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 record review, interview, and observation the facility failed to ensure patient's rights to be free from all forms of abuse, neglect, or harassment by failing to prevent, protect, investigate, and report/respond to an allegation of sexual abuse and/or neglectful supervision in accordance with their policy, for 1 of 1 patients reviewed (Patient #1) with an allegation against another adult patient.

On 3/28/18, Patient #1, a minor, reported to a therapist from another facility that she had sexual relations with a specific named [AGE]-year-old male in administration during her admission [3/21/18] to this facility. On 3/24/18 the facility's Licensed Professional Counselor (LPC) reported this similar allegation to Child Protective Services (CPS), documented on Patient #1's Group Progress Note, but failed to follow the facility's policy and procedures; to notify a supervisor and/or the facility's administration to further ensure protections and an investigation was conducted.

This deficient practice could compromise patient safety by failing to implement protections and further prevention of abuse and/or neglect.

Findings Included:

Review of the facility's Policy and Procedures titled, "Reporting Abuse & Neglect," last revised July 2018 indicated allegations of abuse, neglect, exploitation, or illegal, unethical or unprofessional conduct of a child; that occur inside of the facility's acute care are reported to the Texas Department of State Health Services (DSHS). Any allegation made by a patient that involves abuse, neglect or any harm to a patient must be reported immediately to the supervisory chain of command. When an allegation is made to a therapist, or the therapist becomes aware of such, she notifies the Nursing Supervisor/Director of Nursing and Program Manager. The procedures included the requirements and procedures for facility investigations and patient protections.

Review of the CPS Intake Report # 723 referred to DSHS for investigation under TX 886 revealed on 3/28/18 an allegation was reported on behalf of Patient #1 from a therapist of her current placement where she alleged having had sex with a specifically named [AGE]-year-old in administration, he gave her "5 sticks, blocked door, and she started tripping out."

Record review of the medical record of Patient #1 revealed she was a [AGE]-year-old female admitted under an emergency detention to the psychiatric facility on 3/21/18 with diagnoses including major depression disorder, suicidal ideations, oppositional defiant disorder, and post-traumatic stress disorder related to sexual trauma.

Review of the Group Progress Notes dated 3/24/18 completed by LPC-Intern- A documented Patient #1 shared with group her background of abuse. "She also shared an incident that happened with another patient at admission. Therapist reported the incident to nurse on station and to TXDFPS [Texas Department of Family and Protective Services] accordingly." Report made w/staff #5117, Report # 818.

A copy of the DFPS/CPS Report # 818 was obtained and revealed LPC-A reported on 3/24/18 an allegation of potential neglectful supervision on behalf of Patient #1 during the admission process on 3/21/18. Patient #1 stated she was brought in to the facility by law enforcement and left in the admissions waiting area of the facility. It was unknown who was then responsible for the supervision of Patient #1. There was another adult patient also waiting in the admission area; when Patient #1 and the other adult patient "walked into a bathroom at the facility and had sex." It is unknown if there were facility staff in the waiting area at the time of the incident. Patient #1 has a history of being raped and under CPS substitute care placement at this time.

Review of the facility's Admission log for 3/21/18 revealed Patient #1 and the other alleged specified named "x" adult where admitted on the same date; and could have possibly been in the admissions area together according to the CNO.

A phone interview was conducted with the LPC- A Intern on 10/01/18 at 3:52 p.m., and according to her:
Patient #1 stated to her when at admission, she met her boyfriend that was an adult and they had sex in the bathroom. They both were in admissions, went into the bathroom and had sex. LPC-Intern A indicated she called DFPS to report the allegation on the phone and then told the nurse who was in the nurses station doing something on the computer because it was the first nurse she saw, and wanted her to examine the patient. She does not know the nurse's name she reported it to. When ask, she did not do a separate therapist note. LPC-A intern was asked if she did an internal facility report and answered "no." She confirmed that she did not document it on anything else. She said she was pretty new then, and had just started in January; and this was her first time to make a report. She was not aware she had to report it to another agency [DSHS]. She just knows to report minors to DFPS and to document. She does not know about an internal reporting to administration.

During an interview with the Director of Risk Management (DRM) on 10/01/18 at 4:45 p.m. and according to her:
She confirmed there was not an internal report to administration completed for Patient #1 regarding this specific allegation; that occurred during admissions. She also confirmed there had not been an investigation conducted on behalf of Patient #1. When asked about her expectation of reporting an allegation of abuse and/or neglect; she responded that she would expect the therapist to make sure the patient is safe, and notify a supervisor to make sure safeguards are implemented. The DRM stated that if she had been notified of the allegation; that she could have reviewed the video, interviewed the other patient, and implemented protections.

During a phone Interview on 10/01/18 at 5:02 p.m. with Registered Nurse (RN) - A, who was the RN on duty 03/24/18 was asked if he remembered anything about Patient #1 or a LPC - therapist reporting to him or another staff that Patient #1 had sex with an adult during admission and he responded, 'no."

During a phone follow-up interview with LPC-A intern on 10/3/18 at 02:20 PM stated she was not familiar with the policy and procedures following an abuse/neglect allegation made by a patient. She only knew to report to DFPS since Patient #1 was a minor. LPC-A indicated she did not notify a supervisor on 3/24/18 of the allegation made by Patient #1; but did ask a supervisor, "how to make a report" by calling it in or online? When asked, the LPC-A confirmed she had not given any specific details of Patient #1's allegation to her supervisor. LPC-A further confirmed that she could not identify the staff she reported Patient #1's allegation to in the nurses station; further stating it was a female staff working on the computer; and could not confirm if it was a nurse, mental health tech, or possibly even another staff from another unit.

Observations conducted of the Admissions Area on 10/01/18 at 4:20 p.m. accompanied by the Chief Nursing Officer (CNO) revealed there is only one admission area for both adults and minors. There is a women's and a men's restroom located in a hall in the admissions area. There are 6 assessment rooms along a hallway. At the end is a waiting room area that has two way mirrors facing an office. The office has live video monitoring that is not monitored/observed ongoing according to the CNO.