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.

Based on interview and record review, the facility failed to ensure their policies and procedures protected patient's rights to be free from all forms of abuse or harassment while a patient in the facility. Specifically,
1.) The facility failed to report an allegation of abuse to the appropriate state health care regulatory agency (Department of State Health Services) DSHS for 1 of 1 patients reviewed (Patient #1).
2.) The facility's policy and procedures for how to report abuse/neglect were not specific for reporting allegations of abuse/neglect that occurred in the facility to the appropriate state health care regulatory agency that has authority and licenses the facility, DSHS at (888) 973-0022; and in accordance with the Health and Safety Code 161.132(e).

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 hospital policy entitled, "Abuse and Neglect" with a current effective date and last review date of 12/15 on 09/15/17 at 9:30 a.m. at 10:30 a.m. in the conference room revealed the following in part:

Upon evidence of reasonable cause to believe that a child, an elderly, or disabled person is in a state of abuse, exploitation or neglect, staff are obliged to report the circumstances to the appropriate state agencies.
All patients admitted shall be free from all forms of abuse, neglect, harassment, misappropriation of resident property, and involuntary seclusion.
Patients will not be subjected to abuse from anyone, including but not limited to, facility staff, other patients, visitors, consultants, volunteers or other individuals.
An elder is any person 65 years of age or older.
The term "disabled (or dependent) adult" includes persons who have physical or mental limitations which restrict their ability to carry out normal activities or to protect their rights or who physical or mental abilities have diminished because of age.
Abuse includes the following acts or omissions by a person.
Sexual abuse: Sexual contact, sexual intercourse, or sexual conduct, as those terms are defined by Section 43.01, Penal Code.
All newly hired employees receive training on abuse and neglect during their hospital orientation and annually thereafter.
All cases of suspected abuse/neglect must be reported to authorities. Any member of the healthcare team who has knowledge of or suspects abuse, neglect or exploitation is obligated by State law to report to the Texas Department of Family and Protective Services with the first hour and no later than the 48th hour after the abuse or neglect was suspected and if indicated, a local or State law enforcement agency. A report may be made anonymously. A professional may not delegate to or rely on another person to make the report. Family Protective Services 1-800-252-5400.
Disabled Adult/Elderly Abuse/Neglect
Report to appropriate agencies:
Adult Protective Services of the Texas Department of Family and Protective Services at 1-800-252-5400 after hours or
Police Department

The facility's Abuse/Neglect Reporting policy did not include information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect that occur while a patient is in the hospital and did not include a phone number to the DSHS agency (888-973-0022) for reporting allegations of abuse/neglect.

In an interview on 09/15/17 at 9:45 a.m. in the conference room, S#3 confirmed the above findings.

Review of the DSHS Complaint Intake Information Form with a received date of 08/09/17 revealed a referral from DFPS that stated, "SO has been observed by multiple staff interacting in an inappropriate manner with CL. SO is touching CL on the face and kissing her lips. SO is touching CL on the abdomen, thighs, inner thighs close to the perinatal area. SO has been observed rubbing CL's breasts and indicates this helps her relax. SO is frequently using his finger to remove bowel movements from CL's anus. This is happening too often. So was observed on top of CL whispering in CL's ear. Two weeks ago CL SO was in bed with CL and CL said "Take me away." CO indicated that was because CL liked the person that entered the room. It is unknown if SO is showing any indicators of arousal when these incidents occur."

In an interview of S#7 on 09/15/17 at 11:35 a.m. in the conference room, S#7 stated, "I vaguely recall the patient, her son was always with her and never left her side," "Staff reported that he was on top of her but I don't know how, just inappropriate behavior toward her" and "Staff reported it to me and I reported it to my supervisor and floor manager."

In an interview of S#8 on 09/15/17 at 12:00 p.m. in the conference room, S#8 stated, "The son would get on the bed with the patient, kiss her face and lips and I think this was too intimate. He would lay with her in bed. He was always massaging or caressing her. The patient had a diaper rash. He would always ask for the cream used. He would put it anally. He would put on gloves and put the cream. He would open her legs and have a fan blowing on her wither her perineum exposed and say she was hot." According to S#8, S#8 called APS and filed a police report and the police officer talked to the son in the patient's room.

Review of the hospital's internal investigation on 09/15/17 at 12:20 p.m. in the conference room revealed that on 10/05/16, S#4 and S#5 met with Risk to report concerns expressed by staff regarding the behavior of the son and primary care taker of Patient #1. Risk conducted staff interviews. An LTAC intaker reported observations and concerns to S#7 and S#7 reported them to APS. According to the LTAC intaker in part, "upon entering the room, found patient's son, on bed with patient. Son was wearing clothes but patient was exposed from belly down. Due to patient having a large belly, was not able to observe if patient was wearing a diaper or not but her legs were exposed. The son was startle and immediately got off the bed but patient remained exposed. Son proceeded to rub patient's tummy area. Proceeded to kiss the patient all over face/lips." According to S#8, "the son is 'all over her (patient) all the time' kissing her all over her face, yesterday, S#8 entered patient room and found patient exposed from waist down, legs opened ...S#8 reported son obtains skin creams onto his finger (s) and applies the cream to patient on her private parts."

The hospital reported the abuse allegation to Adult Protective Services (APS) and the local police department. There was no documentation that the facility reported the abuse allegation that occurred in the facility to the appropriate state health care 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(e).

In an interview on 09/15/17 at 10:50 a.m., in the conference room, S#3 confirmed the above findings.