Doctors Hosptal at Renaissance

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 33326 Based on record review, interview and observations the facility’s nursing failed to provide appropriate supervision for patients requiring close levels of observations when the facility’s practice was to schedule sitters with more than one, one-to-one patient assignment, designate the sitter as the primary care giver, and provided inaccurate observation levels to the sitters. This failure places patients and staff at risk for inadequate supervision and injuries. Findings include: Review of the facility provided staffing schedule for 6/5/2026 reflected a sitter assignment for rooms 5404 and 5405. Review of the staffing schedule and physician’s order reflected, on 6/5/26, from 6:15 am untill 6:30 pm, Staff #5, CNA(certified nursing assistant) was scheduled to watch Patient #3 in Room 5404, a patient with physician’s orders for one-to-one monitoring for fall risk. Review of the Patient #3’s observation sheet reflected Q15 minute checks and 1:1. Staff #5 documented patient was trying to get out of bed at 2:30 pm and 2:45 pm. From 5:45 pm until 6:30 pm, Patient #3 was trying to get out of bed and was hallucinating and pulling on IV lines. Review of the staffing schedule and physician’s order reflected, on 6/5/26 at 6:15 am untill 6:30 pm Staff #5 was also scheduled to watch patient #5 in room 5405, a patient with physician’s orders for two-to-one monitoring for fall risk. Review of the Patient #5’s observation sheet reflected Q15 minute checks and 1:1. Staff #5 documented changing Patient #5 linens twice during the day shift. An attempt was made to interview staff #5, the staff was not available. An interview was conducted with Staff #8, sitter on 7/21/26, in the DON’s office at 1:30 pm. Staff #8, CNA stated in part, “We (assigned sitters) sometimes take more than one 1:1 patients. We will sit in the hallway between the two rooms. Sometimes it can be hard; if the patient needs a lot of care, it’s difficult to watch the other patient. The patients in 5404 and 5405, we call them the dynamic duo. One likes to drink coffee all day. I have to keep going to make him coffee, then I have to clean him and help him to the bathroom; he uses a walker. We can ask for help but sometimes they (the other CNAs assigned to the unit) help us, sometimes they are too busy. When we are sitting, we provide all the care for that patient. We change the linens, we take the vital signs and we clean the patients. We document every 15 minutes.” During an interview, on 7/21/26 at 2:30 pm, in the administrative conference room, Staff #1, CNO stated in part, “The staff can watch two patients. It really depends on the type of patient and their behavior; the sitter can only watch one patient if the patient is suicidal.” Staff #1 confirmed the sitters have been providing primary care for their assigned patients and the sitter at times would supervise two patients. Staff #1 confirmed the sitter’s observation sheet did not include the option of a patient being 2: l, only 1:1, Staff #1 stated the sitters would communicate the level of observation for a patient at the hand-off. Review of the facility provided policy “Close Patient Monitoring (one to one) Inpatient Monitoring” (updated 10/2025) reflected, Purpose To provide guidelines, assessment and process to include ordering, initiation, monitoring and discontinuation of the use of close observation as an intervention to prevent harm or death in confused, combative, and/or psychiatric patients. Close observation of patients who have been identified as potentially dangerous to themselves or others is critical in ensuring a safe environment for patients and staff. The hospital will use a clinical assessment approach to determine acuity-based assignment and implementation. A process will be in place to monitor sitter usage to ensure appropriate assignment and management of resources. Definition: A. One to one Observation (1: 1) - the sitter to one to one within arm’s length, in close proximity with no physical barrier in the same room/area. B. Close Observation (2: 1) - the sitter is assigned to more than one patient in the room/area and can care for more than one patient. Suicidal patients are excluded from close observation. Suicidal patients must be a 1: 1.” 4. Responsibilities o Any employee assigned to care for a patient with an order for close patient monitoring. o Employees assigned to close patient monitoring care have the responsibility of promoting patient safety and preventing harm and/or death. o Employee will receive training and education on how to provide safe care to patients on close patient monitoring precautions ...d. Sitter can provide/ assist in the daily patient care depending on the level of monitoring - 1: 1 or 2: 1.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on observation of facility video surveillance, review of facility’s policies and procedures, record reviews and interviews, the facility failed to ensure specific patient rights were protected and promoted under the Patient Rights Condition of Participation, including the right to receive care in a safe setting and the right to be free from abuse or harassment, for an incident involving 3 of 3 patients reviewed, Patient’s #1, Patient #2, and Patient #3. Patient #2, an older male, was brought to the facility under an emergency detention order following allegations that he had inappropriately touched another female resident’s breasts at his place of residence. Despite the facility’s Sexual Acting Out (SAO) policy, which identifies a history of sexual allegations as a trigger for SAO