy with a date of 12/18/2023 revealed,

"Policy: A written copy of the hospital's statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate to the patient's age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient's understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient's assessment of understanding his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission and in a manner that he/she can understand. Complaints and concerns regarding a patient's rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department, who will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patients regarding their rights to health care and health care-related activities during hospitalization ...Procedure: 1. Provide information that outlines the patient rights during the admission process to the patient or someone acting on the patient's behalf for all inpatients, outpatients, and ER patients. A. Patient Rights Information will be provided to the patient in the form of the Hospital's Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgement document, which will acknowledge their receipt of the patient's rights. 3. The admitting or nursing staff may refer to the Interpreter List for patients with language barriers. 4. Obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment ...5. Provide the patient with access to the patient complaint procedure if requested by the patient. 6. Documentation: Treatment Authorization and Terms of Treatment Agreement. Procedure: Outpatient: 1. When the patient enters an outpatient area of the hospital: a. Patient rights are available in English and Spanish and are posted in a visible area of the outpatient area. B. Patient rights will be provided to the patient or surrogate in the form of a handout when the patient enters an outpatient area of the hospital and under any type of procedure ...."

A review of the hospital's statement titled, "Patient Rights and Responsibilities" (no date) revealed,

"UTHET recognizes the rights of human beings for independence of expression, decision, and action and will protect these rights of all patients regardless of age, race, creed, sex, national origin, religion, or source of payment. In order to provide quality healthcare to patients and their families, UTHET maintains that our patients have the following rights to the extent permitted by law: Effective communication that is delivered in a manner which is understandable to each patient, including the use of language interpreters and resources for patients with communication impairments. Information provided in a manner tailored to the patient's age, language, and ability to understand. Respect for cultural and personal values, beliefs, and preferences. Privacy and confidentiality of protected health information, within legal limits, including discrete handling of case discussion, consultation, examination, and treatment. Visitation, including, but not limited to, a spouse, a domestic partner, another family member, or a friend and the right to withdraw or deny such consent at any time. Know the name and professional status of the physicians and others involved in care. Access spiritual guidance and pastoral care support. Effective assessment and management of pain. Access, request amendment to, and obtain information on disclosures of health information, in accordance with law and regulations. Have an individual support present for emotional support during your stay, unless the individual's presence infringes on others' rights, safety, or is medically or therapeutically contraindicated. An environment free from discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Considerate and respectful care that recognizes individual psychosocial, cultural, and spiritual values, beliefs, and preferences. Participate in decisions about care, treatment, and services, including the right to have family and physician promptly notified of admission to the hospital. Involvement of a surrogate decision-maker in making these decisions when the patient is unable. Refuse treatment to the extent permitted by law, and to be informed of the medical consequences of such refusal. Family involvement in care, treatment, and services, decisions to the extent permitted by the patient or surrogate decision maker. Receive information about outcomes of care, treatment, and services, and any unanticipated outcomes. Participate in determining care by consenting to recommended treatments or procedures, formulating advance directives, deciding to withhold informed consent, including informed consent for production or use of recordings, films, or other images of the patient for purposes other than their care. Participate or not participate in a research, investigation, or clinical trial program. Create an advanced directive and have hospital staff and practitioners who provide care in the hospital comply with the directive. Be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse. File a complaint and have complaints reviewed by the hospital. Access to protective and advocacy services. Remain free from seclusion and restraint of any form that is not medically necessary. Optimal comfort and dignity during the terminal stage of an illness ...."

An interview was conducted with Staff # 5 and # 6 on 12/03/2025 at 3:30 PM in the administrative conference room. Staff # 5 and # 6 confirmed that there was no documentation in Patient # 1 and Patient # 10's medical records to prove the patients and/or surrogates were given a "Notice of Patient Rights and Responsibilities" before receiving care at the hospital.

