South Texas Health System

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45847 . Based on record review and interview, Facility A failed to have medical staff that adhered to and followed the policies and procedures of the hospital for 1 of 20 patients (Patient #11) whose records were reviewed. Record reviews revealed that: 1. Facility A failed to have a memorandum of transfer (MOT), according to its policy, available for review for Patient #11 that contained a signed physician certification, with a summary of the risks and benefits reasonably expected from the provision of the appropriate medical treatment at another hospital, or that the benefits outweigh the increased risks to the patients. 2. Facility A failed to follow its policy when upon discovering the missing records they did not implement corrective actions for the involved staff. . Record Reviews: Patient #11, a 27-year-old female, arrived at the ED at Facility A as a walk-in on 01/01/2025 at 11:48 AM with chief complaints of suicidal ideation (SI). Patient #11 was transferred to a psychiatric facility on 01/01/2025 at 11:59 PM. . Patient #11’s medical records contained a memorandum of transfer (MOT) or any documentation in the medical records of a physician certification with a summary of the risks and benefits of the transfers documented by the physician. Patient #11’s medical records contained documentation noting what, if any, medical records were sent to the receiving facilities. . Policy Reviews: Facility A’s “EMTALA - Medical Screening, Stabilization and Transfer” policy, last reviewed and implemented on 07/01/2024, stated on page 2 and 3 of 25: “IV. DEFINITIONS: A. Appropriate transfer Occurs when: (i) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment; (iii) the transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the Emergency Medical Condition for which the individual has presented, available at the time of transfer, including records related to the individuals Emergency Medical Condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary Stabilizing Treatment, and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer; and (iv) the transfer is affected through qualified personnel, transportation, and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.” . Facility A’s medical staff did not follow this portion of its policy related to Patient #11. . And on page 5 and 6 of 25: “S. Physician Certification Refers to written certification by the treating physician ordering the transfer prior to the patient ‘s transfer that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to the unborn child from effecting the transfer. The certification shall include a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer. If a physician is not physically present at the time of transfer, a QMP can sign the certification as long as the QMP is in consultation with the physician and the physician is in agreement with the certification and subsequently, countersigns the certification. The date and time of such certification should closely match the date and time of the transfer.” . Facility A’s medical staff did not follow this portion of its policy related to Patient #11. . And on page 12 and 13 of 25: “4. Requirements for All Transfers of Individuals Who Are Not Medically Stabilized. After Hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, Hospital may arrange an Appropriate Transfer for the individual to another more appropriate or specialized facility. For any transfer of an individual with an EMC that has not been Stabilized, all of the following circumstances must be met: a. Minimize the Risk. Before any transfer may occur, Hospital, as the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. b. Individual’s Request or Physician’s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf indicating the reasons for the request and stating he/she is aware of the risks and benefits of the transfer, or by a physician order with the appropriate physician certification as required under EMTALA. c. Request to Transfer. Hospital as the transferring hospital must call the receiving hospital to verify the receiving hospital has available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment. d. Document the Request. Hospital as the transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer. e. Send Medical Records. Hospital as the transferring hospital must send to the receiving hospital copies of all medical records related to the EMC which are available at the time of transfer. Medical and other records related to individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, microfiche, optical disks, computer disks, or computer memory for a period of 5 years from the date of transfer or such other period as required by law (Please consult the Hospital’s record retention policy). Documentation sent to the receiving hospital must include: i. Copies of the available history, all records related to the individual’s EMC, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent of the individual or the certification of a physician or QMP; ii. The name and address of any on-call practitioner who refused or failed to appear within a reasonable time to provide necessary Stabilizing Treatment; iii. Copies of available records must accompany the individual; and iv. Copies of other records not available at the time of transfer must be sent as soon as practical after the transfer. f. Physician Certification of Risks and Benefits. A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification should meet the following requirements: i. The certification should be specific to the condition of the patient upon transfer. ii. The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility as well as a summary of the material risks associated with the transfer, including the time away from an acute care setting necessary to affect the transfer. iii. The certification must state the reason(s) for transfer. This rationale may be documented on the certification form or elsewhere in the medical record. iv. The date and time of the physician certification should closely match the date and time of the transfer.” . Facility A’s medical staff did not follow this portion of its policy related to Patient #11. . And on page 20 of 25: “VI. Reporting: Hospital personnel must report any incidents believed to be non-compliant with this policy, whether by Medical Staff Members, or by hospital personnel, to the Risk Manager and must complete a Midas RDE. Hospital personnel should also report to the Risk Manager any incidents involving another hospital that transfers a person with an un-stabilized emergency medical condition to the Hospital or is otherwise in violation of EMTALA. Hospital will not take any adverse action or otherwise penalize a person who reports a potential EMTALA violation. The Risk Manager shall advise the Compliance Officer of the report. Investigation of any suspected EMT ALA violations will be coordinated by the Risk Manager, the Department Director and the Compliance Officer. The Risk Manager shall advise the Compliance Officer of the findings of such investigation. When applicable, the Risk Manager will notify corporate legal counsel of EMTALA violations. Employees found to be non-compliant with the EMTALA policy will be subject to corrective action up to and including termination of employment.” . Facility A’s medical staff did not follow this portion of its policy related to Patient #11. . Interviews: Facility A’s Staff #2, the Director of Accreditation & Regulation, was interviewed throughout the investigation beginning on 06/30/2025 at 1:15 PM. Staff #2 was asked if Facility A had any Corrective Actions Currently in place related to EMTALA or this investigation. Staff #2 said no they did not. . Staff #8, the Risk Management was interviewed throughout the investigation beginning on 06/30/2025 at 1:15 PM. Staff #8 was asked if Facility A had followed its transfer policy. Staff #8 indicated that they had. .”