precautions, Patient #2 was permitted to remain in close proximity to minor Patients #1 and #3 in the intake area without SAO precautions, without evidence that risk-related information was communicated to intake staff, and without continuous supervision when Staff #5 left Patients #1, #2, and #3 unsupervised in the intake area. As a result, Patient #1, an 11-year-old female, reported that her breast was touched and grabbed by Patient #2 while she and Patient #3 were left unsupervised in the intake area. Specifically, the facility failed to: A. provide continuous staff supervision and safeguards in the intake area after Patient #2 arrived with documented risk-related information involving sexually inappropriate touching. B. ensure its abuse/neglect policy provided clear, facility-specific instructions for reporting allegations of abuse, neglect, or sexual contact occurring in the psychiatric hospital, including patient-to-patient contact involving a minor and staff failure to provide assigned supervision. C. complete required regulatory self-reporting and facility-level follow-up after the allegation, including reporting to the appropriate regulatory authority, Texas Health and Human Services, Health Facility Compliance. D. ensure staff received and documented the required eight hours of ANE training specific to identifying, preventing, and reporting abuse, neglect, and exploitation in accordance with Texas Health and Safety Code §161.133. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to deficiencies; A0144 and A0145 for evidence of specific findings.”

“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: 21863 Based on observation of facility video surveillance, record review, policy review, and interview, the facility failed to protect and promote each patient’s right to receive care in a safe setting by failing to identify, communicate, and implement sexual acting out (SAO) risk controls for 1 of 1 adult patient reviewed for SAO-related risk, Patient #2, before placing him in proximity to 2 of 2 minor patients, Patients #1 and #3, in the intake area. Specifically, Patient #2 was brought to the facility under an emergency detention order after an allegation that he touched another female resident’s breasts. The facility’s SAO policy identified a history of sexual allegations as a trigger for SAO precautions. However, Patient #2 remained near minor Patients #1 and #3 in the intake area without SAO precautions, without staff awareness of the SAO-related risk, and without continuous staff supervision when Staff #5 left the intake area. This failure placed minor patients at risk for harm and resulted in Patient #1, an 11-year-old female, reporting on 4/15/26 that Patient #2 touched and grabbed her breast while Patients #1 and #3 were left without continuous staff supervision. Findings included: Review of Patient #2’s Application for Emergency Apprehension and Detention dated 4/15/26 documented Patient #2 had dementia/confusion and was accused of inappropriately touching a female resident on her breasts. Patient #2 recently displayed an inappropriate act of touch with another female resident. The presiding Judge signed an order for a mental health warrant for emergency apprehension and detention for preliminary examination by a physician. Patient #2 was ordered to be apprehended at his current residence, obtain a medical clearance if necessary, and then transport to one of 5 named facilities providing psychiatric inpatient mental health services for the purpose of a preliminary examination. Physician Orders for Patient #2 dated 4/15/26 at 16:22 revealed Admission Request, ED Observation: Misc, Pending labs/behavioral placement. Further orders on 4/15/26 at 21:02; ordered Q (every) 15 minutes, observations for Patient #2, for Suicidal Precautions. There was no documentation that Patient #2 was placed on SAO precautions before Patient #1 alleged Patient #2 touched/grabbed her breast, or after the incident. Review of Patient #2 ’ s Intake Assessment entered on 4/15/26 at 21:16 documented patient was a 78-year-old male that was a resident of the Long-Term Care [Named Facility] and presented to the behavioral health facility on an emergency detention order (EDO) that stated patient touched a female resident on her breasts were he resides. Presenting Problem: Assaultive, Other: sexually inappropriate. Dementia/confusion. Suicidal Ideation: None. Review of the facility’s Behavioral Services Sexual Acting Out policy BHR-0027, last reviewed/revised 09/2023, documented the purpose of the policy was “To protect patients and staff from sexual predators.” The policy stated patients would be screened during admission nursing assessment for behaviors that may indicate a need for SAO precautions, including “history of actual allegations of sexual nature,” “history of criminal SAO,” and other sexually provocative/hypersexual behaviors. Physician order will be obtained if an RN (Registered Nurse) initiates SAO precautions. Review of Patient #2’s physician orders on 4/17/26 at 9:30 PM revealed he was not actively on SAO precautions in accordance with the facility’s policy prior to the incident allegation involving Patient #1, or immediately after the incident allegation by Patient #1. Video observations conducted on 4/17/26 at 10:00 PM of the Registration Hallway camera, dated 4/15/2026 at 8:28 PM, 23 seconds (20:28:23), showed Staff #5, a Female Psychiatric Tech in the Intake area leave the hallway where Patient #2 was reportedly sitting in a chair next to her, and where Patient’s #1 and #3 were seen in the TV Waiting Room Camera. Staff #5 walks down the hallway towards the facility’s general