Based on observation, record review, and staff interviews, the hospital staff failed to ensure that 1 (Patient # 1) of 1 patient remained free from all forms of abuse, neglect, and/or harassment when Patient # 1 was physically assaulted by Staff # 7 (Hospital # 1 Security Officer) while receiving outpatient radiology services at the hospital. The hospital staff failed to follow the hospital's "Use of Force, Patient Rights and Responsibilities, and Abuse Identification and Reporting" policies.

Findings include:

A review of Patient #1's medical record was conducted with Staff # 5 and # 10 on 12/03/2025 at 11:35 AM in the hospital's administrative conference room.

Patient # 1 presented to the hospital on 11/24/2025 for outpatient radiology studies. The patient was accompanied by staff from the patient's residence (Hospital #2) as well as Staff # 7 (Hospital # 1 Security Officer).

A review of the hospital's security footage was conducted on 12/03/2025 with the hospital's leadership in the Security Office.

The date of 11/24/2025 was reviewed, and the following was observed on the hospital's security footage,

3:00 PM: The patient was seen in the "ER Entrance Hallway" accompanied by Staff # 7 (Hospital # 1 Security Officer) and staff from Hospital # 2. The patient was escorted to a radiology appointment. There was no further footage of the patient until after the radiology appointment.

3:23 PM: The patient was seen walking through the "ER Entrance Hallway" when the automatic door to the emergency room waiting room opened. The patient attempted to go into the emergency room waiting room. Staff # 7 grabbed the back of the patient's coat in an attempt to keep the patient from entering the emergency room waiting room. Staff # 7 then forcefully pushed the patient outside and pinned the patient to the wall outside of the "Main ER Entrance".

3:24:02-:33 PM: The patient resisted Staff # 7's physical force and swung his fist at Staff # 7's face, contacting Staff # 7's right lower face.

3:24:35 PM: Staff # 7 returned a punch to the patient, punching the patient in the face with his fist.

3:24:38 PM: Staff # 7 forcefully threw the patient to the concrete ground. The patient landed directly on his face. The patient laid on the concrete face down, until 3:24:45 PM when Staff # 7 turned the patient over onto his back. The patient continued to lie on the ground on his back until 3:25:10 PM, when Hospital # 2 staff members assisted the patient up to a sitting position. Blood was observed on the patient's face, shirt, and on the ground where the patient landed.

3:26:35 PM: Staff # 7 can be seen pushing an orange wheelchair toward the patient. The patient was assisted into the wheelchair by Hospital # 2 staff.

3:28:49 PM: The patient was rolled into the hospital's emergency room triage area for further evaluation and examination.

There was no further footage of the patient until 5:24 PM, when the patient walked out of the emergency room lobby. The patient had a bandage on his forehead between his eyes.

5:25:23 PM: The patient got into the Hospital # 2 van.

5:28:17 PM: Hospital # 2 van left the hospital premises with the patient.

Patient # 1 sustained facial injury as a result of the physical altercation with Staff # 7 and required emergency medical care at the hospital's emergency room. Patient # 1 was escorted to the hospital's emergency room on 11/24/2025 at 3:44 PM.

A review of Staff # 14's (Emergency Room Physician) Provider Note dated 11/24/2025 at 4:48 PM revealed the following,

"77-year-old male coming from (Hospital #2) for 2 open wounds on his forehead. Patient has a history of a carcinoma, had biopsies done 10 days ago in Tyler from his dermatologist. Today he was coming to Jacksonville hospital for imaging when he got into an altercation with a security officer who then subsequently threw him down to the ground. Sutures from the 2 wounds broke and with subsequent bleeding. He was then brought into the emergency department for evaluation. He is not on anticoagulation. Denies headache. No loss of consciousness. Review of systems: Skin: Positive for wound. All other systems reviewed and are negative ...PMH: no past medical history on file ..."

The patient was discharged from the hospital's emergency room on 11/24/2025 at 5:39 PM.