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45847 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 1 of 20 patients (Patient #11) whose records were reviewed. Facility A failed to provide an appropriate transfer when: 1. Patient #11 was transferred with incomplete transfer records. The transfer record was missing a summary of risks and benefits, and signed physician’s certification was not found during the medical record reviews. 2. Facility A failed to document in the medical record for Patient #11 what was sent to the receiving facility. . Cross reference to Tag A2409 .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 . Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 1 of 20 patients (Patient #11) whose records were reviewed. Facility A failed to provide an appropriate transfer when: 1. Patient #11 was transferred with incomplete transfer records. The transfer record was missing a summary of risks and benefits, and signed physician’s certification was not found during the medical record reviews. 2. Facility A failed to document in the medical record for Patient #11 what was sent to the receiving facility. . Record Reviews: Patient #11 Medical Record at Facility A: Patient #11, a 27-year-old female, arrived at the ED at Facility A as a walk-in on 01/01/2025 at 11:48 AM with chief complaints of suicidal ideation (SI). . The triage was initiated by the ED RN (Staff #21) at 11:49 AM. . The medical screening exam by the ED Physician (Staff #20) began at 11:52 AM. Notes documented by Staff #20 included: “History of Present Illness The patient (Patient #1) presents with multiples cut on her forearms bilaterally. Patient stated that she just tried to punish herself, not want to kill herself.” “Review of Systems Psychiatric symptoms: Anxiety, depression.” “Active Problems Depressive disorder Suicidal thoughts Viral syndrome Visual hallucinations” . A suicide screening suicide risk completed by Staff #22 at 12:05 PM noted that Patient #11 was a high risk for suicide. . A laceration repair with Dermabond (a sterile, liquid skin adhesive) and steri-strips (thin adhesive bandages) was documented by Staff #21 at 1:00 PM. . The medical record included a “Notification of Emergency Detention” indicated a “Date of Apprehension” as 01/01/2025 and a time of 8:30 PM. The document noted that Patient #1 was “in crisis” and that Patient #1 “is a risk due to self-harming, having suicidal thoughts, being impulsive, which leads to self-harming. This document was signed by Patient #11 at 12:00 AM. . Patient #11 was transferred to a psychiatric facility on 01/01/2025 at 11:59 PM. . The medical record review revealed that Patient #11 did not have the appropriate transfer documents provided to the receiving facility. The “medical benefits reasonably expected” were not documented, physician certification was not signed, summary of the risks and benefits were not included, an accepted transfer was not documented, and there was no documentation of sending the receiving facility all medical records (or copies thereof) related to the emergency condition that could be found during or provided following the medical record was reviewed. . Policy Reviews: Facility A’s “EMTALA - Medical Screening, Stabilization and Transfer” policy, last reviewed and implemented on 07/01/2024, stated on page 2 and 3 of 25: “IV. DEFINITIONS: A. Appropriate transfer Occurs when: (i) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment; (iii) the transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the Emergency Medical Condition for which the individual has presented, available at the time of transfer, including records related to the individuals Emergency Medical Condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary Stabilizing Treatment, and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer; and (iv) the transfer is affected through qualified personnel, transportation, and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.” . And on page 5 and 6 of 25: “S. Physician Certification Refers to written certification by the treating physician ordering the transfer prior to the patient ‘s transfer that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to the unborn child from effecting the transfer. The certification shall include a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer. If a physician is not physically present at the time of transfer, a QMP can sign the certification as long as the QMP is in consultation with the physician and the physician is in agreement with the certification and subsequently, countersigns the certification. The date and time of such certification should closely match the date and time of the transfer.” . And on page 12 and 13 of 25: “4. Requirements for All Transfers of Individuals Who Are Not Medically Stabilized. After Hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, Hospital may arrange an Appropriate Transfer for the individual to another more appropriate or specialized facility. For any transfer of an individual with an EMC that has not been Stabilized, all of the following circumstances must be met: a. Minimize the Risk. Before any transfer may occur, Hospital, as the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. b. Individual’s Request or Physician’s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf indicating the reasons for the request and stating he/she is aware of the risks and benefits of the transfer, or by a physician order with the appropriate physician certification as required under EMTALA. c. Request to Transfer. Hospital as the transferring hospital must call the receiving hospital to verify the receiving hospital has available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment. d. Document the Request. Hospital as the transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer. e. Send Medical Records. Hospital as the transferring hospital must send to the receiving hospital copies of all medical records related to the EMC which are available at the time of transfer. Medical and other records related to individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, microfiche, optical disks, computer disks, or computer memory for a period of 5 years from the date of transfer or such other period as required by law (Please consult the Hospital’s record retention policy). Documentation sent to the receiving hospital must include: i. Copies of the available history, all records related to the individual’s EMC, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent of the individual or the certification of a physician or QMP; ii. The name and address of any on-call practitioner who refused or failed to appear within a reasonable time to provide necessary Stabilizing Treatment; iii. Copies of available records must