lobby/waiting area. Patients #1 and #3 are seen initially in the intake waiting; “TV Room” when Staff #5 leaves the area and subsequently the intake unit by going through a locked/secured door into the facility lobby. At 8:29 PM and 32 seconds, (20:29:32), 1 minute 9 seconds later, Staff #5 returned to the area/hallway where Patient #2 was left, and minor Patient’s #1 and #3 had been left without staff supervision. During interview on 5/14/26 at 5:35 PM, Staff #5 stated she was not aware Patient #2 was brought to the facility for SAO-related behaviors and stated she “did not know.” Staff #5 further stated that, since the incident, the facility changed its process and now requires risk-related paperwork/section information to be provided to staff in intake for awareness. Review of the facility’s Environmental Risk Assessment, date unknown, identified the intake lobby and hallway as risk areas and stated, “Patients always attended and monitored in intake.””

“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: 21863 Based on observations of facility surveillance video, record review, and interviews, the facility failed to protect and promote Patient #1’s right to be free from abuse, neglect, harassment, and harm when Staff #5 left Patient #1, an 11-year-old minor patient, unsupervised in the intake area with Patient #2, an older adult male patient who had been brought to the facility under an emergency detention order following an allegation of sexually inappropriate touching. As a result, Patient #1 reported Patient #2 hugged her and touched/grabbed her breast area while she was without staff supervision. The facility also failed to ensure staff were informed of Patient #2’s known risk-related information, failed to ensure facility-specific abuse/neglect reporting procedures addressed allegations occurring within the psychiatric hospital, failed to self-report the allegation to Texas Health and Human Services, Health Facility Compliance, and failed to ensure staff received required abuse, neglect, and exploitation training. This deficient practice was identified for 1 of 1 minor patient reviewed with an allegation of patient-to-patient sexual contact, Patient #1. Specifically, the facility failed to: A. provide continuous staff supervision and safeguards in the intake area after Patient #2 arrived with documented risk-related information involving sexually inappropriate touching. B. ensure its abuse/neglect policy provided clear, facility-specific instructions for reporting allegations of abuse, neglect, or sexual contact occurring in the psychiatric hospital, including patient-to-patient contact involving a minor and staff failure to provide assigned supervision. C. complete required regulatory self-reporting and facility-level follow-up after the allegation, including reporting to the appropriate regulatory authority, Texas Health and Human Services, Health Facility Compliance. D. ensure staff received and documented the required eight hours of ANE training specific to identifying, preventing, and reporting abuse, neglect, and exploitation in accordance with Texas Health and Safety Code §161.133. These deficient practices resulted in Patient #1 being left unsupervised with an adult patient with known sexually inappropriate behavior allegations and had the potential to place other minor patients and patients requiring close supervision in the intake area at risk for abuse, neglect, harassment, and harm. Findings included: A. Review of the Admissions Behavioral Census Report dated 4/16/26 revealed Patient #1 was admitted 4/15/26 at 16:07, Patient #3 was admitted 4/15/26 at 16:35. Observations were conducted 4/17/26 at 10:00 PM of the surveillance footage from 4/15/26, at 8:28 PM in the intake area, TV room. The video was queued and archived by the Vice President of Behavioral Services (Staff #1). The recording, lasting three minutes and nineteen seconds from 8:28 PM to 8:31 PM, begins with Female Patient #1 present in the room, identifiable by long hair, a white shirt, and red socks, as well as Male Patient #3, wearing all black attire and red socks. Patient #1 is standing, sits down in a chair for a few seconds, and then gets up and walks to the entry of the room, standing at the door. It appears she is talking to Staff #5 at that point. Patient #2 is standing and actively maneuvering and shuffling his feet around. At 42 seconds into the video, it appears Patient #1 goes towards the right end of the short hallway where Patient #2 was reportedly sitting. Patient #3 stays in the TV Room for approximately 8 seconds moving around and watching the TV, when he is seen walking out towards the hallway at 51 seconds and remains outside of the doorway where you can see his red socks until the 1:00 minute mark where he leaves the area. From 1:00 minute to 1 minute, 12 seconds there is no activity seen. At 1 minute and 13 seconds, Patient #1 reappeared from the right side of the hallway and entered the TV room. Patient #3 followed her into the TV room. At 1 minute and 16 seconds, Patient #1 crossed her arms and hands over her breast area, placed both hands on her face, and was observed crying. At 1 minute and 41 seconds, Staff #5 entered the TV room holding a hooded jacket. Patient #1 and Patient #3 pointed toward the hallway. Patient #3 pointed with his thumb and placed his hand near his breast area during the interaction with Staff #5. Staff #5 then left the TV room and walked toward the right side of the hallway. At 3 minutes and 08 seconds, Staff #5 returned to the TV room. Patient #1 spoke with Staff #5 and demonstrated a hugging motion before the video ended at 3 minutes and 19 