University of Texas Health Science Center at Tyler

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the hospital staff failed to ensure that 1 (Patient # 1) of 1 patient received care in a safe setting when Patient # 1 ingested four foreign objects while on a one-to-one suicidal observation status. The hospital staff failed to follow the “Patient Rights” and “Patient Safety Attendant-Sitter Guidelines” policies. Findings include: A review of Patient # 1’s medical record was conducted with Staff # 5 and # 3 on 04/21/2026 at 12:30 PM in the hospital’s administrative conference room. Patient # 1 was admitted to the hospital on 03/13/2026 with a chief complaint of “major depressive disorder, foreign body ingestion- sequela, multiple suicide attempts.” A review of Patient # 1’s History and Physical (H&P) dated 03/14/2026 revealed, “20-year-old female who presented to UT North on 3/6, was medically cleared and admitted to psych, swallowed a pencil, and was urgently transferred to UT Midtown for EGD. The pencil was retrieved, and she had an uneventful post-procedure course (also had a colonoscopy for hematochezia, which showed hemorrhoids as the cause). She has no new complaints but mentions a few symptoms on ROS ...” The patient was placed on a 1:1 observation due to risk for self-harm. A review of the hospital’s “Incident Notification Form” for the date of 03/19/2026 revealed, “Patient ingested 4 marker caps on the morning of 3/19. The patient was on 1:1 observation in the day area. She has a history of ingesting foreign bodies, cutting, and numerous suicide attempts. The patient is seen getting the markers on video, but the ingestion of the caps is not seen on the video. It’s reported by the patient that she ingested them in her room. The patient is currently stable and admitted to 3W Acute Behavioral Health. She was transferred to Midtown for medical services on 03/19/2026. EGD was performed on 03/20/2026, and marker caps were removed from the gastric body. The patient returned to 3W on 03/22/2026. The LAR was notified on 03/20/2026. The patient self-disclosed the ingestion of the caps. She reported to the nurse that she swallowed the caps in her room. Enhanced observation was implemented upon return ...” A review of the hospital’s internal reporting form with a reference number of “PS-2026-085423” dated 03/19/2026 revealed, “Order was placed for patient to not have items that are easily swallowed. Patient is on a finger food diet and has been sent to radiology for diagnostics, which confirmed maker caps present in stomach. Video further found that employee assigned to monitor her 1:1 (Staff # 11) was not fully watching patient and watching patient pick up markers and the staff member was looking at hand held device ...” A review of Staff # 11’s personnel file was reviewed with Staff # 20 (HR Specialist) on 04/21/2026 at 11:45 AM. Staff # 11 was hired into the role of “Psychiatric Nursing Aide I” in November of 2025. According to Staff # 11’s resume, Staff #11 had no prior experience working with psychiatric patients, as required by the “Psychiatric Nursing Aide I” job description. A review of the “Psychiatric Nursing Aide I” job description revealed the following, “ ...Minimum required education/experience: High school diploma or equivalent required. One year of experience caring for psychiatric patients. May accept a combination of education and experience ....” Staff # 11 did not meet the minimum requirements of the “Psychiatric Nursing Aide I role at the time of hire. Staff # 11 did not have constant observation of Patient # 1 while the patient was under a 1:1 observation status for suicide and self-harm risk. As a result, Patient # 1 ingested foreign bodies while under the observation of Staff # 11 on 03/19/2026. This resulted in the patient being transferred to another hospital for a medical procedure to remove the foreign bodies. A review of the hospital’s “Patient Rights and Responsibilities” policy with a date of 12/18/2023 revealed, “Policy: A written copy of the hospital’s statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate for the patient’s age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient’s understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient’s assessment of understanding of his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission and in a manner in which he/she can understand. Complaints and concerns regarding a patient’s rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department, which will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patients regarding their rights to health care and health care-related activities during hospitalization. Procedure: 1. Provide information that outlines the patient’s rights during the admission process to the patient or someone acting on the patient’s behalf for all inpatients, outpatients, and ER patients. A. Patient rights information will be provided to the patient in the form of the Hospital’s Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgment document, which will acknowledge their receipt of the patient rights. A. This document will be maintained in the patient’s medical record ...” A review of the hospital’s “Patient Safety Attendant-Sitter Guidelines” with a date of 02/08/2024 revealed, “General Work Guidelines: 1. The Patient Safety Attendant reports to the charge nurse on arrival to the unit ....4. The patient safety attendant may not make or receive personal phone calls while on duty. This includes the use of personal cellular phones for texting. In case of an emergency, the patient safety attendant will notify the nurse that he/she needs to take a break or make a telephone call. The patient safety attendant will wait for someone to relieve him/her. 5. Patient safety attendants may not sleep on duty. 6. Patient safety attendants may not eat while in the patient room. 7. Any discussions related to the medical or psychiatric condition of the patient are confidential and are not to be reported or shared with anyone. 8. The patient safety attendant does not engage in conversations with the patient regarding his/her medical or psychiatric condition or plan of care, nor does she/he offer suggestions. The patient safety attendant should refer the patient to the nurse or physician to answer any questions regarding care. 9. The patient safety attendant monitors the patient’s verbalization and immediately informs the nurse if the patient expresses any idea or intention to hurt self/others or to leave without the physician’s permission (elopement or against medical advice (AMA)) ...Patient Care: 1. Patient safety attendants should monitor the patient and maintain a safe environment. A. The patient should be placed in hospital-approved clothing. The patient should have restricted access to personal belongings and should be closely monitored ....2. Patient Safety attendants sit in the patient’s room with an unobstructed view of the patient ....Sitter guidelines for patients at risk for suicide or harm to others: In addition to the general sitter patient care, the following guidelines are specific to patients at risk for suicide or harming others. 1. Patients at risk for suicide or harm to others should have a 1:1 sitter unless otherwise ordered by the provider ....6. Document unobstructed view and continuous observation of the patient, patient location, and surveillance of the environment to identify safety risks every 15 minutes ...” An interview was conducted with Staff # 1 and Staff # 2 on 04/21/2026 at 3:00 PM. Staff # 1 and Staff # 2 confirmed there were several gaps identified related to this incident and that the hospital staff failed to follow the hospital’s policies and procedures.”