accompany the individual; and iv. Copies of other records not available at the time of transfer must be sent as soon as practical after the transfer. f. Physician Certification of Risks and Benefits. A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification should meet the following requirements: i. The certification should be specific to the condition of the patient upon transfer. ii. The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility as well as a summary of the material risks associated with the transfer, including the time away from an acute care setting necessary to affect the transfer. iii. The certification must state the reason(s) for transfer. This rationale may be documented on the certification form or elsewhere in the medical record. iv. The date and time of the physician certification should closely match the date and time of the transfer.” . Interviews: Facility A’s Staff #2, the Director of Accreditation & Regulation, was interviewed throughout the investigation beginning on 06/30/2025 at 1:15 PM. Staff #2 was asked if Facility A had any Corrective Actions Currently in place related to EMTALA or this investigation. Staff #2 said no they did not. Staff #2 was asked on 07/03/2025 at 10:32 AM if he could provide any notes regarding the records that accompanied Patient #11 or were faxed to the receiving facility. Staff #2 replied, “We do not have those particular notes.” .”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 21863 Based on record review and interviews, the facility failed to ensure patients’ rights to request or refuse treatment for 1 of 1 patient reviewed (Patient #1) with a patient rights complaint. Specifically, Patient #1 was admitted voluntarily and informed multiple employees of the psychiatric hospital his desire to leave and the employees failed to assist Patient #1 in creating the written request and process the request for discharge from services; in accordance with the facility’s policy and procedures and State Law. Findings included: Review of Complaint Intake Information for TX00533586 dated 2/18/2025, alleged the facility failed to timely discharge Patient #1, a voluntary patient, upon his request pursuant to state law. Further review indicated that Patient #1 was admitted to the facility’s behavioral health voluntarily on 4/1/2024 and signed an Application for Voluntary Admission at approximately 1:58 PM. Patient #1 was at all times a voluntary patient. Patient #1 requested discharge from the facility on 4/2/24 at approximately 1:10 PM and again on 4/3/24 at 08:15 AM in accordance with Patient #1’s records. However, Patient #1 was not discharged until 4/6/24, four days after his initial request. Patient #1 requested discharge from the Behavioral Health facility on at least two occasions, however the hospital failed to follow proper discharge procedure pursuant to the Mental Health Code. Upon Patient #1’s initial request on 4/2/24, the facility’s staff should have assisted Patient #1 in putting this request in writing for him to sign and then notified the physician of this request. However, there is no evidence in Patient #1’s records that staff assisted him in putting the request in writing. There also is no evidence that a physician evaluated Patient #1 to determine whether he met criteria for court-ordered mental health services. If the treating physician determined Patient #1 met criteria for commitment, the facility had an affirmative duty to submit the appropriate application and obtain the necessary order from the court in order to keep Patient #1 hospitalized. The hospital did not do so. Without a court order, the facility should have; at the latest, discharged Patient #1 on 4/3/24 at 1:10 PM. Because the facility failed to discharge Patient #1 upon request and did not obtain a court order to continue his hospitalization, the facility violated Patient #1’s rights as a voluntary patient. Interview with Patient #1 on 5/8/25 at 7:00 PM stated the following, in part; He was transferred from their facility - A to their behavioral health facility - B, “to get help” that they told him he would be able to see a therapist. He had never been to a psychiatric facility or had previously been treated for a psychiatric diagnosis. He said during the admission assessment they told him he could be there a “little bit,” or he could be there “longer.” He said he told them at that time that he was “okay, nothing is going on anymore.” He said he had already snapped himself out of the situation, was not suicidal, and had worked through it. He reported to the admission staff that he wanted to go home and that his wife was on her way; that he needed to work and provide for his family. Patient #1 said he went there voluntarily and then they took him to the back and would not let him out until he talked to the Doctor. He said he kept telling any staff that would talk to him to please let him out, “please, I am begging you. Let me out of here.” He said that any staff he talked to just kept telling him that he needed to talk to the Doctor and then they put him in a room where staff would come in every 30 minutes to an hour to check in on him and then would tell him the Doctor was not available and had not shown up yet. He said they then told him it would be the “next day” and that he could talk to the Doctor then. He then spoke to the Doctor and told him he had a family that he needed to support, he was not suicidal and he knew his reason to live was for his family; that being locked in the facility was “stressing me out, loosing even more money” not being able to work. He said he did everything asked of him and was compliant because he wanted out. He said that on the 4th day of being locked in and not allowed to leave, that another patient told him about the “4-hour letter.” He said that no one had every told him about it prior to the other patient telling him. He said that he felt the Doctor (Staff -A) “tried to trigger” him when there was a meeting “with all of these Doctor’s, I was doing well and then the Doctor [Staff-A] attempted to trigger” him and said, “You look sad.” He said he had been doing everything that he had been asked to do so that he could get out, “I was there voluntary and kept asking can I get out.” He said the staff kept trying to give him “medication,” but he didn’t need any because he was cooperative and felt fine. He said that the Therapist (Staff- B) that he saw told him “it’s up to you when you get out, we can keep you up to 30 days; unless he [Doctor] gave the ok, you can’t get out.” He said I was “happy, upbeat” and even helping other patients that were in there until he started to keep to himself, because he did not want to do anything wrong that would give them a reason not to let him out. He said that he was not given any information or a pamphlet regarding his rights; that he was only given a paper “about the rules while you’re there.” He was asked to “sign here, you’re voluntary.” He said he would tell the staff; “with the white coats that ask you how you’re feeling and any thoughts of suicide today” that he was okay, no thoughts, and to please let him go. He said the whole experience has affected him, his family, and kids; because he has always been there for them and they fear him leaving, not knowing if he will be coming back. Review of Patient #1’s records revealed the following: Psychiatric evaluation