seconds. A second video reviewed for the Registration Hallway, dated 4/15/2026 at 8:28 PM and 23 seconds (20:28:23), showed Staff #5, a female psychiatric technician in the intake area, leaving the hallway where Patient #2 was reportedly sitting in a chair near her and where Patients #1 and #3 were in the TV waiting room. Staff #5 walked down the hallway toward the facility’s general lobby/waiting area and went through a locked/secured door into the facility lobby. At 8:29 PM and 32 seconds (20:29:32), Staff #5 returned to the hallway/intake area where Patient #2 and minor Patients #1 and #3 had been left without staff supervision. The following timeline is provided by the Behavioral Health Clinical Coordinator/Staff #3 by email on 4/20/26 at 04:18 PM regarding Patient #1 ’ s allegation against Patient #2. TIMELINE, in part: 4/15/2026 2030 - Intake tech stepped away to grab patient a sweater upon her request. Female Patient reported an elderly male patient hugged and touched her chest area. This was immediately reported to House Supervisor. 2037 - House Supervisor escalated to AOC [Administrator On-Call] after interviewing both patients. Reports female child patient alleges elderly man hugged and touched her. Elderly patient admitted to hugging patient and denies touching her inappropriately. Elderly patient with history of confusion and dementia. 2050 - House Supervisor contacted Foster parents and made them aware of incident. 4/16/2026 0800 - Administrative team completed camera review. Alleged event occurred out of camera view outside the intake lobby. However, we were able to see when the patient leaves the room and returns into the room. Findings of camera review of 4/15/2026: 2028 (13 seconds) Tech leaves to retrieve patient ’ s sweater as requested. 2028 (39 seconds) Patient leaves intake lobby into hallway out of camera view. 2029 (08 seconds) Patient returns into camera view at the intake lobby doorway. 0902 - Unit therapist completed patient ’ s psychosocial assessment and patient “reported that she had been grabbed and hugged by an adult male patient during intake process.” 1050 - Admin notified Edinburg Police Department of request to make police report. 1220 - Officer from the local Police Department present at facility to complete police report #26-16877. 1255 - Unit therapist completed CPS report. Case report # 304825c0.” Interview on 4/17/26 at 8:37 PM with Staff #1 revealed she was notified of the incident and Patient #1’s allegation. Staff #1 stated the facility reviewed the cameras but could not verify whether the alleged touching occurred because the cameras showed the room and not the hallway where Patient #2 was waiting. Staff #1 stated Patient #1 was seen walking into the hallway where Patient #2 was waiting in the intake area. Staff #1 stated a staff member was always assigned to watch patients and that Staff #5 went to the front lobby to retrieve Patient #1’s sweater. Staff #1 stated they could not confirm whether Patient #2 touched/grabbed Patient #1’s breast. Staff #1 stated Patient #2 reported he “did hug her, but didn’t touch her breast.” Staff #1 stated the facility filed a CPS report and a police report. During an interview on 5/14/26 at 5:35 PM, Intake Staff #5 stated she was assigned to the intake area on 4/15/26 from 4:30 PM to 11:30 PM. Staff #5 described the intake area as including a long hallway, a shorter hallway, and a TV room. She stated the shorter hallway did not have cameras. She also stated patients were not supposed to sit in chairs in the long hallway due to ambulance access and Fire Marshal requirements. Staff #5 stated Patient #1 and Patient #3, described as “two kids,” had been waiting in the intake area/TV room since approximately 5:17 PM after admission and needed to be transferred to the children ’ s unit. The registration representative called the children ’ s unit at 5:17 PM to report their charts were ready. Staff #5 stated Patient #2 arrived from the Emergency Room by ambulance at approximately 7:45 PM. Patient #2 was soiled, and Staff #5 took him to the restroom to clean up and change. When Patient #2 returned, he sat in a chair in the short hallway next to Staff #5. Staff #5 stated Patients #1 and #3 had been waiting approximately three hours and repeatedly asked whether the nurse was coming to take them to the unit. Patient #1 asked for a sweater because she was cold; the sweater had been brought by her mother and was located in the entrance lobby. Staff #5 went to the lobby to retrieve the sweater, leaving Patients #1, #2, and #3 without staff supervision. When Staff #5 returned, she stated Patient #1 and Patient #3 were in separate corners. Patient #1 had “tears in her eyes” and reported, “the old man just touched me.” Patient #1 reported to Staff #5 that she told Patient #2 she was cold, and Patient #2 said, “come here, I want to give you a hug.” When Patient #1 got close to Patient #2, Patient #2 began “smelling the back of her neck” and touched her back. When Patient #1 tried to push him away, Patient #2 grabbed her “breast part.” Staff #5 stated she immediately reported the incident to the House Supervisor and asked Patient #2, “what did you just do right now?” Staff #5 stated Patient #2 appeared confused and responded, “What? I didn ’ t do anything.” At that time, the nurse arrived to take Patients #1 and #3 to the unit. Further interview with Staff #5 stated she was not aware Patient #2 was brought to the facility for Sexually Acting Out (SAO) related behaviors. Staff #5 stated she “did not know.” Staff #5 stated that, since the incident, the facility changed its process and now requires risk-related