“. An on-site Life Safety Code (LSC) Re-Survey was conducted on 03/16/2026. An entrance conference was held for the Director of Quality and Patient Safety and the Chief Operations Officer on the morning of 03/16/2026 to discuss the purpose of the LSC survey and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. An LSC exit conference was conducted on 03/16/2026 with Director of Quality and Patient Safety and the Chief Operations Officer. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure records of the smoke sensitivity tests (part of the fire alarm system testing and maintenance) were available to revie for compliance with NFPA 72, 2010 edition, chapter 14.4.5.3. There was no evidence of when the last smoke sensitivity test was conducted. This deficient practice could expose patients to a smoke inhalation of fire related injuries in the event of a fire due to delayed smoke detection. Findings include: Record review of the Fire Alarm inspection reports indicated there was no smoke sensitivity conducted. Further review of the blue tags posted on the Fire Alarm Control Panel indicted there was written information (date) of when the last smoke sensitivity was conducted. Reference(s): NFPA 72, 2010 edition. 14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer’s calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure records of the smoke sensitivity tests (part of the fire alarm system testing and maintenance) were available to revie for compliance with NFPA 72, 2010 edition, chapter 14.4.5.3. There was no evidence of when the last smoke sensitivity test was conducted. This deficient practice could expose patients to smoke inhalation and fire related injuries in the event of a fire due to delayed smoke detection. Findings include: Record review of the Fire Alarm inspection reports indicated there was no smoke sensitivity conducted. Further review of the blue tags posted on the Fire Alarm Control Panel indicted there was written information (date) of when the last smoke sensitivity was conducted. In an interview at the end of record review, the Executive Director of Physical Plant Operations was informed of the missing documentation, and he stated that his staff would look further for these documents; however, no documentation was provided at the time of exit. Reference(s): NFPA 72, 2010 edition. 14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer’s calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction .”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure a Building System Category Risk Assessment was available for review in accordance with NFPA 99, 2012 edition, Chapter 4. The facility did not have an NFPA 99 Category Risk Assessment. This deficient practice could expose patients to physical harm or injuries in the event of an emergency such as a loss of power. Findings included: Record review of the facility’s documentation revealed the facility provided a risk assessment which did not comply with the NFPA 99 Building System Category Risk Assessment. In an interview at the time of the record review, the Executive Director of Plant Operations confirmed a Building System Category Risk Assessment the meets the requirements of NFPA 99, chapter 4, Building System Category Risk Assessment was not available for review. Reference(s): NFPA 99, 2012 edition. Chapter 4 Fundamentals 4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. 4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 35939 . Based on observation and interview, the facility failed to ensure a Generator remote annunciator was provided at a location where it can be constantly monitored by staff (usually Nurses Station where other alarms and annunciators (such as fire alarm) are located) in accordance with NFPA 99, 2012 edition. There was no remote generator annunciator inside the facility at a constantly monitored location. This deficient practice could result in unannounced generator malfunction, exposing patients to lapse in patient care services. Findings included: Observations at approximately 2:25 p.m. on 03/16/2026 revealed the generator was not provided with a remote annunciator inside the facility where it can be constantly monitored by staff. Further observations revealed that the only annunciator was on the generator itself, which is located in a mechanical/electrical room which is not constantly monitored. In an interview at the time of the observation, the Executive Director of Physical Plant Operations confirmed the generator was not provided with a remote annunciator inside the facility in a location where it can be constantly be monitored by staff. Furthermore, it was revealed the generator is remotely monitored at a different location outside the hospital. Reference(s): NFPA 99, 2012 edition 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine?generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) Overspeed 6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6] 6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1] 6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action. [110:5.6.6.2] 6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics: (1) It shall be battery powered. (2) It shall be visually indicated. (3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. (4) It shall have a lamp test switch(es) to test the operation of all alarm lamps. 6.4.1.1.17.5 A centralized computer system (e.g., building automation system) shall not be permitted to be substituted for the alarm annunciator in 6.4.1.1.17 but shall be permitted to be used to supplement the alarm annunciator. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on observation, document review, and staff interviews, the hospital failed to ensure all patients received care in a safe, ligature-resistant environment in 1 (Geriatric Unit) of 3 units observed. Specifically, the hospital failed to ensure that 7 (Room #403, #404, #405, #406, #409, #410, and #411) of 7 patient rooms observed were furnished with ligature-resistant patient beds. Patients were allowed to be in areas of the Geriatric Unit that had identified ligature hinge points without staff supervision for up to 15 minutes. This provided a patient with enough time to harm themselves without staff present to intervene. Refer to Tag A0144”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40989 Based on observation, document review, and staff interviews, the facility failed to ensure a safe care environment for all behavioral health patients in 1 (Geriatric Unit) of 3 units observed. The Geriatric Unit housed geriatric patients in rooms containing medical beds that were not ligature-resistant. Specifically, the hospital failed to ensure that 7 (Room #403, #404, #405, #406, #409, #410, and #411) of 7 patient rooms observed were furnished with ligature-resistant patient beds. Patients were allowed to be in areas of the Geriatric Unit that had identified ligature hinge points without staff supervision for up to 15 minutes. This provided a patient with enough time to harm themselves without staff present to intervene. Findings: An observation tour of the Geriatric Unit was conducted on 3/11/2026 at 2:19 PM with Registered Nurse (RN) Staff #25 and Assistant Chief Nursing Officer (ACNO) Staff #2. The Geriatric Unit was for patients who were 55 years of age and older. The observation revealed that the Geriatric Unit was a 10-bed unit that consisted of 7 patient rooms. The rooms were as follows: Rooms #403, #404, #405, and #406 were single occupancy rooms. Rooms #409, #410, and #411 were double occupancy rooms. Upon entering Room #404, it was observed that the medical bed frame was constructed of metal. The bed frame was adjustable and allowed the patient to raise and lower it independently. The surveyor elevated the bed and lifted the mattress, revealing multiple hinge points beneath it that could serve as potential ligature attachment points along the metal frame. During the observation tour, RN Staff #25 and ACNO Staff #2, were asked to exit the room. The surveyor then removed the bed sheet from the medical bed and attached it to a hinge point located beneath the mattress, creating a ligature point. Staff were then called back into the room to observe the demonstration that illustrated the ligature risk these medical beds posed to patients. This process was completed in under two minutes and demonstrated how quickly the medical bed could be utilized as a means for self-harm by hanging. An interview was conducted with ACNO Staff #2 and RN Staff #25 on 3/11/2026 at 2:35 PM. ACNO Staff #2 was asked whether all patients on the geriatric unit were required to have a medical bed. ACNO Staff #2 stated that upon admission to the unit, patients automatically receive a physician’s order for a medical bed, and that these are the only beds available on the unit. RN Staff #23 was then asked whether all patients were placed on 1:1 monitoring (continuous monitoring) due to the ligature risks associated with the metal frame. RN Staff #25 confirmed that not all patients were placed on 1:1 monitoring, but suicidal patients were automatically placed on 1:1 monitoring when they were admitted. RN Staff #25 confirmed that other patients could be alone in their room for up to 15 minutes without being observed by a staff member. An interview was conducted with Staff #64 on 3/11/2026 after 3:00 PM. Staff #64 stated that the metal bed frames were identified as a ligature risk on the previous hospital risk assessment. Staff #64 stated that the hospital mitigated that risk by placing all patients who were suicidal on a 1:1 monitoring. Patients not currently designated as a suicide risk and therefore not placed on one-to-one or continuous supervision remain at foreseeable risk of self-harm when the physical environment is not made safe for the behavioral health population it serves. The facility’s reliance on a declaration-based risk model, rather than a proactive environmental safety standard, created an unprotected gap between a patient’s actual deterioration in status and the clinical team’s recognition of that change, placing patients in an unsafe setting”

“Director of Nursing Qualifications CFR(s): The director of psychiatric nursing services must be a registered nurse who has a master’s degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. This Standard is not met as evidenced by: 48653 Based on a review of records and staff interviews, the hospital’s Nursing Services failed to ensure a qualified Director of Psychiatric Nursing was appointed over the hospital’s 4 (3 West, 3 East, 4 West, 4 East) of 4 psychiatric patient care units. Findings include: The hospital had four dedicated psychiatric patient care units (3 West, 3 East, 4 West, 4 East). A review of the hospital’s organization chart with a revision date of 01//05/2026 revealed that Staff # 25 was the Clinical Manager of 4 West and 4 East, and Staff # 63 was the Clinical Manager of 3 West and 3 East. Staff # 25 and Staff # 63 reported directly to the Assistant Chief Nursing Officer (Staff # 2). The hospital’s organizational chart did not include a Director of Psychiatric Nursing. A review of personnel files was conducted on 3/11/2026 with Staff # 22 (Human Resources) in the hospital’s conference room. A review of Staff # 25’s job descriptions with a signed date of 12/04/2025 revealed, “Nurse Manager: Job Summary: Under the direction of the Chief Nursing Officer, and the Director of Behavioral Health Nursing, the Nurse Manager is accountable for the effective delivery of competent, compassionate, and efficient care for Behavioral Health Units assigned on a 24-hour basis. This includes clinical, human resources, and financial management. Responsible for providing supervision and direction for nursing care and performance of duties/tasks necessary to provide high-quality care, according to the policies and procedures, philosophy, and objectives of the hospital and the department .... Minimum Required Education/Experience: Graduate of an approved school of nursing with a bachelor’s degree. Master’s degree preferred. Five years of clinical nursing experience. RN with two years of experience as a nurse manager, charge nurse, or supervisor. RN with two years of recent inpatient behavioral health experience ...” A review of Staff # 63’s job description with a signature date of 11/07/2025 revealed, “Nurse Manager: Job Summary: Under the direction of the Chief Nursing Officer, accountable for the effective delivery of competent, compassionate, and efficient care for Behavioral Health Units on a 24-hour basis. This includes clinical, human resources, and financial management. Responsible for providing supervision and direction for nursing care and performance of duties/tasks necessary to provide high-quality care, according to the policies and procedures, philosophy, and objectives of the hospital and the department .... Minimum Required Education/Experience: Graduate of an approved School of Nursing with an RN degree. Bachelor’s or Master’s degree preferred. Five years of clinical nursing experience. RN with two years of experience as a nurse manager, charge nurse, or supervisor. RN with two years of recent inpatient experience ...” According to the job descriptions, Staff # 25 and # 63 reported directly to the Chief Nursing Officer and the Director of Behavioral Health Nursing. However, the Director of Behavioral Health Nursing role was vacant. In an interview with Staff # 22 (Human Resources) on 03/11/2026 at 1:43 PM in the administrative conference room, the surveyor asked Staff # 22 who was in the position of “Director of Behavioral Health Nursing.” Staff # 22 stated, “There is no one in that role currently”. Further discussion with Staff # 22 revealed that the previous employee, who was in the Director role, had left the position in November of 2024, and the role had not been filled since November 2024. A review of Staff # 2’s (ACNO) personnel file was conducted. Staff # 2 did not have the appropriate psychiatric nursing experience, education, or training to fill the role of Director of Psychiatric Nursing. An interview was conducted with Staff # 2, Staff # 3, and Staff # 22 on 03/11/2026 at 2:00 PM in the administrative conference room. Staff # 2, # 3, and # 22 confirmed that there was no qualified employee in the Director of Psychiatric Nursing role. Staff # 22 stated, “The previous staff member who was filling that role stepped out of the position in November of 2024, and the role never got filled because the nursing managers have the necessary experience and education in psychiatric nursing.””

