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Based on interview and record review, the facility failed to ensure the process and procedures for prompt resolution of patient complaints and grievances in accordance with their Complaint/Grievance policy, for 1 of 1 complaint reviewed regarding Patient #1 who made a complaint allegation of sexual abuse while an inpatient at the facility.
Specifically, on 10/27/15 Patient #1's Case Worker notified the facility of a sexual abuse allegation while Patient #1 was an inpatient from 09/29/15 to 10/02/15. The sexual abuse allegation was immediately reported to the facility's Director of Nursing (DON), and Director of Intake. There was no evidence this allegation was thoroughly investigated by the facility for the possible identification of abuse or mistreatment; resolution, or the findings of this complaint.

Findings Included:

Review of the facility's Patient Complaint Information Form dated 10/27/15 regarding Patient #1 revealed the following:
The facility's Patient Advocate (PA-A) received a report from Patient #1's referred Community Services Director that documented Patient #1 reported to her Mother the week of 10/18/15 that she had been "sexually abused" while at the facility. Patient #1 reported to her Case Worker at the Community Services Center and reported the following: "Patient said she was admitted to [the facility] in the middle of the night, she was sedated, and when she woke in the morning, her private parts were sore, and she had bruises on her thigh. Patient did not report this to anyone at [the facility]. Patient is 14 year old female. When patient told her mom last week about the abuse, she requested her mom that she have a pregnancy test. Test was reported to be negative. Patient was admitted to [the facility] on 09/29/15 at 12:32 a.m. She was discharged home on 10/02/15 at 19:45 p.m. There was no other information provided by the caller from the Community Services Center. Case is reported by Community Services Center to CPS [Child Protective Services]." The facility identified the Occurrence Report as #2015-22703. Name of Director Notified documented the facility's Director of Nursing (DON) and Director of Intake.

Review of the facility's Policy and Procedures titled, Patient Complaint and Grievance Management, last revised 03/2104 revealed, "All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS [Centers for Medicare and Medicaid Services] requirements, are to be considered a grievance for the purposes of these requirements."

The policy indicated in part: 6. Grievance Management Process, 3. All grievances will be thoroughly investigated by:
-A review of the patient's perceptions of the incident;
-A review of all related records; and
-Interview with staff and caregivers involved in the incident or as described in the patient's complaint.
5. Once the investigation is complete, the investigator will write a letter to the patient or their representative with written notice of the decision. The letter will include at a minimum:
-The name of the hospital contact person;
-The steps taken on behalf of the patient to investigate the grievance;
-The results of the grievance process; and
-The date of completion.
9. Documentation
a. The responsible director will document a summary of the investigation and all actions taken on the corresponding occurrence report.
b. All correspondence and documentation from the investigation will be forwarded to and kept on file in the Risk Management Department.

During an interview on 02/18/16 at 3:00 PM with the facility's Manager of Quality Management (QM) indicated there was no evidence of an investigation; and further stated a file could not be located for Patient #1's sexual abuse allegation received on 10/27/15. The Manager of QM confirmed that PA-A received the phone call, logged it into the Complaint/Grievance logs and the Director of Risk Management (RM) received the information.

During an interview on 02/18/16 at 3:15 PM with the Director of RM indicated she had received a phone call from Patient #1's Community Services Case Worker regarding the allegation of sexual abuse made during her inpatient in 09/29/15 to 10/02/15. The Director of RM stated they Case Worker indicated that CPS and "Texas State" had been notified. The Director of RM indicated that the DON was responsible to complete the investigation and should have put notes into the Complaint/Grievance logs regarding the investigation and outcome. The Director or RM confirmed those procedures had not been completed by the DON.

Further interview on 02/18/16 at 3:25 PM with the Manager of QM stated she spoke with the DON, and the DON stated "she had discussions with staff;" but had "no documentation" of interviews or an investigation.

During an exit conference on 02/19/16 at 1:00 PM the facility was provided with the verbal findings of this complaint investigation and was offered the opportunity to provide any further additional information and/or evidence of an investigation regarding this specific complaint made by Patient #1 and reported to the facility on 10/27/15. No evidence was provided.