paperwork/section information to be provided to staff for awareness. Review of the Employee Discipline Form dated 4/16/26 for Staff #5 included a “Final Written” disciplinary step for, Performance.” On Wednesday, April 15, 2026, you were assigned at the intake lobby monitoring patients. During this assignment, you left your post to gather a sweater for a patient. During your absence, an adult patient hugged an adolescent patient, leading to the adolescent patient submitting a complaint and stating that the adult touched her breast. Upon video review, it was identified that the patients under your supervision were left unattended momentarily. Your actions have affected overall patient care and experience. This is a reminder to not leave your post and to ensure that patients are being properly monitored at all times.” Patient record reviews included: Patient #1 Records: Review of Patient #1’s Psychosocial Assessment dated 4/16/26 at 09:02 AM documented the following; Patient reported a family history of CPS involvement when she was 10 years old due to emotional, physical, and sexual abuse from an uncle. During session, patient reported that she was grabbed and hugged by an adult male patient during the intake process [on 4/15/26]. Patient #2 Records: Review of the Application for Emergency Apprehension and Detention dated 4/15/26 for Patient #2 documented Patient #2 has a diagnosis of Dementia which primarily presents in confusion regarding time/place. Patient #2 ’ s recent act of impulsivity puts him at harm for making a decision that will hurt himself. Patient #2 was accused of inappropriately touching a female resident on her breasts. Patient #2 recently displayed an inappropriate act of touch with another female resident. The presiding Judge signed an order for a mental health warrant for emergency apprehension and detention for preliminary examination by a physician. Patient #2 was ordered to be apprehended at his current residency, [Named facility], obtain a medical clearance if necessary, and then transport to one of 5 named facilities providing psychiatric inpatient mental health services for the purpose of a preliminary examination. Physician Orders for Patient #2 revealed Admission Request, ED Observation: Misc, Pending labs/behavioral placement. 4/15/26 at 16:22. Ordered Q-15 minutes Observations for Patient #2, 4/15/26 at 21:02, for Suicidal Precautions. Review of Patient #2 ’ s Intake Assessment entered on 4/15/26 at 21:16 documented patient was a 78-year-old male that was a resident of the Long-Term Care [Named facility] and presented to the facility on an emergency detention order (EDO) that stated patient touched a female resident on her breasts. Presenting Problem: Assaultive, Other: sexually inappropriate. Dementia/confusion. Suicidal Ideation: None. Patient #3 Records: Review of Patient #3 ’ s Admission Assessment completed 4/15/26 at 22:46 documented Patient #3 was a 12-year-old male with active suicidal thoughts with a plan to cut his wrist when he is alone. Patient also reported hearing voices telling him to kill himself. Patient is a danger to self and unable to contract for safety. Review of the facility ’ s Environmental Risk Assessment provided, date unknown, indicated the intake lobby, hallway risks; “Patients always attended and monitored in intake” B.) Review of the facility ’ s Suspected Child, Disabled Person or Elderly Abuse/Neglect Policy and Procedure, #LD-1012, last reviewed/revised 07/2021, was identified as hospital-wide and indicated the following, in part: “It is the policy of [this facility], under the guidance of applicable laws, that any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect, shall report the information to facility management and to the appropriate regulatory agency. This report or communication is incumbent on the person who suspects” Definitions: 3. Neglect - failure to provide for a child’s basic needs necessary to sustain the life or health of a child, excluding failure caused primarily by financial inability unless relief services have been offered and refused. 4. Sexual Abuse - includes fondling a child ’ s genitals, .... II. Reporting Requirements: 2. All cases of suspected abuse/neglect should be reported to the appropriate authorities. A person, (including an employee, volunteer or other person) associated with the hospital, who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the hospital, who is receiving medical services, has been, is or will be adversely affected by abuse or neglect by any person shall, as soon as possible, report the information supporting the belief to the Department of Health, or the appropriate healthcare regulatory agency, by telephone, in writing or by personal visit. B. A report made to an appropriate agency/agencies no later than 48 hours after first suspicion. However, if the victim is in danger or emergent, the report must be made in less than 24 hours, or as soon as possible. Precautions must be taken to protect the victim. C. A report should be made to: 1) Local or state law enforcement or 2.) Texas Department of Family and Protective Services (DFPS): 1-800-252-5400. (www.dfps.state.tx.us) DFPS is appropriate to report to for child, disabled person, and elder suspected abuse or neglect.” Further review revealed the facility ’ s abuse/neglect reporting policy did not provide clear, facility-specific direction for reporting allegations of abuse, neglect, or sexual assault occurring within the facility to the appropriate agency, Texas Health and Human Services (HHSC), Health Facility Compliance (HFC). The policy did not address reporting expectations for allegations of patient-to-patient