“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, document review, and staff interviews, the Governing Body failed to: 1. Ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant. Refer to Tag A0144 2. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed. 3. Ensure Nursing Services developed and implemented an approved written nurse staffing plan or methodology that determined appropriate staffing levels based on patient acuity, staff competencies, and staff training on 1 (3 West) of 1 Behavioral Health Units observed. Refer to Tag A0392 4. Ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of available nursing staff on 1 (3 West) of 1 Behavioral Health Units observed. Refer to Tag A0397”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47892 Based on observation, document review, and staff interviews, the facility failed to ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant. The deficient practices were identified under the Conditions of Participation and 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 Tag A0144”

“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 observation, document review, and interview, Nursing Services failed to: 1. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed. 2. Develop and implement a nurse staffing plan or have a methodology to determine appropriate staffing levels based on patient acuity, staff competencies, and staff training. Refer to Tag A0392 3. Ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of the available nursing staff for 1 (3 West) of 1 Behavioral Health Units observed. Refer to Tag A0397 The deficient practices were identified under the following Conditions of Participation and 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.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47892 Based on observation, document review, and staff interviews, the facility failed to ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant. The deficient practices were identified and 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. On 10/02/2025 at 11:38 AM, Patient #1 was found hanging by a sheet affixed to the shower head in Room #302 on the 3 West Behavioral Health Unit. Staff removed the ligature and lowered Patient #1 to the floor. A Code-Blue (an emergency code that signals a life-threatening medical situation) was initiated. An Ambu-bag (a handheld device used to assist a patient with their breathing by squeezing air into their lungs) was used for ventilation, and Cardiopulmonary Resuscitation (CPR) was initiated. Patient #1 had a Return of Spontaneous Circulation (ROSC-the resumption of a sustained heartbeat and breathing). Patient #1 was then transferred to the emergency department. A review of Nursing documentation by RN Staff #4 (10/02/2025 at 12:26 PM) and RN Staff #7 (10/02/2025 at 12:30 PM) described the patient kneeling in the shower with a flat sheet fashioned into a noose and attached to the shower head, confirming that the fixture served as a ligature point. The deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients with suicidal ideations at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings: A tour was conducted of the Behavioral Health Unit, 3 West, on 10/07/2025 at 10:00 AM with Chief Executive Officer (CEO) Staff #1, Chief Nursing Officer (CNO) Staff #2, and Assistant Chief Nursing Officer (ACNO) Staff #23. The following observations were made. The 3 West Unit was divided into two separate units, the Externalizing and Internalizing sides. Patient Rooms #302-306 were on the externalizing side of the unit. The Externalizing side houses patients who express distress outwardly through behaviors such as agitation, aggression, or defiance, and who require closer observation to ensure the safety of themselves and others. Each patient room had a private restroom that included a toilet, a hand-washing sink, and a shower. Patient #1 was assigned to Room #302. Room #302 was the last room in the hallway, farthest from the nursing station and closest to the entrance/exit locked doors for 3 West. An observation of Room #302 showed a fixed metal shower head protruding 3.5 inches from the wall, 66.5 inches above the floor, with no slope to prevent ligature attachment. A second tour on 10/07/2025, after 3:00 PM, with CNO Staff #2, RN Staff #16, and ACNO Staff #23 confirmed the same fixed metal shower head in all ten patient rooms. A medical record review was conducted on 10/07/2025 at 10:50 AM with CNO Staff #2 and Registered Nurse (RN) Staff #20. The record review showed Patient #1 was a 38-year-old male admitted involuntarily on 9/26/2025 for paranoid delusions, depression, and suicidal ideation. A review of the Psychiatric Evaluation dated 9/28/2025 at 8:16 AM by Resident Physician #26 revealed that Patient #1 was suicidal with a plan to hang himself upon admission. He was placed on standard monitoring with every (Q) 15-minute safety checks. (The Q 15-minute check is a documented observation of the patient’s location and behavior). A review of the nursing notes was as follows: 9/26/2025 at 6:31 PM by RN Staff #4: “ ...Patient received on unit at 1750 in the care of (Physician #15’s name) as involuntary patient ... Reason for admission: PT ANXIOUS AND SCARED. Patient reports depression 7/10, anxiety 10/10, and reports agitation on admission. Patient CSSRS score on admission is MODERATE. Orders for observation: Q 15 minutes. Patient lives ALONE IN VEHICLE Patient report support system: PARENT AND FAMILY. Patients denies alcohol use or use of street drugs. Will continue to monitor and offer a safe environment ...”. 10/01/2025 at 6:34 AM by RN Staff #27: “Patient approached nurse station agitation and paranoid reporting he is being poisoned and needs 911 called and he needs to go to the ER, responding poorly to verbal redirection and education, patient with raised voice and agitated, allowed vital signs, elevated BP possibly d/t agitation 160/106. Dr. (Physician #28) notified and awaiting response”. 10/01/2025 at 12:38 PM by RN Staff #4: “Patient #1 has requested for voluntary discharge at 12:19 PM”. 10/01/2025 at 1:51 PM by RN Staff #4: “Patient withdrew the request. Moving to the externalizing side for increasing psychotic agitation”. 10/02/2025 at 12:27 AM by RN Staff #29: “Pt isolated to room for most of the shift. Upon approach for shift assessment, patient appeared upset and requested to be left alone. He was paranoid and delusional, refusing to answer assessment questions. Around midnight, patient approached nurse reporting he was “red all over” and experiencing “warmness,” pointing to his arms and face. Patient stated, “Nurse is blind if they cannot see the redness.” On assessment, no redness or warmth to touch was noted. Vitals were obtained as requested (see flow sheet). During further assessment for delusions, itching, or other symptoms, patients became increasingly upset, stating that nurse was angry. Assessment was terminated due to patient escalation”. 10/02/2025 at 11:01 AM by RN Staff #4: “Pt noted to be coming out of peers restroom. Treatment team notified”. 10/02/2025 at 11:18 AM by RN Staff #4: “Pt placed on CLOSE OBSERVATION d/t intrusive behaviors, entering others rooms, leading to vulnerability due to risk of harm from others When outside room”. 10/02/2025 at 12:26 PM by RN Staff #4: “At approximately 1138 staff alerted this nurse that pt was hanging in shower. This nurse ran to assist pt. Pt found with PNA, nurses got pt down from ligature and assessed pt. Pt was pale and bluish with pulse. Nurse called for Code, life threatening emergency and crash cart. Med nurse called overhead. Ambu bag applied by this RN, Given a few breaths, rechecked for pulse, no pulse found. Compressions initiated by 2nd RN. Assistance arrived from code team. Crash cart present during code. This nurse removed self from pt side to allow response team room to work. Nurse stayed to assist. Patient moved to hallway and lifted to stretcher. Patient did have a pulse prior to leaving unit”. 