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.

SOUTHWEST GENERAL HOSPITAL 7400 BARLITE BLVD SAN ANTONIO, TX 78224 Sept. 12, 2016
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, 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, the facility failed to report an allegation of sexual abuse/assault to the state health care regulatory agency for 1 of 1 patients reviewed (Patient #1) with a complaint allegation of sexual abuse by another patient (Patient #2), while receiving mental health services; and, who had a guardian of her person. In addition, the facility's policy and procedures for how to report abuse/neglect were unclear, and not specific for reporting allegations of abuse/neglect that occurred in; against the facility, and/or facility employees 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(b).

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 Policy and Procedures titled, Abuse, Neglect, and Domestic Violence, approved 12/2014 revealed, it was the policy of the facility that "All allegations, observations, or suspected cases of abuse, neglect or exploitation that occur in the hospital shall be investigated by the hospital and or its designated personnel. Referral of the allegation, observation or suspected case of abuse/neglect or exploitation shall be referred to the appropriate authorities for investigation, based upon the type of event."

Further review of the policy indicated, "Reportable Concerns and Procedural Steps for Suspected Abuse/Neglect. 3. ALL CASES OF SUPSECTED ABUSE/NEGLECT MUST BE REPORTED TO THE AUTHORITIES. Notification included the appropriate department of Protective Regulatory services [DFPS] and law enforcement officials. 5. In addition to meeting any mandatory reporting requirements, all allegations, observations, or suspected cases of abuse, neglect, or exploitation that occur in the hospital are explored by the hospital and based on the type of event, are referred to the appropriate authorities for investigation."

The facility's Abuse/Neglect Reporting 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 that occur while in the hospital; 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 the DSHS Complaint Intake Information Form dated 09/08/16 revealed a referral from DFPS that indicated Patient #1 was currently a patient in the psychiatric floor of the Hospital. Patient #1 reported that another patient (#2) came in her room and sexually assaulted her on 09/05/16. The Local Police Department is involved. This Complaint/Incident intake was not self-reported by the facility.

Review of Patient #1's records revealed a letter of Guardianship dated 02/04/16 that deemed Patient #1; an incompetent person, and the Texas Department of Aging and Disability Services (DADS) had been appointed as Guardian of the Person of Patient #1. The facility received this specific information on 09/07/16 at 15:00.

Review of Patient #1's Discharge Summary dated 09/08/16 revealed she was a [AGE] year old female with a history of schizoaffective disorder and borderline intellectual function, who resides in a home community based service group home. Patient #1 began a relationship with another individual on the unit (Patient #2). Per review of the video tape, the patient enticed the person into her room and they began to have sexual intercourse. This was immediately discovered by the staff. Initially, the patient said that this was nonconsensual. As a result, police were called as well as consultation with a SANE (Sexual Assault Nurse Examination) nurse was done.

Review of the facility's incomplete/draft internal investigation revealed the incident that occurred between Patient #1 and Patient #2 on 09/05/16 was reported to the local Police Department and facility administrative staff when; MHT-A completing 15 minute safety checks on the female hallway opened Patient #1's bedroom door and found Patient #2 in Patient #1's room; "engaged in inappropriate contact." Patient #1 stated she did have sex with Patient #2 in her bedroom. Patient #1 initially stated she willingly participated and then stated she told Patient #2, "No." A SANE for Patient #1 was coordinated and conducted the next day on 09/06/15. The local Police Department took Patient #2 to another facility for a SANE examination on 09/06/15. There was no indication that the facility reported the sexual abuse/assault 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(b).

Observation on 09/09/16 at 2:30 PM of the facility's admission lobby/waiting area revealed there was not a posting for display readily visible to patients, residents, volunteers, employees, and visitors with a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with the HSC 161.132(e); and which included the number of the Texas Department of State Health Services (DSHS) patient information and complaint line at (888) 973-0022; in English and Spanish.

Further observation on 09/12/16 at 1:30 PM throughout the facility including the mental health services unit revealed there was not a posting of the department's (DSHS) patient information and complaint line phone number at (888) 973-0022; with the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with the HSC 161.132(e); in English and Spanish.

During an interview on 09/12/16 at 12:30 PM with the facility's Director of Educational Services (ES) stated she ensured training of new employees during orientation using a power point regarding how to report abuse and neglect. Further interview, and after review of the power point used for new employee orientation; the Director of ES confirmed that training did not include specifically; reporting allegations of abuse/neglect that occur in the facility; against the facility or facility employees to the appropriate agency that licensed the facility [DSHS] or the appropriate state health care regulatory agency [DSHS].

During an interview on 09/12/16 at 1:50 PM with Patient #1's DADS assigned Guardian stated she received report from Patient #1 claiming that she was sexually assaulted while a patient in the facility. Patient #1's Guardian stated she had not provided Patient #1 consent to engage in consensual sexual activity and that Patient #1 had been deemed incompetent by the court with an IQ of 52; placing her in the Moderate range of Intellectual Functioning.

During the exit conference on 09/12/16 at 3:10 PM the facility's Chief Executive Officer (CEO) confirmed the facility's policy regarding Abuse/Neglect & Reporting, last approved 12/2014 only included reporting abuse/neglect to department of Protective Regulatory services and did not contain the information for reporting to the agency that licensed the facility [DSHS] or the appropriate state health care regulatory agency [DSHS] for allegations of abuse/neglect associated within the facility, against the facility, and/or against an employee of the facility. Further interview with the CEO stated the facility did not feel this incident was a reportable incident to the state health care regulatory agency due to the local Police Department had not pursued criminal charges against Patient #2; and that the incident appeared to be consensual between Patient #1 and Patient #2.

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].