HospitalInspections.org

Based on record review and interviews the facility failed to comply with Federal, State, and Local Laws by failing to report an allegation of abuse in accordance with the Health and Safety Code §161.132(b).
(b) An employee of or other person associated with an inpatient mental health facility, a treatment facility, or a hospital that provides comprehensive medical rehabilitation services, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care professional associated with the facility has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or mental health, chemical dependency, or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the agency that licenses the facility or to the appropriate state health care regulatory agency.

Findings included:

Review of the facility's Policy and Procedures titled, Abuse of Patient, Elder, Child by Staff Identification-Response & Reporting, last reviewed June 2020 revealed the following: The Chief Executive Officer, Director of Quality Management, or their designee, reviews federal and state reporting requirements in KNect/Hospital Division/Policies and Procedures.

Further review revealed the facility's Abuse and Neglect policy did not have any further information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect against the facility and/or facility employees was provided within the policy; or a phone number to the DSHS agency (888-973-0022) was provided within the policy.

During an interview on 05/11/21 at 12:35 pm the Facility's DQM stated that they did not report the incident to the state. They send the information to corporate and they determine what is reported. The DQM continued that that is just the way we have always done it.

During an interview on 05/11/21 at 12:40 The Facility's CEO stated that corporate decides what is reported.