completed 4/2/24 at 10:20 AM by Doctor/Psychiatrist -A indicated “Patient is admitted after he attempted suicide. Patient attempted suicide by wrapping an electric cable around his neck. Patient said that when the police came to his car he already had taken away the cable. Patient said he did that because he has been very upset about losing $10,000 in his stock. He says that he been trying to recuperate and keep gambling and he spent the money from many family members. He says he does that on the side and he has his own private business. Patient said that he regrets what he did and that he is not suicidal. He believes he should be going home because his family needs him. Patient said that he is not depressed despite of having this financial stressors and not sleeping. Patient denies any past psychiatric history. Patient does not have any medical problems. Patient denies hallucination. He does not use drugs or alcohol he does not smoke. He said that he lives with his wife and his 3 children. He says that there are no marital problems. Patient says he is not suicidal.” Justification for Hospitalization: “No Justification for Hospitalization documented.” “I certify that the inpatient psychiatric facility admission was medically necessary for treatment which could reasonably be expected to improve the patient’s condition. Based upon the available information, I expect that this patient will require medically necessary care beyond two (2) midnights.” Medications: Scheduled: 0, Continuous: 0, PRN: Olanzapine 5mg Dis Tab (Zyprexa) 5 mg 1 tab oral, q 6 H INITIAL DISCHARGE PLAN: Discharge home when psychiatrically stable. There was not any documentation or discussion by the Psychiatrist/Doctor-A that Patient #1 had requested to be discharged. BH Discharge Planning Note dated 4/2/24 at 1:10 PM by staff -D, Therapist/Social Services documented, “met with patient to complete 24-hour introduction. Patient was agreeable and cooperative during interaction; however asking for discharge.” Bio-Social Assessment completed 4/3/24 at 08:15 AM by Therapist-B indicated Patient #1 denies being suicidal or homicidal ideations, denies auditory/visual hallucinations. Patient states he felt a little depressed, missing his family. Patient stated he “made a big mistake and ask if he can leave but was denied by doctor.” Treatment team will reevaluate patient’s progress tomorrow. Patient does not have history of inpatient or outpatient psychiatric treatment. Employment Barriers: Pt. stated inpatient is a barrier as he cannot leave. There was not any further documentation that Therapist -B or any other facility staff assisted Patient #1 with his request to discharge, or a subsequent physician assessment after the initial psychiatric evaluation by Doctor/Physician-A. 4/3/24 at 1:43PM, Treatment Plan, Discharge Criteria: No suicidal or homicidal ideation, Improvement in mood, thinking, and/or behavior, Verbal commitment for aftercare, appointment arranged with psychiatrist and/or therapists, Reduction of target symptoms. Review of the “Progress Note-Physician” completed by Nurse Practitioner- C on 4/3/24 at 2:50 PM, on 4/4/24 at 12:30 PM, and 4/5/24 at 12:45 PM all documented the same information, in part: “Met with the patient this morning. Patient is calm and cooperative. The patient is reporting no symptoms of depression and anxiety. The patient is reporting no symptoms of auditory hallucinations and visual no hallucinations. Denies suicidal ideation. Denies homicidal ideation _ The patient is not prescribed medication at this time. Reports that his sleep is good and appetite is good. Patient reports not having suicidal thoughts and states that he is now understanding that he needs to speak to his wife and let her know what is happening and not keep secrets from her wife is aware of what is going on and they have been talking about it. Assessment: The patient is calm and cooperative. The patient continues to report no suicidal ideation. The patient is denying auditory and visual hallucinations. Thought content is circumstantial. The patient’s ADLs are good.” Discharge Planning: Discharge Home with Family, Saturday Review of Patient #1’s records revealed he was not administered any medications. Patient #1 signed his discharge information on 4/4/24 at 7:48 PM. Interview on 3/26/25 at 4:20 PM with the facility’s Director of Accreditation and Regulatory Services stated the following, in part; The two staff that were verbally told that the patient wanted to leave, did not document any follow up, or escalate the patient’s request to leave. There was not a 4-hour letter completed. The Discharge planners begin the process after admission and if the patient states they want to leave, then it needs to be escalated. Patients are supposed to be provided with a booklet upon admission that includes their rights and information for requesting discharge if voluntary. Interview on 3/26/25 at 4:35 PM with Therapist -B, who was the Licensed Professional Counselor (LPC) Supervisor stated the following, in part; he most likely told the patient he was there for a reason and explained to him why he was there; because he was minimizing the situation. Therapist -B stated, “I don’t discharge, the doctor has the final say and we error on the side of caution.” The doctor was going to probably say no if we asked him or would ask for a four-hour letter. We usually ask the patient’s to give us five to seven days for treatment; usually for mood. Therapist - B stated we usually do not do a discharge on the first day; rule of thumb, to explain the process. Therapist - B vaguely remembered this patient. If he asked to leave, the rationale was that he could no longer be a danger. If he was asking the doctor to discharge, then he would have given us the information and we’d submit it to the doctor after the treatment team reviewed and we would provide the information. The team wants collateral from the family; to find out what happened, and if he’s safe. We try to do due diligence. The patient’s intake was voluntary. The doctor sees them within 24 hours. The Therapist/LPC will see them within 72 hours for the treatment plan and then somewhere along the line he requested to leave. The nurses will tell them about having to complete a four-hour letter and that request; 4-hour letter is from the nurse and they help them to complete it. The patient stated he was denied from the doctor he saw. The doctor saw him a day after admission, the doctor usually will reevaluate the next day. Interview on 3/26/25 at 4:50 PM with the Risk Management Director confirmed there was not a 4-hour letter, a grievance, an internal [midas] report, or an AMA [Against Medical Advice] completed for Patient #1. Review of the facility’s policy/procedure titled, Discharge Against Medical Advice 4 Hour Letter, last revised 4/1/2023 indicated the following in part; Procedure: A, 2. Any patient admitted on a voluntary basis has the right to request discharge. C. Licensed staff will provide the patient with paper and appropriate writing instrument to use in filing the request for discharge and assist with completing the request if the patient is unable to do so independently. E. Staff will notify the attending psychiatrist, or psychiatrist on-call, of the patient’s request for discharge, as soon as possible, so a resolution may be obtained within 4 hours of the request. F. The