Based on interview and record review, the facility failed to ensure the patient's rights to be free from all forms of abuse or harassment by failing to investigate and report/respond to an allegation of sexual abuse in accordance with their Complaint/Grievance policy, for 1 of 1 patients reviewed (Patient #1) with a complaint allegation of sexual abuse while an inpatient. In addition, the facility's procedures for; how to report abuse/neglect/exploitation were inconsistent amongst policies, unclear, and not specific for reporting allegations of abuse/neglect against the facility and/or facility employees to the appropriate state health care regulatory agency; Department of State Health Services (DSHS) at (888) 973-0022.

Specifically, on 10/27/15 Patient #1's Case Worker notified the facility of a sexual abuse allegation while Patient #1 was an inpatient from 09/29/15 to 10/02/15. The sexual abuse allegation was immediately reported to the facility's Director of Nursing (DON), and Director of Intake. This allegation was not reported to the state health care regulatory agency and; there was no evidence this allegation was thoroughly investigated by the facility for the possible identification of abuse or mistreatment.

This 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 the facility's Patient Complaint Information Form dated 10/27/15 regarding Patient #1 revealed the following:
The facility's Patient Advocate (PA-A) received a report from Patient #1's referred Community Services Director that documented Patient #1 reported to her Mother the week of 10/18/15 that she had been "sexually abused" while at the facility. Patient #1 reported to her Case Worker at the Community Services Center and reported the following: "Patient said she was admitted to [the facility] in the middle of the night, she was sedated, and when she woke in the morning, her private parts were sore, and she had bruises on her thigh. Patient did not report this to anyone at [the facility]. Patient is 14 year old female. When patient told her mom last week about the abuse, she requested her mom that she have a pregnancy test. Test was reported to be negative. Patient was admitted to [the facility] on 09/29/15 at 12:32 a.m. She was discharged home on 10/02/15 at 19:45 p.m. There was no other information provided by the caller from the Community Services Center. Case is reported by Community Services Center to CPS [Child Protective Services]." The facility identified the Occurrence Report as #2015-22703. Name of Director Notified documented the facility's Director of Nursing (DON) and Director of Intake.

Review of the facility's Policy and Procedures titled, Patient Complaint and Grievance Management, last revised 03/2104 revealed, "All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS [Centers for Medicare and Medicaid Services] requirements, are to be considered a grievance for the purposes of these requirements."

The policy indicated in part: 6. Grievance Management Process, 3. All grievances will be thoroughly investigated by:
-A review of the patient's perceptions of the incident;
-A review of all related records; and
-Interview with staff and caregivers involved in the incident or as described in the patient's complaint.

Review of the facility's policy titled, Abuse, Neglect, or Exploitation of an Adult, Elderly, or Disable Patient, last revised 02/2012 revealed inconsistent procedures which included:
II. Reporting: Reporting Abuse and Neglect:
1. A person having cause to believe that an elderly or disabled person is in the state of abuse/neglect/exploitation shall report the immediately to the "Department of Family and Protective Services" (DFPS).
2. A person, including an employee, volunteer, 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 reasonable believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of 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, chemical dependency, or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the appropriate state health care regulatory agency." No further information regarding the specific state health care regulatory agency was provided; or a phone number to the agency was provided within the policy.

Further review of the policy revealed "How to report:
When an employee of [The facility] has reason to report abuse/neglect/exploitation and after the Attending Physician, Department Director, House Supervisor and Social Services have been notified a report will be filed with the "Department of Family and Protective Services" and documented in the patient's medical record.

Review of the facility's Policy and Procedures titled, Child Abuse and Neglect, last revised 04/2012 revealed in the area of "Reporting: If a professional has cause to believe that a child has been abused or neglected or may be abused or neglected, or that a child is a victim of an offense under Section 21.11, Penal Code, and the professional has cause to believe that the child has been abused, the professional shall make a report not later that the 48th hour after the professional first suspects that the child has been or may be abused or neglected or is a victim of an offense under Section 21.11, Penal Code. A professional may not delegate to or rely on another person to make the report.