10/02/2025 at 12:30 PM by RN Staff #7 “This RN in nurses’ station completing a separate task, and on phone with House Supervisor to request assistance when PNA staff approached the nurses’ station and reported that a patient was found hanging in the shower. Charge RN immediately proceeded to the patient’s room. This RN informed the House Supervisor that a code was being called and immediately went to assist CRN. Patient was found in the shower, kneeling, with a flat sheet fashioned into a noose around the neck, attached to the shower head. Patient appeared cyanotic. Ligature was removed from the shower head, and the patient was safely lowered to the ground by Charge RN and this RN. A faint carotid pulse was palpable; no spontaneous respirations were observed. Crash cart and code were called. Ambu bag requested and ventilation initiated. Patient lost pulse; chest compressions were initiated immediately. Code team arrived shortly thereafter. This RN was relieved from compressions and remained present to assist as needed throughout the code. ROSC achieved prior to patient leaving unit”. A review of Resident Physician #11’s progress note dated 10/01/2025 at 8:00 AM was as follows: “Comments: Interval events were reviewed - pt became acutely paranoid early this morning and claimed he was poisoned. There is a notable change in mental status today compared to our previous interviews. The patient is paranoid and says there is a chemical in his body increasing his internal temperature. Plan to start risperidone for psychosis. Update: Pt requested voluntary discharge shortly after the morning meeting. He withdrew the request but was verbally aggressive and threatening when I spoke with him. He said he needed to leave to meet God. The patient said someone was standing next to me who I could not see. He is exhibiting numerous signs of psychosis. The current symptoms are driving problematic behaviors. Recommend pursuit of involuntary treatment if the patient requests voluntary discharge again.” A review of Resident Physician #11’s progress note dated 10/02/2025 at 8:00 AM was as follows: “Pt continues to exhibit signs of psychosis and has been engaged in intrusive/paranoid behaviors such as entering other patient rooms to take showers. Nursing reports describe paranoid behaviors and other delusional complaints. He told staff he spit out risperidone yesterday morning but asked for an additional dose yesterday afternoon and appeared to take it without issue. Pt denied SI during the resident assessment this morning and he has not engaged in any self-harming or suicidal behaviors in the hospital. Plan to titrate risperidone for psychosis/mood and upgrade obs to close-obs when out of his room for intrusive/impulsive behaviors”. Physician #11 entered an electronic order on 10/02/2025 at 11:05 AM that read, “Maintain visual contact (Close Observations). The order was modified by Physician #11 on 10/02/2025 at 1124 AM to read, “Close observations while outside of the room”. On 10/08/2025 at 1:22 PM, a review of the recorded camera footage dated 10/02/2025 at 11:00 AM to 11:51 AM on the Externalizing Patient side of 3 West was conducted with CNO Staff #2, RN Staff #3, RN Staff #16, and ACNO Staff #23. The review of footage was as follows: 11:00 AM-PNA Staff #5 was seen at the nurses’ station. 11:00:45-PNA Staff #5 and PNA#6 were in the seen in the hallway. 11:03:24-PNA Staff #5 and PNA Staff#6 were no longer visible in the hallway of the patient rooms. 11:05:22-Case Manager (CM) Staff #24 entered Patient #1’s room (room #302). 11:06:50-CM Staff #24 exited Patient #1’s room. 11:07:21-PNA Staff #6 walked down the hallway and stopped short of Patient #1’s room. 11:08:15-Patient #1 exited room #302 and walked down the hall to the nurses’ station. 11:08:40-Patient #1 returned to room #302 and closed the door. PNA Staff #6 followed Patient #1 back down the hall to room #302, but Staff #6 did not open the door and enter the room. 11:10:42-Patient #1 exited room #302 and returned to the nurse’s station. 11:11:27-Patient #1, PNA Staff #5, and PNA#6 were standing in the hallway by the nurses’ station. 11:11:37-Patient #1 returned to room 302 and closed the door to the room. 11:33:57-CM Staff #24 opened the closed door and entered Patient #1’s room. 11:34:22-CM Staff #24 exited Patient #1’s room and was seen talking to PNA Staff #6 outside Patient #1’s room. 11:34:34-CM Staff #24 reentered patient #1’s room. 11:34:44-PNA Staff #6 stood at the doorway of room #302 and looked inside Patient #1’s room. 11:34:48-PNA Staff #6 opened the doors and looked in room #303 and #304. 11:34:49-CM Staff #24 exited Patient #1’s room. 11:35:30-PNA Staff #6 was seen outside the nurses’ station. 11:36:14-PNA Staff #6 was seen standing outside the nurses’ station, looking at his Rover (a rover is a handheld electronic device used for documentation). 11:38:05-PNA Staff #5 and PNA Staff #6 were standing in the hallway near room #302, Patient #1’s room. 11:38:40-PNA Staff #5 entered Patient #1’s room. 11:39:30-PNA Staff #6 entered Patient #1’s room. 11:39:44-PNA Staff #5 was seen exiting room #302 and running to the nurses’ station. PNA Staff #6 was seen standing in the hallway outside room #302. 11:39:46-PNA Staff #5 was seen hitting on the glass at the nurses’ station (to get the attention of the nurses in the closed and locked nurses’ station), 11:39:49-RN Staff #4, RN Staff #7, and RN Staff #8 ran down the hallway to Patient #1’s room. 11:40:04-RN Staff #8 ran back to the nurses’ station and called an emergency code. 11:40:51- PNA Staff #5 was seen taking the emergency cart to room #302, Patient #1’s room. 11:41:00-Family practice physicians and the house supervisor arrived on the unit. 11:41:47-Physician #15 and Residents arrive on the unit. 11:41:51-Physician #25 arrived on the unit. RN Staff #4, RN Staff #7, and RN Staff #8 were still engaged in the emergency code. 11:51:30-Patient #1 was taken to the emergency Department (ED) by stretcher. An interview with CNO Staff #2 on 10/07/2025, after 10:30 AM, confirmed that Case Manager Staff #24 exited Room #302 at 11:34:22 AM and told PNA Staff #6 the patient was not in the room. Q15-minute documentation showed PNA Staff #6 documented “resting in room” at 11:35 AM. The recorded video footage showed he was at the nurses’ station and could not see Patient #1. CNO Staff #2 confirmed that PNA Staff #6 did not visually observe Patient #1 “resting in his room” at 11:35 AM as documented. The camera footage confirmed PNA Staff #6 was at the nurse’s station on 10/02/2025 at 11:35 AM and could not see into Patient #1’s room. Further review of the recorded camera footage revealed that from 11:11 AM to 11:38 AM, no staff member had visually observed Patient #1 for 27 minutes. An interview was conducted with CEO Staff #1 and Facilities Director Staff #13 on 10/08/2025 at 9:30 AM. During the interview, Staff #13 provided documentation for the shower head model installed in 10 of 10 patient rooms on 3 West, identified as the Act-O-Matic Showerhead AC-450 manufactured by the Sloan Valve Company. Staff #13 confirmed that the shower heads installed in all patient rooms on 3 West were the same model. When asked if the product was ligature-resistant, Staff #13 stated the manufacturer’s product specifications indicated only that the shower head was for institutional use and did not specify that it was ligature-resistant. A cross-reference to the same product number on the Grainger.com website confirmed that the Act-O-Matic Showerhead AC-450 is NOT ligature-resistant. Staff #13 verified that there was no documentation available to demonstrate that the shower heads installed on the 3 West Behavioral Health Unit were ligature-resistant. An interview conducted with CEO Staff #1, CNO Staff #2, and Quality Director Staff #3 on 10/08/2025 after 2:00 PM confirmed that the facility had failed to identify that the shower heads in patient rooms (#302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) on 3 West were not ligature-resistant, which posed a substantial risk to patient safety. An interview conducted with CEO Staff #1, CNO Staff #2, and Quality Director Staff #3 on 10/08/2025 after 2:00 PM confirmed that the facility had failed to identify that the shower heads in patient rooms (#302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) on 3 West were not ligature-resistant, which posed a substantial risk to patient safety. 40989 An observation tour of the Internalizing side of the Behavioral Health Unit, 3 West, was conducted on 10/07/2025, after 3:00 PM, with CNO Staff #2, RN #16, and ACNO Staff #23. The Internalizing side of 3 West houses patients who direct distress inward, rather than outward, showing depression, anxiety, or suicidal thoughts, and require close monitoring for self-harm. During the tour, PNA Staff #21 explained that Q15-minute checks were documented on the Rover electronic device and that the information was synced to the patient’s medical record. While observing the unit, a patient entered Room #312 and closed the door; staff confirmed patients were allowed to shut their doors while inside. An interview was conducted with Staff #3 and RN Staff #23 on 10/08/2025 after 1:00 PM. RN Staff #23 and Staff #3 were asked if patients were allowed in their rooms with the doors closed. Staff #3 stated, “We do not lock the patient rooms on the unit. Patients can go in and out of their rooms whenever they want to. We rely on close observation or 1:1 orders as deemed necessary for closer monitoring. TVs were removed from the rooms to discourage them from staying in their rooms”. Staff #3 and RN Staff #23 were asked if the hospital had a policy regarding when patients were allowed to stay in their rooms with the doors closed. After multiple requests, no policy was provided for review. A review of the incident log for October 2025 was conducted with Quality Director Staff #3 on 10/02/2025 at 3:13 PM. The incident report was documented as follows; “This RN in nurses’ station completing a separate task, and on phone with House Supervisor to request assistance when PNA staff approached the nurses station and reported that a patient was found hanging in the shower. Charge RN immediately proceeded to the patient’s room. This RN informed the House Supervisor that a code was being called and immediately went to assist CRN. Patient was found in the shower, kneeling, with a flat sheet fashioned into a noose around the neck, attached to the shower head. Patient appeared cyanotic. Ligature was removed from the shower head, and