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 review of facility documents, review of medical records and staff interview, the facility failed to ensure patients had the right to receive care in a safe setting.

Findings included:

Facility policy titled "Patient Rights" stated in part, "Purpose: 1. To support the patient's rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States and the State of Texas ...
Delineation of Patient Rights: 2. These rights shall include, but are not limited to:
...c. the right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs and promotes respect and dignity for each individual."

Facility policy titled "Patient Safety - Safety - Risk Management Program" stated in part, "Reporting: 8. All incidents involving injury, medical errors, risk-prone patient behavior or environmental safety accidents will be documented on an incident report by the staff concern."

Facility policy titled "Identifying and Reporting Abuse, Neglect and Sexual Exploitation" stated in part, "Policy: Abuse, Neglect or Exploitation of Patients Occurring in the Hospital: ...7. Physical evidence of abuse, neglect or sexual exploitation. Any of the following physical findings shall require gathering of additional information and explanation from parents, guardians, other patients or hospital staff members:
(a) Bruises and lacerations ...
(c) Head, mouth and face injuries including hematomas ...
9. Disclosures by patients. Each member of a patient's treatment team shall remain alert to disclosure by the patient during assessments, therapies and other activities of possible abuse, neglect or sexual exploitation.
Policy: Action on suspected abuse, neglect or sexual exploitation occurring in the hospital: 1. Internal reporting requirement. Any patient disclosure ... shall immediately be reported to the Director of Nursing or Nursing Supervisor, the patient's attending physician and the Chief Executive Officer. If the patient involved is a minor, the patient's parent or legal guardian shall be notified ...
7. Incident report. An incident report shall be completed.
...10. Initiation of investigation. An investigation of the incident or incidents shall be initiated immediately ..."

Review of the medical record for patient #2 revealed a nursing note dated 3/1/18 at 3:00 pm that stated in part, "Pt [patient] reported a small red spot on his neck about the size of a dime. Unclear how he acquired the mark."

Nursing note dated 3/1/18 at 5:00 pm stated in part, "Pt's dime size red mark remains. No pain reported at this time by pt."

No further information regarding this incident was documented. No incident report was completed. No notification was provided to supervisors, physicians, or guardians. No investigation was completed regarding the bruise.

In an interview with the risk management director on the afternoon of 10/1/18, when asked the proper procedure if a patient reports a new bruise to a staff member, she stated, "I would talk with my supervisor, especially he's been here for a month and he's saying there's this bruise. You should tell your supervisor, report to the physician and go from there. I would absolutely involve the supervisor, the physician, and guardian to go forward ... Inquire further and talk with the supervisor and absolutely the physician and the guardian." When discussed no incident report or follow-up, she confirmed this during the interview.