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 provide care in a safe setting when the treatment plans, for patients with a history of being sexually abused and or violent behavior, were not documented, in order to protect the patient and others from risk of victimization and assault. (Patients #2, #4 and #11)

Findings include:

Review of the facility provided policy Sexual Victimization and Sexual Perpetration- Early Identification, Prevention, Response & Notification Policy (last reviewed 3/2018) reflected, "Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents, as well as any verbal/physical threats of sexual incidents ...To provide a Response and Notification Plan in the event of a sexual allegation and/ or incident...
EARLY IDENTIFICATION: Potential for Sexual Victimization: History of being sexually abused/assaulted, being developmentally disabled ...historical data is gathered from the patient, ...and available medical, social, and legal history .... Unit/Clinical Team: Update the patient's treatment plans as applicable ...."

Review of the facility provided policy Treatment Planning (Last reviewed 11/2007) reflected, " ...Guidelines for Treatment Plans: A. The Treatment Plan shall identify problems and specify those to be addressed during the treatment episode. Rational for not addressing an identified problem shall be documented .... shall review the comprehensive plan with documentation of with any major change of condition, interventions or addition of problems ...."

Review of Patient #2's medical records revealed a 54- year-old-male admitted on [DATE] for mood stabilization with a history of major depressive disorder, severe psychosis, ETOH and Cocaine use, Patient #2 did not have a history of sexual abuse or acting out.

Review of the Nurse's Notes dated 12/23/17 reflected, " ...Patient reportedly touching another patient inappropriately and making sexually explicit remarks. Other patients witnessed activity and reported to staff. Contacted House Supervisor regarding situation .... Decision made to call Dr. Orders received to transfer to PICU and add SAO precautions."

Review of the Physicians orders dated 12/23/17 at 6:45 pm reflected,
1. Transfer patient to PICU
2. Add SAO (Sexual Acting Out) Precautions

Review of the Treatment plan revealed it had not been updated to reflect the incident on 12/23 and the need to place Patient #2 on SAO Precautions.
Review of Patient #4's medical records revealed a [AGE]-year-old female with history of sexual abuse when she was 12, and major depressive disorder and suicidal ideation's was admitted on [DATE].

Review of Patient #4's Nurse's note dated 2/23/17 revealed, "Patient #4 stated she had been sexually assaulted three weeks ago."

Review of the Patient #4's Nurse's notes dated 2/24/17 at 6:20 pm reflected "Pt alleged that a male pt, brushed her on her breast and grabbed it, while in line waiting to get some lunch ...."

Patient #4's Initial Treatment plan dated 12/15/17 was not completed to reflect risk of victimization and was not updated to reflect the two new reports of sexual assault.

During an interview on the afternoon of 4/9/18, Staff #10, Director of Risk Management stated, "The treatment plan should have been updated ...I don't see where it was updated .... "

Review of Patient #11's Medical Records reflected a 16-year-old-female admitted with a complaint of suicidal ideation and a history of Sexual Abuse and Violence toward others.

Intake Psychosocial Assessment, "Trauma/Abuse History ...Sexual ...Date of Events: 2 weeks ago ....Current Risk to Others: ... fought Girl at ... 2 wks [sic] ago ....Acute Risk Factors ...History of Violence to Others ...HIGH RISK ...Overall Assessment of Risk, Suicide/Self Harm, Moderate Risk, Sexual Victimization, Moderate Risk ...Homicide/Assaultive, mild risk"
Review of Patient #11's Nurses Notes dated 2/25/19 at 6:30 pm reflected, "Pt reports that she had a physical altercation with another pt in the Cafeterial [sic] ....", and on 2/27/18 at 2:45 p.m. reflected, "Pt observed fighting peer in dayroom ...."
Review of Patient #11's Incident Reports dated 2/27/18 at 4:30 p.m. reflected, "Attacked another patient" and 2/27/18 at 2:45 p.m. reflected, "Attacked another patient"

Review of Patient #11's Treatment Plan reflected, "Danger to Self ..." The treatment plan did not reflect the Danger to Others or the Risk of Victimization and was not updated to reflect the two incidents of aggression toward others.

During an interview on 4/10/18, in the facility conference room, Staff #11, LCSW (Licensed Social Worker) stated, "The team updates the treatment plans ...if someone has a history of sexual abuse they can have increased panic attacks ..." Staff #11 confirmed the treatment plan did not reflect the risk for Victimization and were not updated to reflect the altercations with peers.

Review of the facility provided Policy Patients' Rights (last review date: November 2017) reflected " ...The hospital shall abide by the Texas Department of State Health Services (TDSHS) Bill of Rights for Patients"
Review of the TDSHS Bill of Rights for Patients reflected, "...5. You have the right to be free from mistreatment, abuse, neglect, and exploitation."