abuse, staff-to-patient abuse, abuse by an adult toward a minor, or staff neglect. In addition, the policy did not instruct staff that failure to maintain assigned supervision may constitute suspected neglect under Texas Administrative Code, Subchapter Q, Rule §1.204, “Abuse, Neglect, and Exploitation Defined.” C.) Review of the Texas Unified Licensure Information Portal (TULIP) for the facility revealed the facility did not submit a self-reported incident for the allegation of patient-to-patient abuse and staff neglect for failure to provide supervision to the appropriate state regulatory agency who has authority for allegations that occur within the facility through TULIP, or notification otherwise to Texas HHSC, HFC complaint intake and incident on behalf of Patient #1. Interview on 5/19/26 at 11:10 AM with the Vice President of Quality/Staff #6 confirmed the facility had not completed a self-reported incident of abuse and/or neglect on behalf of Patient #1 to the regulatory authority, Texas Health and Human Services; and had not completed a Root Cause Analysis (RCA) following the incident. Staff # 6 stated when the incident report came in, the allegation was that Patient #2 “hugged” Patient #1 “and potentially touched her breast.” Staff #6 said that Staff #5 should never have left anyone unsupervised. The incident was an “individual behavior,” and would not trigger an RCA unless there was a “process issue.” D.) Review of Staff #5’s Student and Group Transcript [Training] Record, generated 5/14/26, in her employee file revealed there was no documented evidence that she received the required eight hours of in-person training specific to identifying, preventing, and reporting abuse, neglect, and exploitation. Staff #1, Vice President of Behavioral Services, confirmed during an interview on 5/19/26 at 11:10 AM that behavioral health employees had not received a minimum of eight hours of in-person training specific to identifying, preventing, and reporting abuse, neglect, and exploitation. Staff #1 provided General Hospital Orientation training materials sent by email on 5/14/26 at 10:32 AM. The materials included Policy Number HR-1024, which addressed orientation content and included the topic, “c. How to recognize signs of abuse and/or neglect.” In addition, Staff #1 provided a HealthStream training module titled “Rights and Responsibilities Basics, Patient-Facing.” The module included a lesson titled “Abuse and Neglect,” which contained five slides addressing abuse and neglect. The slides defined types of abuse, identified signs of abuse, and referenced the duty to report suspected child abuse or neglect. However, the module did not provide facility-specific reporting instructions beyond directing staff to “Review facility policies for reporting all types of abuse.” Review of Texas Administrative Code (TAC), Title 25, Part 1, Chapter 1, Subchapter Q, Rule §1.204. Abuse, Neglect, and Exploitation Defined. (a) Abuse defined, [in part]. (1) Abuse of a child includes the following acts or omissions by any person: (A) mental or emotional injury to a child that results in an observable and material impairment in the child’s growth, development, or psychological functioning; (B) causing or permitting the child to be in a situation in which the child sustains a mental or emotional injury that results in an observable and material impairment in the child’s growth, development, or psychological functioning; (E) sexual conduct harmful to a child’s mental, emotional, or physical welfare; (F) failure to make a reasonable effort to prevent sexual conduct harmful to a child; (b) Neglect defined, [in part]. (1) Neglect of a child includes: (B) the following acts or omissions by any person: (iv) 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; or Review of TAC, Title 26, Chapter 568, Rule 568.121. Staff Member Training (a)(1)(D)(i)(ii)(I)-(III); staff to receive eight hours of training; specific for identifying, preventing, and reporting abuse, neglect, and exploitation in accordance with Texas Health and Safety Code §161.133, abuse, neglect, and exploitation (ANE).”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 41048 Based on review of records and interviews the facility failed to follow its policy and procedure “Patient Grievance Policy / Complaint Resolution” to ensure patient complaints, grievances, or allegations of abuse or neglect were documented and processed in a timely manner fashion in 1 of 1 patient’s (Patient # 1) record reviewed. A review of patient #1’s chart revealed she was admitted to the facility on 6/5/25 for Sepsis and End Stage renal disease requiring hemodialysis with a history of end stage renal disease, high risk for pressure injury of skin, diabetic ulcer of right foot, diabetic ulcer of left foot, Diabetic neuropathy, generalized abdominal pain, Class 1 obesity, Diabetes mellitus type 2 and difficulty walking. Patient #1, a 52 y/o female, presented to the ER with a history of end stage renal disease (ESRD) on peritoneal dialysis, nausea vomiting and diarrhea for 3 weeks. Patient #1 reported unknowingly injecting Ozempic daily instead of weekly and found to be sepsis secondary to acute cystitis with nausea, vomiting and diarrhea. The patient was admitted and treated with antibiotics, started on hemodialysis and had consultations for wound care and physical therapy and occupational therapy. The patient was discharged on 6/12/2025 to home with family. A review of the patient rounding log revealed that on 6/12/2025 at 9:53 AM patient #1 complained to the patient experience representative that she was left soiled for a long time and not cleaned until 