The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

VALLEY BAPTIST MEDICAL CENTER- BROWNSVILLE 1040 W JEFFERSON ST BROWNSVILLE, TX 78520 Feb. 8, 2018
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the facility failed to ensure their policies and procedures protected patients' rights to be free from all forms of abuse harassment while a patient in the facility. Specifically, the facility's procedures for how to report abuse/neglect/exploitation were not specific and did not include the reporting requirements regarding allegations of abuse/neglect against the facility and/or facility employees to the appropriate state health regulatory agency that has 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).

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment of patients in the facility by compromising their safety.

Findings included:

Record review of DSHS Intake Complaint Form, dated 02/05/2018, revealed that a Sexual Assault Nurse Examiner (SANE) employee reported an allegation of sexual abuse made by Patient #1 towards a Personal Care Technician at this facility. The SANE employee reported the allegation of sexual abuse to the Department of Family and Protective Services (DFPS) but not to DSHS. The SANE program is physically located at a sister facility in a nearby city. This facility utilizes that SANE program for forensic medical examinations for allegations of sexual abuse.

Review of the facility's Policy and Procedure titled Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault, effective 03/27/2014, revealed but was not limited to the following: "All individuals in (corporate name) facilities, including patients, have the right to be free of abuse, neglect and assault. The Administrator on Call (AOC) or designee of each (corporate name) facility is responsible for immediate reporting of allegations of abuse, neglect or assault occurring in the (corporate name) facility to the local police and/or other appropriate authorities and to (corporate name) so that the proper investigation of alleged criminal or other inappropriate conduct may be conducted by those authorities.

Further review revealed the facility's Abuse and Neglect policy did not have any further information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect against the facility and/or facility employees was provided within the policy; or a phone number to the DSHS agency (888-973-0022) was provided within the policy.

Review of facility curriculum slides for reporting abuse and neglect, dated April 2006, did not reveal information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect against the facility and/or facility employees was provided within the curriculum; or a phone number to the the DSHS agency (888-973-0022) was provided within the curriculum.

Interview by phone on 02/05/2018 at 7:30 PM with the SANE employee who completed the forensic medical exam for Patient #1 confirmed that she reported the allegation of sexual abuse to DFPS. She confirmed she was not aware that she should have reported an allegation of sexual abuse occurring at a hospital to DSHS. She confirmed that she is employed by a sister facility in a nearby city but the SANE program at her facility provides forensic medical examinations for allegations of sexual abuse that occur in most hospitals in the area.

Interview on 02/08/2018 at 9:45 with facility risk management staff confirmed the facility believed the SANE employee had reported to the appropriate agency at the time of the allegation. They were not aware that she had reported to DFPS and not DSHS as required by state law.

Interview on 02/08/2018 at 11:30 AM with facility Clinical Educator for ICU, Cath Lab, Telemetry, and Emergency Department (ED) confirmed that the facility curriculum slides for reporting abuse and neglect were used to train facility staff on where to report abuse and/or neglect that occurred either out of the facility or in the facility. She confirmed the number for DSHS was not on the facility curriculum slides.

Health and Safety Code 161.132 (b) indicates: b) 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 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 agency that licenses the facility (DSHS) or to the appropriate state health care regulatory agency (DSHS).