Staff # 7 (Security Officer) completed an "HRP (high-reliability platform) report" on 11/24/2025 for the incident involving himself and Patient # 1. Staff # 7 documented the following,

"Security staff was assaulted in the process of removing a threatening person from the ER lobby. Suspect was ultimately removed from the location after law enforcement intervention."

The HRP was reviewed by Staff # 9 (Security Manager) and subsequently closed. There was no documentation made by Staff # 9, Quality Staff, or Risk Management Staff. There was no internal investigation into the event by hospital administration.

The Emergency Room staff members did not report a possible incident of abuse and/or harassment in accordance with the hospital's "Abuse Identification and Reporting" policy.

A review of Staff # 7's personnel file revealed the following education modules were completed by Staff # 7 on 8/03/2025: "2025 Annual Code of Business Conduct and Ethics Evaluation, Patient or Resident Safety Basics, Patient-Facing, Rights and Responsibilities Basics, Patient-Facing, Employee Safety Basics, Patient-Facing, Workplace Safety Basics"

Staff # 7 completed the education module titled "Workplace Violence Recognize and Respond and Skills of De-escalation" on 02/24/2025.

Staff # 7 did not receive any disciplinary action or formal education as a result of the event and was allowed to continue to work at the hospital with access to patients and visitors.

A review of the hospital's "Use of Force" policy (no date) revealed,

""Policy: To clearly define the circumstances under which the use of force by a Security Officer may be considered justifiable, the Security Department will follow the guidelines established in the State of Texas Penal Code, Chapter 9. This policy is intended to be a guide to the use of force and the moral and ethical approach to the use of force. This policy is not intended as a strictly enforced set of rules, rather it must be interpreted in conjunction with the totality of circumstances and the Officer's judgement. Protection of human life is the primary goal of the Hospital; therefore, Security Officers have a responsibility to use only the degree of force necessary to protect and preserve life and will exercise caution for the protection of innocent life. UTHealth East Texas places a greater value on human life and on the protection of property; therefore, the use of deadly force is not endorsed to protect property interests.
Definitions: 1. Force means both non-deadly force and deadly force 2. non-deadly force means a level or degree of force that is not intended to cause, known to cause, reasonably capable of causing, or reasonably likely to cause death or serious bodily injury under the circumstances known to the user. 3. Deadly force means force that is intended or known by the actor to cause, or in the manner of its use or intended use is capable of causing death or serious bodily injury. 4. Hospital is the particular facility involved whether a hospital unit specifically or any other unit of the UTHEALTH East Texas. 5. Officer or Security Officer is a person employed by UTHEALTH East Texas as a part of its designated security unit. 6. Suspect means any person that a Security Officer may question or is a cause of an incident. PROCEDURE: 1. No officer may use any amount of force, degree of force, or level of force that is excessive, unnecessary, or unreasonable under the circumstances. The following is a non-exhaustive list of factors to be taken into account when determining the appropriate response: a. the nature and seriousness of the risk of injury to anyone; b. the nature and seriousness of the alleges offense; c. the physical and mental condition of the suspect; d. the behavior and actions of the suspect; e. any relevant actions by a third party; f. the feasibility and availability of alternative actions; and g. the opportunity and actual ability of the suspect to injure the Officer or another. 2. Application of Force: a. This policy applies to the Security Officers of UTHET. It does not apply to other employees who are not necessarily trained for or familiar with this area of responsibility. All other such employees within the System are instructed to refrain from any use of force on behalf of the Hospital, its property, patients and guests except in extreme circumstances when someone's safety or life is endangered and no Security Officer is reasonably available. B. Before using the lowest level of force or escalating to a higher or more severe level of force, a Security Officer will, unless impractical under the circumstances, exhaust every reasonable means of obtaining compliance, including a non-physical display of authority and verbal commands, directions, or notifications. ac. If emergency circumstances make it immediately necessary, a Security Officer may reject any lesser level of force or may escalate to the highest and most severe level of force deemed necessary in the circumstances by the Security Officer so confronted. d. A Security Officer shall be able to justify the use of force at any level. 3. Use of Non-deadly force: An officer may use non-deadly force in the following situations and when and to the degree the officer reasonably believes the non-deadly force is immediately necessary to: a. make, or overcome resistance to an arrest that a Security Officer is authorized to make under the law; b. defend the Officer from the violence of another directed against said Officer; c. prevent escape from lawful custody; d. prevent the commission of a crime for which the Officer has enforcement jurisdiction; e. prevent a self-inflicted wound or suicide; and f. prevent or interrupt interference with the lawful possession of property. g. When the Officer reasonably believes that the force is lawful and in compliance with this policy. 4. Verbal Abuse: No Officer will use force solely in response to mere verbal provocation or to abusive language directed at the officer. 5. Justification for the Use of Deadly Force: Justification for the use of deadly force must be limited to the facts reasonably apparent to the officer at the time said officer decides to use the force. 6. Avoiding the Use of Deadly Force: At the point when an Officer should reasonably perceive that the potential exists that deadly force may be an outcome of any situation, the Officer must plan ahead and use reasonable alternatives if time and opportunity permits. In each case, a 'reasonable alternative' is defined as an action, which may be taken by the Officer that may allow the Officer to avoid the use of deadly force. The reasonable of the action is based upon the time available, the opportunity of performing the action, and the facts apparent to the Officer prior to and during the incident..."