psychiatrist will determine if the patient meets the criteria for regular discharge, involuntary commitment, or discharge AMA. G. (i) A voluntary patient is entitled to leave an inpatient mental health facility in accordance with this section after a written request for discharge is filed with the facility administrator or the administrator’s designee. The request must be signed, timed, and dated by the patient or a person legally responsible for the patient and must be made a part of the patient’s clinical record. If a patient informs an employee of or person associated with the facility of the patient’s desire to leave the facility, the employee or person shall, as soon as possible, assist the patient in creating the written request and present it to the patient for the patient’s signature. (ii) The facility shall, within four hours after a request for discharge is filed, notify the physician responsible for the patient’s treatment. If that physician is not available during that period, the facility shall notify any available physician of the request. (iii) The notified physician shall discharge the patient before the end of the four-hour period unless the physician has reasonable cause to believe that the patient might meet the criteria for court-ordered mental health services or emergency detention. (iv) A physician who has reasonable cause to believe that a patient might meet the criteria for court-ordered mental health services or emergency detention shall examine the patient as soon as possible within 24 hours after the time the request for discharge is filed. The physician shall discharge the patient on completion of the examination unless the physician determines that the person meets the criteria for court-ordered mental health services or emergency detention. If the physician makes a determination that the patient meets the criteria for court-ordered mental health services or emergency detention, the physician shall, not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs, either discharge the patient or file an application for court-ordered mental health services or emergency detention and obtain a written order for further detention. The physician shall notify the patient if the physician intends to detain the patient under this subsection or intends to file an application for court-ordered mental health services or emergency detention. A decision to detain a patient under this subsection and the reasons for the decision shall be made a part of the patient’s clinical record. Texas Administrative Code, Title 26, Part 1, Chapter 320, Subchapter A, Rule §320.13(a)(2) If an individual informs a person associated with or employed by the department facility, community center, or psychiatric hospital of the individual’s desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time. Without regard to whether the individual agrees to sign paperwork requesting discharge from services, the request will be documented and processed by staff. The refusal or inability of the individual to sign the request for discharge will be documented on the unsigned written request.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 40989 Based on observation, medical record review, document review, and interview the Governing Body failed to: 1. ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed. The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Refer to A0145 2. ensure a written nurse staffing plan with an approved matrix/grid was enforced to ensure an adequate number of Registered Nurses (RN) and Mental Health Techs (MHT) were available to meet the needs of all patients on 2 (BH4 and BH5) of 2 patient care units reviewed. Refer to A0392”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32143 Based on medical chart reviews, interviews, and observations the facility failed to ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed. The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Refer to A0145”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 40989 Based on document review and interview the hospital failed to have an organized nursing service that ensured safe staffing levels for patient care on 2 (BH4 and BH5) of 2 patient care units reviewed. The facility failed to have a safe staffing matrix that clearly delineated the Licensed Vocational Nurse (LVN) and the Mental Health Tech (MHT) from the Registered Nurse (RN). Also, the facility failed to follow the hospital policy titled, “Appropriate Staffing Levels”, Policy Number: BHC.CE 0003c”. Refer to Tag A0392”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 32143 Based on medical chart reviews, interviews, and observations the facility failed to ensure that the policy for Abuse, Neglect, and Sexual Acting Out (SAO) was followed. The facility failed to recognize patients who were ordered to be on SAO precautions. The facility failed by placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child. The facility failed to educate the staff on SAO and how to provide protection and a safe environment to prevent sexual abuse in 4 of 4(#1-#4) patients reviewed. The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings: A review of patient #2’s(alleged victim) medical record revealed he was a 15 y/o male admitted to the facility on 01/22/2025 with a diagnosis of SI and depression. A review of the nursing progress note dated 1/26/25 at 2118 stated, “Pt reported to RN at 1830 that another male pt (pt#1 alleged predator) forced him to “suck it” on January 25. ___ (pt #2) reported that he was alone in the room with ____ (pt #1) after taking a shower, and ____ (pt #1) threatened “You better suck it, or I’m going to beat your ass”.___ (pt #2) reports that ____ (pt #1) has been threatening him with violence as well as “using a gun”. ____ (pt #2) reported all that happened was oral sex to RN. Pt #2 was interviewed in front of witness _____ (staff #18) MHT. When RN questioned pt if they reported the incident to any staff, pt verbally denied informing anyone. RN immediately reported to MD _____, House Supervisor, _____(therapist), and administration. Pt was offered PRNs but refused stating “I’ll take them with my night medications”. Pt receiving therapy with therapist for psychosocial needs. Administration and therapist are contacting parents at this time. Victim was moved to a separate unit with increased surveillance. RN will endorse to night shift.” A review of the nursing progress report dated 1/26/2025 @ 21:43 stated, “Mother came to STB to pick up patient #2 due to allegations. As per attending doctor on call patient to be discharge to mother. Attending psychiatrist spoke to mother regarding allegations and patient’s discharge readiness. Mother stated she is patient’s primary support and was able to identify ways to help patient when signs of crisis emerge. Patient’s mother provided with discharge information and medication list. RN House Supervisor informed mother she will be called Monday Morning with follow up appointments. Mother was facilitated information by PD officer at scene so patient can have a sane exam as per mother’s wishes. Patient denies SI, HI, depression, anxiety or hallucinations.” A review of patient #1’s medical chart revealed he was a 13 y/o male admitted to the facility for suicidal Ideation (SI) with a plan. It was documented that the patient had no history of sexual abuse as a perpetrator or