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 and interview, the facility failed to ensure patient's rights to be free from all forms of abuse, neglect, or harassment by failing to implement interventions to prevent, protect, and report/respond an allegation of sexual assault; and/or potential neglectful supervision in accordance with their policies and procedures, for 1 of 1 patients reviewed (Patient #1) with an allegation of sexual assault against another patient, [Patient #2].


1.) The facility did not have evidence an allegation of sexual assault was reported to the Department of State Health Services (DSHS) in accordance with their policy and procedures; and State Law. On 8/11/19 Patient #1 who was an [AGE]-year-old adult monitored under Child Protective Services (CPS), reported to facility staff that she was sexually assaulted by another [AGE]-year-old male Patient [#2].

2.) The facility failed to prevent, protect others, and respond with an individualized plan of care in accordance with their policy and procedures to address Patient #2's displays of sexually inappropriate behaviors on 8/08/19 and 8/10/19 prior to; and after an allegation of sexual assault made against Patient #2 on 8/10/19 at 19:00.

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

Findings Included:

1.) Review of the facility's Policy and Procedure titled, "Medical Evaluation of Alleged Rape/Sexual Contact," effective 1/31/17 indicated in part; in the event of an incident of sexual contact that has occurred while the patient is on hospital premises, notification by the Director of Compliance, Quality, Risk or, during evenings, nights and weekends, the House Supervisor or Administrator on Call will occur with the following time frames: "d. Notification of Department of Health Services: within 24 hours of the confirmed event."

Review of the facility's Policy and Procedures titled, "Patient Abuse & Neglect," last revised 1/23/19 indicated in part; in accordance with state and federal law, suspected cases of abuse and or neglect of child/adolescents or adults will be reported to the appropriate protective services agency. Written report to the appropriate protective service agency follows within five days of oral reports by the responsible staff member. The procedures included the requirements and procedures for facility investigations and patient protections. "3. It is the policy of the [facility] to Report abuse and neglect. A person, including an employee, volunteer, or other person associated with the facility who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the facility who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect by any person shall as soon as possible report the information supporting the belief to the department or to the appropriate state health care regulatory agency in accordance with HSC 161.132 (a). Department of State Health Services (DSHS) at (888) 973-0022."

Review of the Child Protective Services Intake Report # 959 dated 8/11/19 and referred to DSHS (the appropriate state health care regulatory agency with the authority over the facility) for investigation under TX 912 (aka State Complaint ID # 1) revealed Patient #1 alleged she was sexually assaulted on 8/10/19 by another male patient (Patient #2) while a patient in the facility. The local police department was notified and Patient #1 was taken to a local Hospital for a sexual assault nurse examiner (SANE) assessment. The CPS report revealed the Forensic Nurse from the local Hospital was the reporting party for this complaint (as mandated); when Patient #1 was brought in for a SANE due to being assaulted by another Patient [#2] at the behavioral health facility.

Review of the Licensed Professional Counselor Intern (LPC- Intern A) Therapy Services Note dated 8/15/19 at 11:37 documented this therapist faxed the Sexual Assault case with the local Police Department (PD) case number to Patient #1's CPS caseworker for her records. In another review of a Therapy Services Note written by LPC- Intern A dated 8/15/19 at 11:03 documented the local PD investigators were interviewing Patient #1 regarding the investigation of a sexual assault that occurred on 8/10/19 with another Patient [#2]. There was not any documentation by LPC- Intern A of a report made to DSHS (the regulatory authority over the facility) regarding the allegations of sexual assault.

During an interview with the Administrative Assistant to the Chief Executive Officer (AA to CEO) on 8/19/19 at 4:45 p.m. she indicated she was not sure if this sexual assault allegation made by Patient #1 had been reported to DSHS because the facility did not have a Director of Quality, Compliance, and Risk. The AA further stated that "someone from Corporate may have reported it" to DSHS; and that she would need to "follow-up with the Corporate office" to the facility for verification.

On 8/20/19 at 12:00 PM, this surveyor reviewed the State Wide Database Program [TULIP] to determine if the facility had reported this sexual assault incident to DSHS [Health and Human Services Commission] - Complaint Intake. Upon review, there was not evidence the facility had made an oral report, email, or facsimile report of the sexual assault allegation made by Patient #1 against Patient #2; and in accordance with their policies and procedures. The only report made was to CPS from the Forensic Nurse form the local Hospital where Patient #1 was sent for a SANE.