the patient was safely lowered to the ground by Charge RN and this RN. A faint carotid pulse was palpable; no spontaneous respirations were observed. Crash cart and code were called. Ambu bag requested and ventilation initiated. Patient lost pulse, chest compressions were initiated immediately. Code team arrived shortly thereafter. This RN was relieved from compressions and remained present to assist as needed throughout the code. ROSC achieved prior to patient leaving unit”. An interview was conducted with the Quality Director, Staff #3, on 10/08/2025 after 10:00 AM. Staff #3 confirmed that a Root Cause Analysis (RCA) had been initiated but was not complete. Staff #3 was asked if the hospital conducted a ligature risk assessment on the behavioral health units. Staff #3 confirmed that environment of care rounds for ligature risks were performed once a year and typically during the fourth quarter. A review of the document titled “Mental Health Environment of Care Checklist” dated October 2024 confirmed the showerheads on the Behavioral Health Unit, 3 West, were not identified as a ligature risk. During an interview on 10/08/2025, Staff #3 acknowledged documentation errors were identified during the incident review. Staff #3 confirmed that PNA Staff #5 documented that Patient #1 was awake in the shower at 11:38 AM. This was the same time that Patient #1 was found hanging. Staff #3 stated that during an interview with PNA Staff #5, PNA Staff #5 confirmed the documentation and stated that the Rover (a handheld electronic device used to record patient safety checks) contained preset options for the patient’s location and behaviors, and “awake in shower” was the closest available choice. Video footage confirmed that PNA Staff #5 immediately went to the nurses’ station without delay and alerted the nurses. This was consistent with the timeline seen in the video. An interview was conducted with Staff #3 and RN Staff #23 on 10/08/2025 after 1:00 PM. Staff #3 confirmed Patient #1 had been on a 1:1 (constant monitoring) for high suicide precautions in the Emergency Department, but observation levels were downgraded to Q 15-minute checks, and suicide precautions were lowered to a moderate level when Patient #1 was transferred to 3 West because the unit was considered ligature-free.”

“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 observation, document review, and interview, Nursing Services failed to: 1. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed. 2. Develop and implement a nurse staffing plan or have a methodology to determine appropriate staffing levels based on patient acuity, staff competencies, and staff training. The deficient practices were identified under the following Conditions of Participation and 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: An observation tour was conducted on the Behavioral Health Unit, 3 West, on October 7, 2025, at 10:20 AM, with Chief Executive Officer (CEO) Staff #1 and Chief Nursing Officer (CNO) Staff #2. The Behavioral Health Unit had two entry doors onto the unit. There was one central nursing station. The nurses’ station had locking doors located on each side of the station, accessible only with a key. The front of the nursing station was shielded by non-breakable glass to prevent patients from reaching into the nurses’ station and removing items from the desk. This single unit was divided by a locking door accessible by badge only, which separated patients by acuity. Rooms #302, 303, 304, 305, and 306 were private rooms located on one side of the locked door. These rooms were used for more aggressive patients and were referred to as the “Externalizing Side”. Externalizing patients expressed their emotions outward and were more aggressive. These patients required closer and more frequent observations. Rooms #312, 313, 314, 315, and 316 were double occupancy rooms located on the opposite side of the locked door. These rooms were used for less aggressive patients and referred to as the “Internalizing Side”. Internalizing patients’ directed distress inward, rather than outward, showing depression, anxiety, or suicidal thoughts, and required close monitoring for self-harm. Inside the nurses’ station was a large monitor with multiple camera views of the unit. On 10/07/2025, after 10:00 AM, RN Staff #8 confirmed that there was not always someone in the nurses’ station to monitor the video cameras and that no staff were ever assigned specifically for this task. CNO Staff #2 confirmed that the wall construction and locking door in the middle of the unit were completed about a year ago. The physicians wanted the ability to separate the more aggressive patients from the others. CNO Staff #2 confirmed that all patients on 3 West were still considered acute psychiatric patients, and the unit was considered 1 unit; therefore, it was not staffed as two separate units. CNO Staff #2 was asked if the hospital had a nurse staffing plan that included the Behavioral Health Unit. CNO Staff #2 confirmed the hospital did not have a written nurse staffing plan. A review of the “UT Health Tyler North Campus 3 West Acute Behavior Health Minimum Staff Matrix” was as follows: “3 West Acute Behavior Health 7a-7p, 2RN’s & 4 PNA’s 7p-7a, 2RN’s & 4 PNA’s If additional staff is needed based on acuity, clinical judgement, or shortages, the following steps should be followed: Monday through Friday 8am to 5pm: 1. Escalate needs to the House Supervisor who will assist with calling on-call or off-duty staff. If no one is available or additional resources are still needed, move to Step 2. 2. Access Float Pool. If no one is available or additional resources are still needed, move to Step 3. 3. ACNO will evaluate staffing throughout the facility and float any additional resources to the 3 west. If no one is available or additional resources are still needed, move to Step 4. 4. ACNO will notify the Administrator on Call (AOC). If no resources are identified, move to Step 5. 5. Notify the Chief Nursing Officer (CNO). The CNO will work with the AOC and house supervisor to limit admissions and close beds as necessary. Monday through Thursday 5pm to 8am and Friday 5pm through Monday at 8am: 1. Escalate needs to the house supervisor who will assist with calling on-call or off-duty staff. The house supervisor will evaluate staffing throughout the facility and float any additional resources to the emergency department. If no one is available or additional resources are still needed, move to Step 2. 2. Access Float Pool. If no one is available or additional resources are still needed, move to Step 3. 3. House supervisor will contact the Administrator on Call (AOC). If no resources are identified, move to Step 4. 4. Administrator on Call will notify the Chief Nursing Officer (CNO). The CNO will work with the AOC and house supervisor to limit admissions and close beds as necessary. An interview was conducted with the Interim Director, RN Staff #16, on 10/08/2025 after 9:00 AM. RN Staff #16 stated that the minimal staffing matrix had not been revised after the unit was divided into two sides by the locked door. Also, RN Staff #16 confirmed that the staffing matrix was used for the entire unit and that the unit had never been staffed as two separate units. Further review revealed there was no approval date, effective date, review date, policy number, or who approved the staffing matrix on the document. After multiple requests for this information, none was provided for review. A review of the staffing assignment sheets dated September 26 through October 2, 2025, for the Behavioral Health Unit, 3 West, was conducted on October 8, 2025, with RN Staff #16. The staffing assignment sheets were separated into AM Staff and PM Staff. The AM Shift was 7:00 AM-7:00 PM, and the PM Shift was 7:00 PM-7:00 AM. The review was as follows: “September 26, 2025 AM-Patient Census-13, 1 Charge Nurse and 1 Medication Nurse, 1 Unit Clerk, 5 Psychiatric Nurse Assistants (PNAs) PM-Patient Census 11, 2 RN’s, 4 PNAs September 27, 2025 AM-Patient Census 13, 2 RN’s, 5 PNAs PM-Patient Census 13, 2 RN’s, 5 PNAs September 28, 2025 AM-Patient Census (Not documented) 2 RN’s 4 PNAs PM-Patient Census 13, 2 RN’s, 5 PNAs September 29, 2025 AM-Patient Census 13, 2 RN’s, 4 PNAs PM-Patient Census 12, 2 RN’s, 4 PNAs September 30, 2025 AM-Patient Census 12, 2 RN’s, 5 PNAs, 1 Unit Clerk PM-Patient Census 12, 2 RN’s, 4 PNAs & 1 PNA on orientation October 1, 2025 AM-Patient Census 12, 2 RN’s, 4 PNAs PM-Patient Census 12, 2 RN’s, 4 PNAs October 2, 2025 AM-Patient Census 12, 2 RN’s, 4 PNAs, & 1 PNA on orientation PM-Patient Census 11, 2 RN’s, 4 PNAs”. During an interview with RN Staff #16 on 10/08/2025 after 9:00 AM, it was confirmed that the Behavioral Health Unit, 3 West, was only staffed as one unit. RN Staff #16 confirmed that the staffing assignment sheets did not reveal patients’ names or room assignments. The surveyor was unable to determine whether adequate nursing staff and other personnel were available for appropriate and safe patient care based on the patient’s acuity and the staff’s competencies and training. Confidential interviews were conducted on 10/07/2025 and 10/08/2025 with AM and PM Nursing and PNA Staff. The following was stated about staffing: “The unit is