6 am and that she wanted pain medication but was not administered any because she had been given pain medication already. The Medication Administration record for 6/11/2025 shows that she was medicated for pain at 11:28 PM. Reassessment done at 02:04 AM. There was no incident report, or a complaint or grievance entered for patient #1 concerning her complaints. The patient experience log showed that the charge nurse was notified, and that the unit director would be informed of the incident. No follow up with patient #1 was found. No documentation that the complaint was process as an unresolved complaint. (Look at this sentence so that it’s clearer to the reader) A review of the policy and procedure “ Patient Grievance Policy / Complaint Resolution” states, “POLICY It is DHR’s policy to document, address and resolve all verbal or written grievances received from patients, families, visitors, and other customers in a timely manner. DEFINITIONS Grievance: a formal or informal written or verbal complaint that is made to OHR or OHR employees by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to DHR’s compliance with the CMS Hospital Conditions of Participation (COPs), or a Medicare beneficiary billing complaint. Verbal Complaint: a verbal complaint is a patient grievance if: A. The complaint involves abuse, neglect, patient harm, or hospital compliance with COPs. B. It cannot be resolved at the time of the complaint by staff present. C. Is postponed for later resolution. D. Is referred to other staff for later resolution; or E. Requires investigation and/or requires further actions for resolution.” “PROCEDURE: ...3. Any OHR employee who receives a grievance from a patient, family, visitor or other customer will proceed as follows: i. Immediately attempt to resolve the identified concerns on the spot at the time the grievance is received. A. Grievances involving situations or practices that place the patient in immediate danger should be referred to the Charge Nurse or the department Director for immediate resolution. B. Grievances alleging patient, family member or visitor harm or those threatening legal action should be immediately forwarded to Quality Compliance Department and/or the Risk Management Department. ii. If unable to resolve the identified grievance at the time it is received (i.e., requires investigation or requires further action for resolution), then the OHR employee or department Director will immediately contact the Guest Relations Director who will document the grievance on the Service Recovery Form and attempt to resolve the issue and/or will involve appropriate hospital personnel for follow-up actions .... v. All grievances shall be attempted to be resolved within seven (7) business days from the date of grievance. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven (7) days from grievance receipt from the patient, family member or visitor, then the Patient Grievance Committee shall inform the patient, family member or visitor that OHR is still working to resolve the grievance and that OHR will follow-up with a written response within (30) thirty business days.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 21863 Based on record review and interview, the facility’s registered nurse failed to supervise and evaluate the nursing care in accordance with the patient’s needs, facility’s policy and procedures; and the physician’s order for 1 of 1 patient (Patient #1) reviewed with complaint allegations in the area of nursing services. Specifically, Patient #1’s Post Anesthesia Care Unit (PACU) record dated 10/30/23 from 12:18 PM to 8:45 PM (over 8 hours) did not include nursing documentation or monitoring for fluid output once the wound vac was placed and did not include assessment documentation of the wound site dressing after the initial post-operative assessment in order to ensure Patient #1 was free from surgical complications. Findings included: Review of Complaint Intake Information for TX00478758 dated 11/6/23 for Patient #1, revealed the following allegations: On 10/30/23 Patient #1 had a wound debridement on the left lower buttock. While in the recovery room, a wound vac was placed over the wound. Patient #1 had concern while in the Post Anesthesia Care Unit (PACU) due to the wound vac started to continuously beep. The nurse on duty was aware and stated it was not a concern. Patient #1 was then moved to an inpatient hospital room. The nurse on that unit said something was not right with the wound vac and she removed it; finding that Patient #1 was “bleeding profusely.” Patient #1 was then taken back into surgery and a blood transfusion was performed. Patient #1 was not provided with any explanation as to the reason for the bleeding or wound vac issues. Review of facility Policies and Procedures revealed the following: 1.) Intake and Output Guidelines Policy #: PC-3040, last reviewed/revised 09/23, in part; It is the policy to accurately measure the total amount of fluids taken in and eliminated by all routes to determine fluid balance status and needs -as ordered by a physician. PROCEDURE INDICATIONS MAY INCLUDE: o Physician orders “Intake and Output” o The nurse caring for a patient on I&O is responsible to ensure that accurate intake and output records are maintained. o The patient’s intake and output, by all routes, is accurately recorded on the patient’s chart. ASSESSMENT: o Physician’s order o Total output to include urine from bedpan, bedside commode, Foley catheter, emesis, blood loss, drainage from gastric decompression, wound drainage, paracentesis, thoracentesis or other procedure, i.e., Jackson Pratt DOCUMENTATION: o Total and record I&O each shift on graphic sheet and Cerner as appropriate. 