a victim. Pt. #1 was placed on Routine, Homicide/Assault/Aggression, and every 15-minute check (q15). A review of patient #2’s medical chart revealed he was a 15 y/o male admitted to the facility on 01/22/2025 per his mother, the patient is also being accused by her ex (not the father of the patient) of having sexually assaulted 9yr old stepsister and has open CPS case. He had been hallucinating along with paranoia and cybersex/watching pornography. During the intake process, it was recommended by the intake staff to place patient #2 on an SAO precaution. The patient had a physician order for SI and elopement precautions but did not have an order for Sexually Acting Out (SAO). A review of patient #3’s chart revealed he was a 13 y/o male admitted to the facility on 1/19/25 for Intermittent explosive disorder, Suicidal ideation, and Aggression. It was documented that the patient had no history of sexual abuse as a perpetrator or a victim. Pt. #3 was placed on Routine, Homicide/Assault/Aggression. A review of patient # 4’s chart revealed he was 16 y/o male. He was admitted on 1/17/25 for SI with a plan. Patient #4 has a history of sexual abuse by a cousin. He is an involuntary patient. He was placed on SI, Routine, At Risk for Victimization, and elopement precautions. On the morning of 1/29/25, the survey team toured the facility with Staff # 5, Director of Nurses (DON). The DON took the team to Units 4 and 5, which are the patient rooms for adolescents and teens. Staff # 5 was asked about the process for showers and hygiene. Staff #5 stated that the patients share a room and one bath. The patients are in beds A and B. Between the hours of 9-10 pm, the patients assigned to bed A come to the room and take care of all their shower and hygiene needs while group B waits in the day room. At 9:30 pm, group B comes to the room for shower and hygiene time. Lights out at 10:00 pm. Staff #5 confirmed that the patients are never in the rooms together during shower and hygiene time. An interview was conducted with staff # 12 MHT and Staff # 11 RN on 1/29/25 in the afternoon. Staff #12 stated that he has worked at the facility for 2 1/2 years. Staff #12 stated a little before 9 pm one MHT watches the patients in the day room while the other MHT puts hygiene products and towels on the beds. All patients are brought back to their rooms to complete shower time and lights are out by 10:00 pm. Staff #12 confirmed that this had been the routine for the last 2 ½ years that he had worked at the facility. Staff #12 was asked if he was aware if any of the patients were on SAO precautions and how would they be monitored. Staff #12 stated he was not aware of any patient on SAO precautions and stated if they were on precautions they would be watched more carefully. Staff #11 RN confirmed that the hygiene time was conducted with all patients together at the same time. Staff #11 stated that on 1/20/25 patient #1 had come to her and asked to be moved to another room. Patient #1 stated that patient # 3 was weird and he felt very uncomfortable. Staff #11 asked patient #1 what “weird” meant but he did not feel comfortable speaking with her. Staff #12 stated that on 1/20/25 patient #1 stated that he had asked the nurse to move him because patient #3 was making sexual suggestions to him. He stated that patient #3 told patient #1 that “if he was hard right now, he would suck him off.” Patient #1 had made the outcry. Staff #11 stated that she called the house supervisor staff # 13. The house supervisor notified the physician moved patient #3 in with another boy and left patient #1 alone in his room. Staff #11 was asked why patient #3 was not left alone and patient #1 was moved in with another child since he made the outcry. Staff #11 stated she was not sure. Staff #11 was unable to verbally refer to the SAO policy and how the patients should be separated and monitored. An interview was conducted with staff # 13 RN House Supervisor. Staff #13 stated that on 1/20/25 patients #1 and #3 were separated and placed in separate rooms. Staff #13 was unable to tell me what room and with what child patient #3 was placed with. Staff #13 stated that patient #1 was agitated earlier because his mother would not answer the phone. She stated that patient #1 liked a female patient on the unit and acted out in front of her regularly. Staff #13 stated patient #1 would curse at the staff and was very manipulative. Staff #13 stated that patients #2 and #4 identified as homosexual and had requested to room together. Staff #13 stated that she was trying to make sure that patients #2 and #4 were not placed together. Staff #13 stated that she called the physician and moved them for the night to be addressed in the morning. Staff #13 was asked about patients on SAO or if she was aware any of the patients were past victims of sexual assault and she stated, “No.” Staff #13 stated that bed boards decide if the patients need to go on an SAO, but she was “unsure” if anyone gets recognized as a predator or a victim. A review of patient #1’s chart and #3’s chart revealed there was no documentation of the alleged incident when the physician was called, when and where patients were moved to other rooms, or what administrative personnel was notified of the incident. During an interview with staff #1 and #2 on 1/29/25 revealed the following roommates and dates for patients #1-4. 1/18/25-1/19/25 Patient #1(alleged predator/victim) roomed with patient #3(alleged predator/victim). 1/20/25 Patient #1 was left in his room alone and patient #3 was placed in another room with another child after alleged sexually inappropriate behavior. 1/21/25-1/22/25 Patient #1 and patient #4 were roommates. 1/23/25 Patients #2 and #3 were roommates but Patient #2 wanted to be in the room with #4 because they “liked each other” according to staff #12 and #13. Patient #2 insisted he be moved out of patient #3’s room. Patient #2 stated it was because he didn’t like patient #3. 1/23/25 Patient #2 and patient #1 were placed in the room together even though patient #2 was on an SAO precaution and had an open case for alleged sexual assault. Patient #3(alleged predator and victim) stated he was forced to give patient #1 oral sex in the shower on 1/19/25. Patient #4 stated he was forced to give oral sex in the shower with patient #1 on 1/23/25 however, they were not roommates on this date. Patient #2 stated he was forced to give oral sex and was penetrated rectally on 1/25/25 in the shower. Patient #2 was taken to the hospital for a sexual assault examination on 1/26/25. The test came back negative. An interview was conducted with Staff #1, #2, #3, and #5 on 1/29/25 in the afternoon. Staff #1 confirmed the facility did not have a policy for showering or hygiene time. Staff #2 stated that he looked at videos and monitored different shifts but was not aware the adolescent patients were not following the rules for shower time. Staff #1 stated that on the evening of 1/26/25, they were made aware of patients #2, #3, and #4’s allegations of sexual assault. Staff #1 stated the police arrived with the parents and demanded their children be discharged. Staff #1 stated the psychiatrist spoke with the parents and patients. There was no documentation in the patient charts of any assessment by the psychiatrist before discharge. Patient #1 was not discharged until 1/29/25. An interview was