always staffed as one unit and never two”. “We are responsible for all the patients regardless of what room they are in. We go to both sides of the unit to do assessments and give them medications”. “We relieve each other for lunch. There is no one else who comes to this unit to relieve us for a break or lunch. We know it leaves only one nurse on the unit, but that is the only choice that we have. The PNAs have to do the same thing”. “The doctors determine the acuity of the patients. The doctor had to approve when a patient was moved from one side to the other. Our census is never over 14, but the unit can be very unmanageable if the patient’s behavior is hard to control. We can call the House Supervisor and ask for another nurse, but we most likely will not get one. Sometime in August or September, the night shift had only one nurse. The medication nurse came in sick and passed all the patient medications and then left. We were told there was no one to relieve or replace her, and no one could float to the unit because they were not trained. They will send another PNA before they send an extra nurse”. “The admissions nurse will bring a new admit and then leave. We still have to do the initial admissions assessment. We are responsible for all admissions, discharges, shift assessments, medications, emergency codes, answering the telephone, assisting the physicians and residents when needed on both sides of the locked door. Sometimes we are both on one side of the locked door, and all the patients on the other side are being cared for by the PNAs. It can be very overwhelming at times”. “All of us (PNAs) go back and forth to both sides of the unit and relieve each other for lunch. Sometimes there are just 4 of us, and when one person leaves for lunch then that just leaves one person on that side”. An interview was conducted with RN Staff #8 on 10/07/2025 after 12:30 PM. RN Staff was asked if she was the nurse caring for Patient #1 on 10/02/2025. RN Staff #8 confirmed that the nursing staff was not assigned to specific patients. RN Staff #8 was asked to tell the surveyor about the incident with Patient #1 on 10/02/2025. RN Staff #8 stated that the PNA came to the nursing station window and was hitting the window to get our attention, and told us that Patient #1 was hanging in the shower. We immediately got up and ran to the room. RN Staff #4 and #7 got the patient down, placed him on the floor outside his door, and I ran back to the nurses’ station and called the code. RN Staff #8 was asked if a nurse was caring for the patients on the internalizing side of the unit. RN Staff #8 confirmed that only PNA Staff were on that side of the unit during the event with Patient #1.RN Staff #8 stated, “The PNA could have come to the other side of the locked door to get a nurse, but the hallway was full of physicians and residents, along with other staff, and it would have been hard for them to get to a nurse. We were all there with the patient. A review of the video camera footage dated 10/02/2025 from 11:00 AM through 11:51 AM confirmed there was no nurse available on the locked patient side of the unit. An interview was conducted on 10/08/2025 with CNO Staff #2. During the interview, Staff #2 stated that the hospital did not have a written nurse staffing plan or an acuity tool to determine staffing needs based on patient acuity levels or staff training and competencies. CNO Staff #2 confirmed the UT Health Tyler North Campus 3 West Acute Behavior Health Minimum Staff Matrix gave directions on who to contact for additional staff, but did not have an acuity tool to determine when to ask for an adjustment in staffing. CNO Staff #2 stated, “We have talked about adding a nurse to the daily schedule because the PNAs do not have critical thinking skills, but we have not done that yet”.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 40989 Based on observation, document review, and staff interviews, Nursing Services failed to ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of the available nursing staff on 1 (3 West) of 1 Behavioral Health Units observed. . The deficient practices were identified under the following Conditions of Participation and 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: An observation tour was conducted on the Behavioral Health Unit, 3 West, on October 7, 2025, at 10:20 AM, with Chief Executive Officer (CEO) Staff #1 and Chief Nursing Officer (CNO) Staff #2. The Behavioral Health Unit had two entry doors onto the unit. There was one central nursing station. The nurses’ station had locking doors located on each side of the station, accessible only with a key. The front of the nursing station was shielded by non-breakable glass to prevent patients from reaching into the nurses’ station and removing items from the desk. This single unit was divided by a locking door accessible by badge only, which separated patients by acuity. Rooms 302, 303, 304, 305, and 306 were private rooms located on one side of the locked door. These rooms were used for more aggressive patients and were referred to as the “Externalizing Side”. 312, 313, 314, 315, and 316 were double occupancy rooms located on the opposite side of the locked door. These rooms were used for less aggressive patients and referred to as the “Internalizing Side”. Inside the nurses’ station, there was a large monitor with multiple camera views of the unit. On 10/07/2025, after 10:00 AM, RN Staff #8 confirmed that there was not always someone in the nurses’ station to monitor the video cameras and that no staff were assigned specifically for this task. A review of the staffing assignment sheets dated September 26 through October 2, 2025, for the Behavioral Health Unit, 3 West, was conducted on October 8, 2025, with RN Staff #16. The staffing assignment sheets were separated into AM Staff and PM Staff. The AM Shift was 7:00 AM-7:00 PM, and the PM Shift was 7:00 PM-7:00 AM. The staffing assignment sheets failed to identify specific nursing and PNA assignments. The review was as follows: September 26, 2025 AM-Patient Census-13, 1 Charge Nurse and 1 Medication Nurse, 1 Unit Clerk, 5 Psychiatric Nurse Assistants (PNAs) PM-Patient Census 11, 2 RN’s, 4 PNAs September 27, 2025 AM-Patient Census 13, 2 RN’s, 5 PNAs PM-Patient Census 13, 2 RN’s, 5 PNAs September 28, 2025 AM-Patient Census (Not documented) 2 RN’s 4 PNAs PM-Patient Census 13, 2 RN’s, 5 PNAs September 29, 2025 AM-Patient Census 13, 2 RN’s, 4 PNAs PM-Patient Census 12, 2 RN’s, 4 PNAs September 30, 2025 AM-Patient Census 12, 2 RN’s, 5 PNAs, 1 Unit Clerk PM-Patient Census 12, 2 RN’s, 4 PNAs & 1 PNA on orientation October 1, 2025 AM-Patient Census 12, 2 RN’s, 4 PNAs PM-Patient Census 12, 2 RN’s, 4 PNAs October 2, 2025 AM-Patient Census 12, 2 RN’s, 4 PNAs, & 1 PNA on orientation PM-Patient Census 11, 2 RN’s, 4 PNAs An interview was conducted with RN Staff #16 on 10/08/2025 after 9:00 AM. RN Staff #16 was asked who made the staffing assignments for 3 West? RN Staff #16 confirmed that staffing was made by her and the House Supervisor. RN Staff #16 was asked if nurses and PNAs were assigned to specific patients. RN Staff #6 stated, “There are two RN’s, but they are not assigned to specific patients”. RN Staff #16 confirmed that the PNA staff were not assigned to specific patients. She stated, “The PNA tasks and responsibilities were rotated every two hours. Someone will do 15-minute checks for two hours and then rotate, and someone will be the float for 2 hours and then rotate that, but no specific patient assignments were made”. There was no way for the surveyor to determine which nurse or PNA had primary responsibility for which patient and which side of the unit or room number the patient was assigned to. An interview was conducted with RN Staff #8 and RN Staff #14 on 10/07/2025 after 1:00 PM. RN Staff #8 and RN Staff #14 were asked if either of them made patient assignments for the nursing staff and PNAs. RN Staff #8 confirmed that patient assignments were not made for the nursing staff or the PNAs. Staff #14 stated, One of us is the Charge Nurse and the other is the Medication Nurse, but we are not assigned to specific patients. The medications nurse will give all the patients their medications, and the charge nurse gets all the shift assessments done, and then we just do what needs to be done. RN Staff #8 stated that the PNAs were not assigned certain patients either, unless they were monitoring a patient who was on a 1:1 or a close observation, and then they rotated that too. An interview was conducted with PNA Staff #21 and PNA Staff #22 on 10/07/2025. PNA Staff #21 was asked if she was given patient assignments when she was on the schedule. PNA #21 replied that she was not given specific patients unless she was monitoring a close observation patient. PNA Staff #22 confirmed that an RN did not give them specific patient assignments, and it was not documented on the daily schedule. On 10/08/2025, RN Staff #16 confirmed that the staff assignment sheets did not include patient care assignments for the RNs or the PNAs. RN Staff #16 further confirmed that patient names or room numbers were not documented on the staffing assignment sheets to correlate with the assigned nurse staff for the period of 9/26/2025 to 10/02/2025.”