On 8/20/19 at 12:20 PM the AA to the CEO and the CEO presented this surveyor with the facility's Handwritten "Complaint Form" and "Narrative" completed by the CEO. The Complaint Narrative form included a Facsimile (Fax) Transmittal Sheet dated 8/11/19 to DSHS: Patient Care Unit, Fax number 512-834-4504 by the CEO; without confirmation of transmission.

In a follow-up interview on 8/20/19 at 12:20 PM with the AA to the CEO and the CEO confirmed the facility was not able to provide evidence of Fax Transmission/Confirmation, or a complaint intake number when asked; regarding the Complaint Form and Narrative dated 8/11/19. The AA and the CEO explained the facility had suffered an electronic systems failure; companywide [nationally] on the early morning hours of 8/11/19 affecting their electronic health records systems, internet, communications, etc.; and further confirmed it was probable the Fax dated 8/11/19 was not accomplished when originally sent.

2.) Review of the Policy and Procedure titled Management of Patients displaying Hypersexual or Sexually Inappropriate Behavior, effective 1/31/17 indicated Prevention: "2. Following admission, if hypersexual or inappropriate sexual behavior is identified or suspected through direct observation or report (including patients with a history of inappropriate sexual behavior involving others) the patient's psychiatrist will be notified for final assessment and determination of orders. An individualized plan of care shall be initiated that addressed the hypersexual/sexually inappropriate behaviors and delineates strategies in order to prevent an inappropriate event. Besides the treatment plan, if the patient has a history of inappropriate sexual behavior involving others, the patient will be placed on a constant observation status at a minimum, or higher (if one to one status is ordered by the patient's physician."

Patient #2: Review of Patient #2's Nursing Admission assessment dated [DATE] at 07:40 indicated Patient #2 "appears manic, labile, with SAO [Sexually Acting Out] behavior." Patient is disoriented, out of touch with reality.

Review of Patient #2's Initial Psychiatric Evaluation dated 8/8/19 at 11:46 indicated Patient #2 was a [AGE]-year-old male with paranoia and delusional behavior and mental health deterioration. When asked about sleeping patterns; Patient #2 stated, "I slept in the hospital and I had sex with [named female] in the hospital and she was a virgin, but hey, I don't know nothing she just got on top of me." Patient was not orientated to place, situation, or person.

Review of Patient #2's Registered Nurse (RN) Mental Status assessment dated [DATE] at 02:10 indicated Patient displayed impulsive behavior AEB [As Evidence by] standing near medication window and staring at female staff. Patient with Delusions and "Sexual preoccupation." Patient voiced delusional beliefs of having a "pink Lamborghini." Asking staff if they would like to ride in it.

Further review of the Mental Status Assessment by the RN indicated the following: "Pt displayed impulsive behavior AEB standing near medication window and staring at female staff. Pt distractible during assessment. Pt displayed disorganized thoughts and disorganized speech. Pt. voiced delusional beliefs of having a pink Lamborghini. Pt asking staff if they would like a ride in it. Pt displayed hypersexual behavior. Pt saying out loud, what color of underwear do you wear. Pt. rambling during assessment. Pt compliant during medication pass. No aggression noted. Constant redirection in place.

Review of Patient #2's Interdisciplinary Treatment Plan of Care (POC) signed on 8/12/19 revealed the Goals/Interventions did not include an initiation or interventions to prevent an inappropriate sexual event after Patient #2 displayed SAO behaviors on 8/8/10 and again on 8/10/19 at 02:10. The Treatment POC also did not include an initiation of Goals/interventions to protect others as a response following the allegations made against Patient #2 by Patient #1 that she was sexually assaulted on 8/10/19 at approximately 18:00. The only Goal addressed for Patient #2 was to address his active paranoia and delusions.

Further review of Patient #2's records revealed no evidence that he was placed on constant observation status at a minimum, or higher to protect others following allegations against him of sexual assault. It was noted that Patient #1 was placed on one to one status in accordance with Physician Orders on 8/10/19 at 21:00 and the patients were separated.

Patient #1: Review of Patient #1's Initial Psychiatric Evaluation dated 8/8/19 indicated Patient was an [AGE]-year-old female admitted for increased depression with suicidal ideas and plan to overdose. Patient reports after discharge from another psychiatric unit recently, she lived in the streets and had multiple rapes [5 times] in the past month and drug use with multiple unknown substances. Patient has a childhood history of physical and sexual abuse and stated having auditory hallucinations telling her negative and derogatory comments.