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 that all 14 patients residing on the Geri-Psych Unit were free from possible abuse and neglect:

A hospital Social Worker (# 71) received knowledge of possible abuse of a discharged Patient (# 1) by a CNA (# 65) who was currently employed. The facility failed to investigate this allegation.

Findings include:

Intake # TX 262

Review of the clinical record of Patient # 1 revealed she was [AGE] years old and had been admitted to the facility on on [DATE]. Her medical history included the following: Depressive Disorder, Suicidal Ideation, Hypertension, and Cerebral Vascular Accident (CVA/ " stroke " ). Patient # 1 was assessed as aphasic with right-sided weakness.

Further review of a History & Physical, dated 03-19-12 read Patient # 1 was " very depressed but cooperative ... able to communicate by writing ... She understands very well ... " Patient # 1 had been admitted to the hospital geropscyh unit due to increased depression concerning her grandson ' s suicide 3-4 months prior. Patient # 1 was discharged from the hospital on02-16-2012 and returned to the nursing home.

Interview (telephone) on 03-23-12 at 4:00 p.m. with hospital social worker ( Staff # 71) reported that on 03-08-12 she telephoned a local nursing home where Patient # 1 currently resided and inquired about her planned return to the hospital ' s geropsych unit. She went on to say the nursing home ' s social worker returned the call on 03-09-12 and said Patient # 1 would not be returning to the hospital ' s Geropsych Unit because " something had happened there that scared her. " Staff # 71 said the nursing home social worker told her " Patient # 1 said a male Certified Nurse Aide (CNA/ ID # 65) touched her inappropriately while giving her a shower. " Staff # 71 went on to say she was unsure whether to report this as alleged abuse because she did not hear it directly from Patient # 1. Staff # 71 said she left a telephone message and text for the Interim Director (ID # 72), as well as a handwritten note about allegation of abuse. Review of Social Worker (ID # 71) personnel file revealed she was hired on 06-21-2010 and last received Abuse, Neglect, Sexual Abuse training on 07-21-2011.

Interview (telephone) on 03-23-12 at 5: 15 p.m. with Interim Geropsych Unit Director(ID # 72) he reported he had no knowledge of the allegations that Patient # 1 had possibly been abused by CNA # 65. He denied receiving any messages or texts regarding this issue.

Interview on 03-23-12 at with Interim Geropsych Manager (Staff # 52) she stated CNA # 65 was currently employed on the Geropscyh Unit and worked the night shift.

Review of the current Geropscyh Unit patient roster revealed there were currently 14 inpatients on the unit.

Interview on 03-23-12 at 5:20 p.m. with the hospital Risk Manager (# 51), she stated this alleged abuse should have reported and investigated using the established hospital process.

Review of facility policy titled " Abuse, Neglect, Exploitation (Suspected) of Adult, Elderly or Disabled person, reviewed 11/10, read: " Policy: (facility) will respond quickly and effectively to any actions or behaviors that may be construed as abuse, neglect, or exploitation ...1. The licensed employee who observed the suspected abuse will initiate the reporting process by: A. Notifying and discussing with director or Nursing Supervisor... "