“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: 40989 Based on document review and interview the hospital failed to comply with the EMTALA (Emergency Medical Treatment and Labor Act) requirements at 42 CFR §489.24(d)(1). One of 1 (Patient #1) patient reviewed was discharged home while experiencing an unspecified psychotic disorder (a psychiatric emergency) before being stabilized. Physician #13 discharged Patient #1 home against the recommendations of the attending psychiatrist on 4/08/2024. Refer to Tag A2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 40989 Based on record review and interview the facility failed to provide stabilizing treatment to 1 (Patient #1) of 1 patient reviewed who was experiencing a psychiatric emergency before discharging the patient home. Medical record reviews were completed on 5/16/2024 after 10:00 AM with RN Staff #9, Emergency Room (ER) Director of Nurses (DON) Staff #4, and Chief Nursing Officer (CNO) Staff #2. Findings: Patient #1 was discharged against the psychiatrist’s recommendation for inpatient care on 4/08/2024 at 9:16 PM. Patient #1 was then admitted to an acute care hospital ER, Facility #2 on 4/09/2024 at 11:55 AM for similar and worsening symptoms. This was within 14 hours of discharge from The University of Texas Health Science Center ER. Patient #1 was subsequently admitted to the Behavioral Health Hospital, Facility #4, for management and stabilization on 4/09/2024 at the recommendation of Facility #2’s Psychiatrist. Patient #1 was a 38-year-old female who arrived at the ER by private vehicle on 4/08/2024 at 5:02 PM accompanied by her mother. The chief complaint was “Psychiatric Evaluation”. A review of the triage note dated 4/08/2024 at 5:13 PM by Registered Nurse (RN) Staff #11 was as follows: “Patient arrives to the ER with her mother via POV (by private vehicle). Patient’s mother states that patient has not eaten x 1 week. Patient’s mother states patient has not bathed for 2 weeks, patient states she bathed 2 days ago. Mother states that the boyfriend told her that the patient said the bathtub is poisoned so she refuses to use it. Mother states that the patient called the police on her a month ago because patient stated mom was putting [white stuff through the vents to poison me]. Mother states the patient has a history of Bipolar. Patient states she has been having auditory and visual hallucinations. Patient is an established patient with the Local Mental Health Authority, Facility #3. Patient states she does not wish to be dead but does not wish to keep going on the way it is now. Denies homicidal ideation (HI)”. Patient #1 was triaged with an acuity level of 3. The ER acuity level is a numerical scale (1-5) used to determine the immediate needs of a patient presenting to the ER. 1 being emergent or life-threatening and 5 being non-urgent. A review of Physician #13’s Emergency Medicine Note dated 4/08/2024 at 6:20 PM was as follows: “ ...Patient is a 38-year-old female with a history of anxiety disorder, bipolar disorder, depression, and methamphetamine use disorder who was brought in by her mother for concern of severe depression, stop eating and drinking for 1 week and stop bathing for the past 2 weeks. Patient reports having auditory and visual hallucinations, uncertain if commanding. Pt also admits to may be (sic) suicidal. A review of systems revealed that Patient #1 was positive for hallucinations and suicidal ideas ...Her mood is depressed, and her Affect is flat. Speech is delayed ...” Further review of Physician #13’s ER Course and Impression documentation dated 4/08/2024 was as follows: “1910 (7:10 PM)-I took over care from Physician #12. Pt has hallucinations, acting strange, and is not bathing. H/o methamphetamine use. Needs urine test. 2108 (9:08 PM)-UDS (urine drug screen) positive for methamphetamines. Pt denies suicidal ideation (SI) or homicidal ideation (HI) to me. Pt feels safe but wants help with hearing voices and with drug use. Pt stable at this time and medically clear. No emergent criteria for admission at this time. 2110 (9:10 PM)- Pt hesitant to leave because she says her mom won’t let her come back home. Pt does have a boyfriend that she could stay with she says ...” During the medical record review, RN Staff #4 and #9 confirmed Patient #1’s urine drug screen resulted positive for amphetamines and cannabinoids and that Patient #1 had a medication history of Adderall. Further review of the medical record revealed Physician #13 ordered a Psychiatric Consultation for a Psychiatric Assessment on 4/08/2024. Physician #14 consulted on Patient #1 on 4/08/2024 at 7:11 PM. A review of the Psychiatry Consult was as follows: “ ...The patient was brought in by her mother for depression, suicide, and bizarre like behavior. The patient states that she can eat and her stomach is upset. She states she thinks she is dying and she smells like death. The patient currently has chest pain with point tenderness. It is a stabbing sharp pain non radiating 10 out of 10 pain. It has been going on for the last 3 days and feels like a panic attack... Patient #1 was seen in the ER on 1/13/2024 with a similar presentation. Collateral information: (Patients mother) She states that her daughter has not eaten in 4 days due to her stomach hurting. She has been hearing voices, telling her that people are poisoning her. She can’t shower because there is blood and poison in the bathtub. She has called the police on her parents multiple times. She has not been taking her medications for a couple of days because she has been with her boyfriend. Her boyfriend just broke up with her and she could no longer stay with him. She would tell her mom that she wished she was dead and a week ago she took pills to overdose. She had multiple hospitalizations here and a previous history of suicidality trying to overdose on pills ... Mental Status Evaluation: Appearance: disheveled Behavior: psychomotor retardation Speech: delayed and soft Mood: not a great mood Affect: blunted Thought Process: blocked Thought Content: suicidal ... Assessment of Patient: The patient’s current condition appears to be similar to that of prior admission with underlying psychotic disorder exacerbated by concurrent methamphetamine use and medication non-adherence. The patient’s acute risk of suicide is high due to her currently endorsing suicidal ideations and her chronic risk of suicide is high due to previous suicide behaviors. Diagnostic consideration, given to unspecified psychotic disorder, unspecified mood disorder, and Stimulant Use Disorder. The patient would benefit from admission to an acute psychiatric unit for close monitoring for safety and adjustment of psychotropic medications. Overall not stable for discharge due to current suicidal ideation and bizarre behavior. Treatment plan was discussed with the patient and inpatient admission is appropriate at this time. Will defer medication initiation to primary excepting (sic) team. The patient voiced understanding and agreed with the treatment plan. The psychiatric service will continue to follow the patient as necessary ... Diagnostic Impressions: Unspecified psychotic disorder Unspecified mood disorder Stimulant use disorder ...” The attestation statement signed by Physician #15 (Attending Psychiatrist) was as follows: “The patient’s history, physical exam findings, pertinent ancillary data, assessment, and plan were discussed with the Resident Physician, and I agree with the details as documented by the Resident Physician in their note. Additionally, I personally examined this patient and I agree with the details as documented by the Resident Physician ...” ER, DON Staff #4 confirmed Patient #1 was discharged home by Physician #13 on 4/08/2024 at 9:16 PM against the recommendation of Psychiatrist #14 and Psychiatrist #15. An interview was conducted with the ER DON, Staff #4 on 5/15/2024 at 12:15 PM. ER DON Staff #4 was asked why the patient was discharged after the psychiatrist made the recommendation for admission to stabilize the patient. ER, DON Staff #4 replied, “I don’t know. The resident saw the patient, but the attending also saw the patient and agreed with the resident’s assessment and plan. This patient has been here several times and had several inpatient stays for psych”. ER, DON Staff #4 confirmed there was no documentation by Physician #13 as to why he did not agree with the psychiatrist and admit the patient. ER, DON Staff #4 was asked if there was bed availability on 4/08/2024 at the hospital and she confirmed there was availability for a new admission. ER, DON Staff #4 was asked if the ER nurses or the ER Physicians have the behavioral health patients agree and sign a patient safety plan before discharge. ER, DON Staff #4 stated, “No they do not. Psychiatry may but the ER staff does not.”