conducted with staff # 15 police investigator on 1/29/25 in the afternoon. Staff # 15 stated that he had interviewed staff and patients #1-4’s allegations of sexual assault. Staff #15 had two case numbers for patients #2 and #3 but was not opening any other cases. Staff #15 stated he would have his investigation completed in a couple of weeks but at this time had no further information to share. Staff #15 did confirm that the SANE exam was negative for patient #2. According to the facility policy “Title: PC.3100 Victims of Abuse “the facility failed to report the abuse to the state immediately. The policy stated, “Immediately report abuse, illegal conduct, neglect, unethical conduct, and unprofessional conduct as required by 25 TAC §133.47 & 134.46, Abuse and Neglect Issues: What to report: 1) Abuse/Neglect/Exploitation of a child 2) Abuse, neglect or exploitation of an elderly or disabled person 3) Abuse and neglect of individuals with mental illness 4) Illegal, unethical, and unprofessional conduct Immediate reporting of a specific related to abuse and neglect is required by 25 TAC §133.47 & 134.46, Abuse and Neglect Issues. The definitions of abuse, illegal conduct, neglect, unethical conduct, and unprofessional conduct are defined under §133.47 & 134.46.” Staff #1 confirmed the facility had failed to immediately inform the state. A review of the policy and procedure Title: BHC.2750 Sexually Acting Out and Victimization stated, “12. Response to alleged sexual familiarity occurrences: Facility staff and physicians should take all reports of sexual familiarity between patients seriously and respond accordingly. Sexually Acting Out Protocol will be completed by the Supervisor/Designee. Designated staff will follow the protocol instructions in the event of sexual acting out between patients and/or allegations against staff to include the following: a. All patients who allege sexual assault will be placed on 1: 1 observations or as ordered by a physician. 1 :1 observations will be discontinued upon the written order of a physician only. b. Attending physician will be contacted for any patient involved in sexual, misconduct (i.e., inappropriate touching, gestures, or comments) to determine level of observation orders c. Separate the parties involved. Reassign patients to separate care areas. Explain intervention. Add red dot to observation record to identify high risk monitoring of SAOA patients boarding from other care areas. Use high risk notification form to provide SBAR to transferring staff. d. Notify Administration/Designee. e. Administration/designee will notify state agencies (as applicable). f. Notify each patient’s attending physician immediately. g. Chain of command: reporting unsafe conditions, staff behaviors. h. In the case of a minor or patient declared legally incompetent, the patient’s parent or legal guardian should be notified of the incident by the appropriate personnel. 1. Staff will interview involved parties separately to determine exact nature of the alleged occurrence and complete a nursing assessment/reassessment. J. The physician along with Administration/Designee will determine whether evaluation in an emergency room is needed (i.e., allegation of rape). If deemed appropriate, nursing staff will transfer the patient to the emergency room for evaluation as soon as possible upon written order of a physician. If for any reason a delay in treatment occurs, the Administrator on Call will be contacted for further recommendations with subsequent documentation placed within the medical record. In order to preserve evidence, patient should not be allowed to change clothes or shower prior to transfer. k. Examination requirements: a. the physician, in collaboration with the nursing staff, will determine the potential risk of sexually transmitted diseases (SID). b. the physician and/or designee will complete a mental status examination and incident review and determine whether a rape kit, and/or testing should be done for HIV, Hepatitis B, Hepatitis C, and/or any SID and order as appropriate. Pregnancy testing may also be considered. Plan B reviewed/offered as appropriate. The physician should discuss these issues and concerns (potential risks and testing) with the patient or guardian and off er and discuss medical options as appropriate. 1. Designated staff should notify appropriate state or local authorities as required by State statutes. If uncertain, consult with the corporate Legal Department. Discuss with alleged victim, parent/guardian regarding patient rights to initiate criminal proceedings/press charges. 13. Documentation and evidence retention: Staff will complete documentation of any incidents of sexual familiarity in the patient’s medical record; the documentation will include the following: a. Document clearly that this is an allegation, unless witnessed by staff, using words like allegation, alleged or possible. b. Do NOT use names of the other patient(s) allegedly involved; use peer (For example, use male peer or female peer). c. Give basic, concise, objective information about the incident. Document only what was observed or reported by the patient and document it as such. d. Document your interventions separately according to events that transpired with each patient (ie. talked with patient, supported, processed, etc.). Follow up at a later time with the patient who has made allegations and document the interaction. e. Document behavior immediately following disclosure and soon after (ie. Is the patient upset, tearful, withdrawn or talking, laughing with peers, jovial, etc.?). f. Evidence retention: written statements, surveillance/security tape, copies of external reports. Secure crime scene if applicable. Room or area where event took place should be taken out of service and not cleaned until cleared by law enforcement. 14. When an occurrence of sexual familiarity is discovered, steps should be taken to prevent recurrence. A preventative approach should be instituted as part of the patient’s treatment plan. 15. Staff Development- Clinical orientation and annual updates include: a. Review of SAOV and SAOA Policy, b. monitoring and patient observation, c. review of patient boundary violations, early identification of SAOV and/or SAOA behaviors(s) and intervention, and d. effective communication among caregivers.” Staff #1 confirmed on 1/29/25 in the afternoon that she did not know what was in the SAO policy and wasn’t familiar with it. Staff #1 confirmed that patients were not being monitored or identified properly while on SOA or Victim precautions. Staff #1 confirmed that patient #1 was not placed on an SAO or placed on a 1:1 observation on 1/20/25 when he made an outcry of sexual assault. Patient #3 did have an order for SAO and was placed in a room with another patient without consideration of the SAO and a current sexual assault claim. Staff #1 confirmed that there was no documentation on patient #1 or patient #3 on 1/20/25 concerning sexual allegations, the patients moved to other rooms, or that the administration or parents were notified. There was no reassessment of the patients to ensure there was no sexual misconduct on that shift. Staff #1 confirmed that the patients were not being separated or monitored in their rooms during shower time which allowed the patients to have an opportunity for sexual misconduct and potentially for sexual abuse. A review of the employee files #16 RN, #12, #13 RN HS, and #14 RN HS revealed they had not received 8 hours of Abuse, Neglect, and Exploitation (ANE) training.