A review of the hospital's "Patient Rights and Responsibilities" policy with a date of 12/18/2023 revealed,

" Policy: A written copy of the hospital's statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate to the patient's age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient's understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient's assessment of understanding his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission and in a manner that he/she can understand. Complaints and concerns regarding a patient's rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department, who will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patients regarding their rights to health care and health care-related activities during hospitalization ...Procedure: 1. Provide information that outlines the patient rights during the admission process to the patient or someone acting on the patient's behalf for all inpatients, outpatients, and ER patients. A. Patient Rights Information will be provided to the patient in the form of the Hospital's Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgement document, which will acknowledge their receipt of the patient's rights. 3. The admitting or nursing staff may refer to the Interpreter List for patients with language barriers. 4. Obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment ...5. Provide the patient with access to the patient complaint procedure if requested by the patient. 6. Documentation: Treatment Authorization and Terms of Treatment Agreement. Procedure: Outpatient: 1. When the patient enters an outpatient area of the hospital: a. Patient rights are available in English and Spanish and are posted in a visible area of the outpatient area. B. Patient rights will be provided to the patient or surrogate in the form of a handout when the patient enters an outpatient area of the hospital and under any type of procedure ...."

A review of the hospital's "Abuse Identification and Reporting" policy with a date of 05/06/2024 revealed,