. A request for the ER Policies and discharge policy was made on 4/08/2024. ER DON Staff #4 confirmed there were no ER-specific policies, and the ER followed the same policies as inpatient services. Also, it was confirmed there was no discharge policy. ER, DON Staff #4 stated, “If there are specific discharge needs the staff calls Case Management. There is always someone on call in the case management department”. An interview was conducted with Physician #8 on 4/08/2024 at 1:00 PM. Physician #8 confirmed she was the Psychiatrist that was assigned to the ER. Physician #8 was asked if she was the attending psychiatrist for the residents. Physician #8 replied, “There is always an attending psychiatrist available for the residents. I am here Monday through Friday and I provide services for the ER. After hours there is always someone on call and the residents communicate with us on every patient that is seen. The residents are covering the ER 24/7 on a call rotation and the attending psychiatrist does the same. They are never left without someone to contact or to be there with them”. Physician #8 was asked if the ER physician and the psychiatrist work together to determine the best outcome for the patient. Physician #8 stated, “Yes”. An interview was conducted with Physician #7, ER Physician, on 4/08/2024 at 2:10 PM. Physician #7 was asked if the Psychiatry Residents were consulted on patients who needed a psychiatric evaluation in the ER. Physician #7 stated, “They look at the board on the computer and see if there are patients that need to be evaluated by psych and they go and see them. Sometimes we will both go to the patient’s room together and I will do the medical clearance and introduce the resident and they will continue with the psych assessment. Sometimes they just see the patient if the chief complaint is psychiatric evaluation needed”. Physician #7 was asked if the ER physicians would discharge patients even when the consulting psychiatrist is recommending inpatient care. Physician #7 stated, “The ER doctor determines if the patient is clear for discharge or not”. The complainant alleged that she was told by the local mental health authority, Facility #3, to take the patient to the ER for an assessment, and when they did not admit the patient, she was told to take the patient to an acute care hospital ER, Facility #2. A review of the call logs provided by the local mental health authority; Facility #3 was as follows: “ ...The Local Mental Health Authority, Facility #3 documented on 4/08/2024 at 4:42 PM that Patient #1’s mother contacted the local mental health authority, Facility #3, and requested assistance for her daughter, Patient #1. She was advised to take the patient to the ER or she could call back on the morning of 4/09/2024 and have the client referred to the (Mental Health Clinic) MHC for assessment. A follow-up call was documented by Facility #3 at 6:04 PM. Patient #1 was in the ER at The University of Texas Health Science Center for an assessment at that time. An additional follow-up call was documented on 4/09/2024 at 10:37 AM and no information was provided to Facility #3 due to HIPPA. The call center, Facility #3, had the spelling of the patient’s last name incorrect. On 4/10/2024 at 10:41 AM Facility #3 contacted the Social Worker at Facility #2, an acute care hospital and confirmed Patient #1 was treated in their ER and admitted to a psychiatric hospital, Facility #4 for in-patient Care on 4/10/2024. A review of the medical record provided by the acute care hospital; Facility #2 dated 4/09/2024 revealed Patient #1 arrived a 11:55 AM noting the same chief complaints as the previous hospital. Patient #1 was examined through telehealth services by Psychiatry on 4/09/2024 at 3:10 PM. A review of the telehealth services was as follows: “ ...HISTORY OF PRESENT ILLNESS: Patient presents ER today due to concern for possible needing psychiatric admission. Patient is a longstanding history of bipolar disorder, is on multiple medications for depression and family states that she is “like a zombie” that she does not take a shower, does not eat, is having hallucinations and paranoia. She sees people that are not there, sees blood in the shower so she will not take a shower for weeks, she states she is taking her medications. She denies any active suicidal ideation or homicidal ideation, however, does have a history of overdose as a suicide attempt in the distant past. She denies any major trauma, or other complaint. Pt UDS positive for Amphetamines and Cannabinoids. Pt endorses taking Adderall,(an amphetamine drug used to treat attention deficit disorder) Klonopin (a medication used to control panic attacks and seizures), Zyprexa (an antipsychotic medication). Per med list pt is on guanfacine (a medication used to treat ADHD), Klonopin, and also Restoril (a medication used to treat insomnia). Patient was seen via telehealth video conferencing in secure location. Pt is awake, alert, and oriented x 4. Pt states name and DOB. Pt also identified by staff/family at bedside. Pt is voluntary. Consult reason listed as “psychotic”. Pt is having difficulty responding to questions. Pt is responding to stimuli, continues to move her hands and look around the room. Pt states she guesses she is depressed. Pt states she came to the hospital because she is hearing things. Pt states she is hearing things in the shower, cannot sleep, issues with her couch. Pt states the house is messed up and she cannot wear her clothes. Pt states that everyone else says it is not real. Pt states she lives with her parents. Pt states does not work or go to school. Pt states she does take medication. Pt states she takes Klonopin, Depakote, levothyroxine, and Zyprexa. Pt states she has been taking her medication prior to coming here. Pt states she is hearing the voices a lot. Pt states the voices are telling her to do things. Pt states “sorry for being rude”. Pt states they tell her how to shower, how to sleep, everything and all day every day and it is very loud. Pt states the voices do not tell her to hurt herself or others. Pt states no SI or HI. Pt denies VH. Pt states she has been diagnosed with bipolar, anxiety, and schizophrenia. Pt then states has not been diagnosed with schizophrenia, but it seems she may have it. Pt endorses she has used etoh (alcohol). Pt states her medications have not been helping with her voices at all. Pt would like her meds looked at/adjusted ... Disposition: At this time, patient does present as gravely disabled. Recommend inpatient psych stay secondary to elevated risk factors, and a lack of meaningful protective factors. At this time, patient requires active treatment furnished directly by inpatient psychiatric facility personnel at levels of intensity and frequency exceeding what may be rendered in an outpatient setting. My recommendation is patient would benefit from inpatient psychiatric stay for stabilization and management once medically cleared. The patient is not psychiatrically cleared. Patient would benefit from inpatient psychiatric placement for further treatment and evaluation once medically cleared to discharge ...” The patient was transferred via ambulance to an inpatient Behavioral Health Hospital, Facility #4 on 4/09/2024 at 10:27 PM for inpatient behavioral health care. Patient #1 was discharged home from The University of Texas Health Science Center, against the psychiatrist’s recommendation for inpatient care on 4/08/2024 at 9:16 PM. Patient #1 was then admitted to an acute care hospital ER, Facility #2 on 4/09/2024 at 11:55 AM for similar and worsening symptoms. This was within 14 hours of discharge from The University of Texas Health Science Center ER. Patient #1 was subsequently admitted to the Behavioral Health Hospital, Facility #4, for management and stabilization on 4/09/2024 at the recommendation of the Psychiatrist.”