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40989 Based on document review and interview the hospital failed to have an organized nursing service that ensured safe staffing levels for patient care on 2 (BH4 and BH5) of 2 patient care units reviewed. The facility failed to have a safe staffing matrix/grid that clearly delineated the Licensed Vocational Nurse (LVN) and the Mental Health Tech (MHT) from the Registered Nurse (RN). Also, the facility failed to follow the hospital policy titled, “Appropriate Staffing Levels, Policy Number: BHC.CE 0003c”. Findings: An observation tour of the Behavioral Health Unit was conducted on 1/29/2025 after 9:00 AM with Director of Nurses (DON) Staff #5 on 1/29/2025. The Behavioral Health Unit had 6 separate units. 4 units were for adult patients and 2 units were for pediatric patients, ages 7-17. BH4 was the primary pediatric unit and BH5 was an additional unit for pediatric patients and was only used as a swing unit when patient census and patient care required additional rooms. BH4 and BH5 shared one nursing station and the two units were separated by a locked door. A review of the staffing sheets dated 1/15/2025-1/28/2025 was completed with Director of Nurses (DON) Staff #5 on 1/29/2025 after 2:00 PM. The staffing sheets indicated the staff name and their discipline assigned to each unit for AM shift and PM shift. The staff scheduled for the AM shift worked from 7:00 AM-7:00 PM. The staff scheduled for the PM shift worked from 7:00 PM-7:00 AM. A review of the staffing matrix/grid for BH4 and BH5 (Pediatric) units revealed the unit was staffed according to a 3-shift schedule. The 3 shifts included a day shift, an evening shift, and a night shift. The BH4 Unit matrix/grid revealed the Licensed Practical Nurse (LPN) and the Mental Health Tech (MHT) were counted as one. There was no way to determine the staffing needs of each discipline to ensure patient and staff safety. The BH5 Unit matrix/grid revealed the Registered Nurse (RN), LPN, and MHT were counted as one and there was no way to determine the staffing needs of each discipline to ensure patient and staff safety. Further review revealed the staffing matrix/grid did not match the actual working shifts for the BH4 or BH5 Units. This surveyor could not determine if the BH4 or BH5 Pediatric units were staffed appropriately to ensure patient and staff safety. An interview was conducted with DON Staff #5 on 1/29/2025 at 5:35 PM. DON Staff #5 was asked how he staffed the units according to the staffing matrix/grid. DON Staff #5 stated, “I don’t use that grid. That grid is for 3 separate shifts. I use this grid that was shared from one of our other UHS facilities to staff the units”. DON Staff #5 was asked if the staffing matrix/grid that was being used was sent through the staffing committee for approval. DON Staff #5 confirmed the staffing matrix/grid had not been approved by the Chief Nursing Officer (CNO) or the Staffing Committee for use at the facility. DON Staff #5 was asked who relieved the RNs for a lunch break if there was only one RN scheduled. DON Staff #5 stated, “The RNs get the nurse that’s working the other unit to relieve them”. DON Staff #5 confirmed that 3 separately locked units for adult patients share one nursing station and two separately locked pediatric patient units share a nursing station. DON Staff #5 was asked to review the staffing schedule for 1/15/2025 on BH4. The staffing schedule revealed that a Licensed Vocational Nurse (LVN) was scheduled on BH4 with the word (split) beside the employee’s name. DON Staff #5 was asked to clarify what the word “split” meant. DON Staff #5 stated, “That means the employee administered all medications to patients on both BH4 and BH5 pediatric units”. DON Staff #5 was asked if the LVN was scheduled to work on B. DON Staff #5 stated yes. DON Staff #5 was asked who covered for the LVN while they passed medications on the other unit. DON Staff #5 stated, “The RN was still on the unit and there was a Mental Health Tech (MHT) there also but, no one took her place while she was on the other unit”. DON Staff #5 was asked if the LVN was scheduled to work both pediatric units for the day. DON Staff #5 confirmed the LVN was scheduled to work two separate locked units and administer medications to all patients on both BH4 and BH5 pediatric units on 1/15/2025. An interview was conducted with RN Staff #13 on 1/29/2025 at 2:03 PM. RN Staff #13 was asked how lunch breaks were managed on the night shift. RN Staff #13 stated, “The nurses will give each other lunch breaks. I work with adolescents mostly. Sometimes we only have one unit open for pediatric patients. So, there were not always 2 RNs on the unit. At times we would have an LVN, and we would just relieve each other for a lunch break. Both of the pediatric units share a nursing station, but they are 2 separately locked units”. RN Staff #13 was asked if she had to clock out for lunch. RN Staff #13 stated, “Yes, we have to clock out for lunch but sometimes we just eat at the desk in the nurse’s station or go to the nutrition room to eat quickly”. Does the House Supervisor come and give lunch breaks? RN Staff #13 replied, “Not usually”. A review of the facility policy titled, “Appropriate Staffing Levels”, Policy Number BHC.CE 0003c, with a last review date of 9/01/2023 was as follows: “Scope All operating inpatient facilities that are Behavioral Health Division subsidiaries of Universal Health Services, Inc. that participate in Medicare and Medicaid programs and UHS of Delaware Inc. and their personnel who support the Behavioral Health Division operations. Purpose To assure compliance with all laws, rules and regulations relating to federal and state health care programs. Policy It is the policy of South Texas Health System Behavioral to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and is reviewed annually. Procedure I. The Chief Nursing Officer is responsible for developing a core staffing plan for each patient care unit based upon population served. The staffing will include Registered Nurses (RNs) and Mental Health Technicians (MHT) 2. In development of the core staffing plan, each CNO shall consider the following: a. Each patient care unit will have a minimum of one RN at all times. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented ...” A telephone interview was conducted with DON Staff #5 on 1/30/2025 at 10:24 AM. DON Staff #5 was asked if the Chief Nursing Officer (CNO) developed the staffing plan and staffing matrix for the behavioral health unit. DON Staff #5 stated the staffing matrix was part of the hospital staffing plan. DON Staff #5 confirmed the facility did not have a CNO at the time and he was unsure if an interim had been placed in that position. DON Staff #5 confirmed the staffing plan that was in use at the time of the survey came from another UHS facility as a guide/tool. DON Staff #5 was asked if there was documented relief for the RNs during their scheduled lunch breaks. DON Staff #5 confirmed there was no documented relief for the RNs. DON Staff #5 also confirmed the facility policy titled; “Appropriate Staffing Levels” had not been reviewed annually as required by the facility policy.”