"Purpose: 1. To identify possible victims of abuse or neglect that present to an Inpatient or Outpatient location and/or setting using community established indictors (elder, adult, or child). 2. To establish the mechanism by which a possible victim will be automatically screened and assessed at the location or setting by an appropriate qualified nurse in that location or setting that will lead to an examination, treatment and referral for follow-up in order to meet their physical and psychological needs. 3. To ensure that notification to appropriate authorities is in accordance with Texas State Law. Definitions: 1) Neglect: A form of abuse, defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 2) Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. This includes staff neglect, indifference to infliction of injury, or intimidation of one patient by another. 3) Child: A person under 18 years of age. 4) Elder Abuse: "An act which results in harm or threatened harm, to the health or welfare of an elderly person" -according to the American Medical Association (AMA) These include: a) Physical abuse or neglect b) Psychological abuse or neglect c) Material abuse or exploitation d) Violation of personal rights or exploitation 5) Endangered Adult: An individual who is of legal age but is: a) Incapable by reason of insanity, mental illness, mental retardation, senility, habitual drunkenness, excessive use of drugs, old age, infirmity, or other incapacitating processes of managing either their property or caring for self. b) Harmed or threatened with harm as a result of neglect, battery or exploitation in the individual's personal services or property. 6) Psychological Abuse/Neglect: a) Verbal assaults such as screaming or ridicule and threats that induce fear but do not make use of a weapon. b) The failure of the caretaker to satisfy emotional or psychological needs of a dependent or elder dependent (social isolations or lack of stimulation). 7) Material Abuse/Exploitation: Stealing or misusing money or property belonging to the elderly or endangered adult. 8) Violation of Personal Rights or Exploitation: Depriving an elderly adult of the right to freedom of choice, life or privacy ....Procedure: 1) The Health Care Provider will use established objective criteria for identifying possible victims of abuse. Physical and behavioral criteria for identifying possible victims of abuse are listed within the policy. 2) Once the possible victim has been identified, the health care provider will follow the established flow chart: "Managing the Abused/Neglected Patients": see attached. 3) Appropriate authorities (CPS, APS, law enforcement) will be notified of ALL possible/actual victims of abuse/neglect. This referral will be documented in the medical record. 4) All possible/actual cases of abuse/neglect will be reported to Quality Improvement department via electronic Event Reporting system. a) Quality Improvement and Risk Management staff will be able to view the report in the electronic Event Reporting system. 5) Patients undergoing a sexual assault exam will be placed in a private room as medically indicated. 6) Visual and auditory privacy will be provided for any interviewing or examinations for all possible/actual abused or neglected patients. 7) An available list of private and public community agencies are attached as attachment C. 8) Physical and Behavioral Criteria for Identifying Possible Victims: a) Physical: These injuries cover a wide range and most commonly include burns, lacerations, contusions, fractures, head injuries and dislocations: i) Injuries that are not in keeping with the patient's level of development or physical capabilities ii) Explanations for the injuries are implausible iii) Physical markings consistent with the use of objects iv) Skeletal injuries: untreated; in various states of healing; unexplainable v) Unexplained bruises, lacerations and welts: may be in various stage of resolution vi) Defensive injuries: hand and foreman injuries resulting from protecting oneself vii) Injuries consistent with "Shaken Infant Syndrome": internal cranial bleeding, retinal hemorrhages viii)Poor hygiene, inadequate clothing ix) Apparent malnutrition, non-organic failure to thrive x) Unattended medical or physical needs (decayed teeth, broken glasses, overgrown nails) b) Behavioral: i) Irritability ii) Sleep disturbances (insomnia, nightmares) iii) Difficult concentrating iv) Exaggerated "startle" response v) Phobias, obsessions vi) Depression vii) Anxiety/apprehension/fearfulness/suicidal viii)Withdrawal ix) Reluctance to establish eye contact with the health care provider x) Extreme dependence on the partner and reluctance to make simple decisions without partner approval xi) Verbal statement or accusations xii) The abuser may also give clues by appearing dominant, answering questions for the partner, usurping his/her care to make their own medical decisions c) Pediatric Specific Indicators: Adopted from the manual for "Sexual Assault Nurse Examiner" Training-attachment B. d) Documentation Guidelines: All documentation will be specific to facts, observations and description. Any impressions/beliefs are not appropriate. An assessment will be conducted and documented upon entry into hospital and an ongoing basis. Documentation should include: i) Specifics regarding physical findings (i.e. 1-3 purple circular region on left inner wrist) ii) Behaviors observed iii) Any unsolicited verbal statements iv) Any contact with outside agencies. v) Any persons working with patient/family from outside systems will have their identity verified with their respective agency and documents (i.e. CPS, S.O. - badge number and verification with their office) vi) Referral for support; medical and psychosocial follow up plans ..."

An interview was conducted with Staff # 1 and # 2 on 12/03/2025 at 4:30 PM. Staff # 1 and # 2 confirmed they watched the security footage of the event and confirmed that Staff # 7 failed to follow hospital policy and that the security manager (Staff # 9) failed to properly investigate and escalate the event to hospital administration for further investigation and action.