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WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX Oct. 9, 2018
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that the rights of 1 of 10 patients (Patient #1) to be free from abuse, as revealed by the lack of an investigation completed after a patient alleged she was sexually abused.

Findings included:

TX 790

Record review on 10/8/18 of Patient #1's clinical chart revealed she was a [AGE]-year-old female admitted to facility on 3/27/18, with the diagnosis of Schizoaffective disorder, bipolar type, and discharged [DATE] to her mother's home. While in the facility, Patient #1 had called her mother and complained she had been raped, but could not say by who. The mother then contacted the facility and reported the allegations on 3/30/18.

Record review of nursing notes on 3/31/18 at 8:45 am from Staff #56, revealed that the patient's mother had called and reported that her daughter, Patient #1, told her she was raped the night before by a big guy and dragged to another room.

Record review on 10/8/18 at time of survey of facility's Incident Report concerning Patient #1's allegations revealed the following: " ....date of incident; 3/30/18 .... Physician notified of complaint, .....Incident type; Patient Care 71 .....Outcome; ...no apparent injury ...Intervention; place on precautions".

Record review of facility's own investigation of alleged incident revealed there was no investigation performed per facility policy.

In an interview on 10/8/18 at 12:30 pm, Staff #55 stated she was not aware of any written investigation concerning the allegations from Patient #1.

In an interview on 10/8/18 at 1:30 pm, staff # 53 stated that staff #54, who was no longer employed at the facility, should have conducted and completed a full written investigation. There were no staff that were able to locate and show proof that a full investigation had occurred and was documented.

Record review of facility policy titled "Suspected Abuse, Neglect and Sexual Exploitation" dated 4/2013, stated that an investigation into alleged sexual abuse will be initiated immediately and shall include interviews documented, dated, and signed by the person conducting the interviews and this documentation involving the alleged incident shall be forwarded to the Director of Risk Management or Chief Nursing Officer within 24 hours or by the next working day.