2.) Postoperative Documentation Policy #: SUR-1113, last reviewed/revised 09/23, in part; o The postoperative nurse should provide quality nursing documentation that helps to ensure continuity of care, provides legal evidence of the processes of care delivered and supports evaluation of patient care. PROCEDURE: The postoperative nurse documents intake and output. o The postoperative nurse documents the plan of care, treatments, interventions, patient response and discharge planning including outcomes. 3.) Assessment Of Surgical Patients Policy #: SUR-1026, last reviewed/revised 09/23, in part; - The patient’s physiological response and tolerance to the procedure are continually reassessed throughout the operative experience by all members of the surgical team, including the Circulating RN and the anesthesia provider. Modifications and changes in the plan of care are based on reassessment data. - The patient’s postoperative status is reassessed upon admission, throughout the patient’s stay and upon discharge from the Post Anesthesia Care Unit (PACU). This information is documented on the PACU Record and communicated to the Nursing Services staff, who will continue the care of the patient. The data is available on the patient’s medical record to provide collaborative interdisciplinary care for the patient’s optimal and expedient recovery. Review of Patient #1’s PACU Post-Operative Report dated 10/30/23 from 12:18 to 20:45 documented the following: A.) Initial Post-Operative Assessment completed by Registered Nurse (RN) #2 at 12:18 checked the box indicating [surgical] dressing was “clean/dry/intact” with type: foam to left buttock. Wound Vac Continuous at 125 mmHg [millimeter of mercury]. Further review of the Post-Operative Report’s Nurse’s notes and additional notes revealed no further documentation regarding the surgical dressing. B.) In the area of Intake on the Post-Operative Report documented, “No IVF [Intravenous Fluids] in PACU.” The Output area of the Post-Operative Report was documented F/C [Foley Catheter] for Type and Amount of Output as; 1600 and 500 for the amounts, with no times. The nurse’s notes on the post operative report indicated the following at 12:38: Patient received from phase I, wound vac in place to left buttocks at 125 mmHg on continuous. Further review of the Post-Operative Report revealed there was not any documentation of the wound vac drainage fluids (output); to include if any fluids were captured from the wound vac into a reservoir/cannister. Review of Patient #1’s Intake and Output (I&O) orders from Physician #1 dated 10/30/23 at 16:32 indicated “routine” I&O orders. Review of Patient #1’s History and Physical dated 10/30/23 at 19:19 documented Patient #1 as a 50-year-old male with stage IV decubitus ulcer at the left gluteus. Patient admitted and underwent a left ischial decubitus debridement including bone with a wound VAC placement in preparation for definitive surgical intervention in 48-72 hours. Interview on 12/5/23 at 4:50 PM with Registered Nurse (RN) #1 who treated Patient #1 once transferred from PACU to the floor stated after she received Patient #1 from PACU, the CNA reported to her that Patient #1 wanted to talk to her because the wound vac kept beeping. RN#1 said she removed the blankets back from Patient #1 and saw bleeding from the wound vac bandage area. RN #1 said she cleaned up Patient #1 to make sure it was not old blood and then 30-45 minutes later, it continued to bleed out around the bandage, so she notified the Doctor reporting that it was, “bleeding like a faucet.” RN #1 said she had already changed out the gauze and it continued to soak up with blood. RN#1 told the Doctor that he needed to come and assess Patient #1 because there was “too much blood” and she was holding the gauze in the wound with her finger to keep the patient from bleeding out and his blood pressure dropping. RN #1 said the wound vac was “not working” for whatever reason that was; but thought it may be due to the foam placement. Interview on 12/5/23 at 5:13 PM with the Wound Care RN stated that output fluids from a wound vac should be documented in the patients record. The Wound Care RN stated the wound vac machine will alarm if there is a leak, or some type of malfunction. An alarm can occur if there is a kink in the hose, or the canister needs to be changed from the output, or there could be an issue with placement. The Wound Care RN stated there should be documentation in the patients record in the area of Wound Vac; however confirmed Patient #1 did not have any nursing documentation in the record related to the fluid output of the wound vac. Interview on 12/5/23 at 6:00 PM with the PACU LVN #1 stated that he cared for Patient #1 in phase 2 of the PACU while Patient #1 was waiting for a bed to transfer to the floor. LVN #1 said if the wound vac is alarming/beeping then it could be due to a “leaky seal”. LVN #1 stated when a wound vac alarms, that he verifies the seal and then verifies that there is drainage into the canister. LVN #1 stated he does not document in patient’s records the output of fluids that are captured from the wound vac; post-surgical. LVN #1 said that when he transfers a patient from PACU to the floor, he reports to the floor nurse if it’s the “first canister or not too much drainage.” LVN #1 confirmed there was not any documentation in Patient #1’s record regarding an output amount of fluids from the wound vac. LVN #1 also confirmed that he had not completed any documentation of the visualization of the wound dressing site to include if it was intact, bleeding, etc.”