Further review of the policy states "How to report: When an employee of [the facility] has reason to report child abuse and/or neglect and after the Attending Physician, Department Director, House Supervisor and Social Services have been notified a report will be filed with the Department of Family and Protective Services (DFPS) and documented in the patient's medical record."

Record review of Patient #1's Nursing Notes on 09/29/15 at 01:10 AM revealed Patient #1 was admitted to the adolescent unit with suicidal ideation/attempt. Patient #1 reported she hears voices and sees shadows. Registered Nurse (RN)-A skin assessment revealed "multiple superficial lacerations to the left inner forearm, 1 cut above the right knee. Examined the thighs and no cuts seen there."

Review of Patient #1's Nursing Notes on 09/29/15 at 5:33 PM revealed RN-B assessment documented Patient #1 "has superficial cuts to left arm and right thigh. Scabbing present."

Review of Patient #1's Discharge Summary dated 10/02/15 revealed Patient #1 was to follow up with the Community Center Services for Individuals with Mental Health and Mental Retardation (MHMR) services.

During an interview on 02/18/16 at 3:00 PM with the facility's Manager of Quality Management (QM) indicated there was no evidence of an investigation; and further stated a file could not be located for Patient #1's sexual abuse allegation received on 10/27/15. The Manager of QM confirmed that PA-A received the phone call, logged it into the Complaint/Grievance logs and the Director of Risk Management (RM) received the information.

During an interview on 02/18/16 at 3:15 PM with the Director of RM indicated she had received a phone call from Patient #1's Community Services Case Worker regarding the allegation of sexual abuse made during her inpatient in 09/29/15 to 10/02/15. The Director of RM stated they Case Worker indicated that CPS and "Texas State" had been notified. The Director of RM indicated that the DON was responsible to complete the investigation and should have put notes into the Complaint/Grievance logs regarding the investigation and outcome. The Director or RM confirmed those procedures had not been completed by the DON.

Further interview on 02/18/16 at 3:25 PM with the Manager of QM stated she spoke with the DON, and the DON stated "she had discussions with staff;" but had "no documentation" of interviews or an investigation.

During an interview on 02/18/16 at 3:30 PM with the Vice President (VP) of QM stated she thought since the sexual abuse allegation had reportedly been reported to CPS (division under DFPS); that there was no further reporting necessary. The VP of QM indicated she was not aware that specific abuse/neglect allegations made against the facility and/or facility staff were supposed to be reported to the state health care regulatory agency; Department of State Health Services (DSHS).

During an interview on 02/19/16 at 8:30 AM with the Complainant stated that Patient #1 had been seen for a sexual assault examination after she made an allegation of sexual abuse while in the behavioral facility from 09/29/15 to 10/02/15. The Complainant indicated that Patient #1 confirmed she did not tell anyone while an inpatient at the facility; but told her mother and Community Case Worker after she had been discharged and was completing her follow-up services. Patient #1 reported the allegation may have occurred on 09/29/15 and reported that she had bruises to her body and her vaginal area was sore when she woke. Patient #1 was sent and assessed for a sexual assault examination; however over a month had elapsed since the original event allegedly occurred.

During an interview on 02/19/16 at 9:25 AM with Patient #1's mother stated Patient #1 reported to her an allegation of possible sexual abuse after she had been discharged from the facility a week or two before she told her. Patient #1's mother stated she was admitted 09/29/15 and she kept receiving phone calls from the facility for consent to give her daughter a "sleeping pill" and she finally agreed. Patient #1 stated to her; when she woke up the next day, later in the evening, she had "bruises on her thighs, and her vagina hurt; and didn't know what happened." Patient #1's mother stated she took her daughter to the Community Services Case Worker following the allegation to seek further direction, treatment, and services. Patient #1's mother stated the Community Services Case Worker handled the allegation from there by referring her daughter for a sexual assault examination, notifying the facility, and notifying the local Police Department. Patient #1's mother stated that her daughter believed something happened to her during her inpatient stay and that her "story has never changed."