Healthbridge Childrens’s Hospital of Houston

“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: 38387 Based on record review and staff interviews, the facility failed to meet the Conditions of Participation for Nursing Services as evidenced by: Nursing services failed to ensure there were doctor’s orders for each catheter change and followed facility policy for bladder scans for Patient #A. Refer to A0392 Nursing services failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility’s policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of six sampled patient (Patient #A), had renal kidney failure and the facility did not initiate their sepsis protocol and transfer the patient timely. Refer to A0395”

“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: 38387 Review of the facility policy, record review and confirmed in interview, the facility failed to provide patient care as ordered and per facility policy for one (Patient #A) of six patients reviewed. Nursing services failed to ensure there were doctor’s orders for each catheter change and followed facility policy for bladder scans for Patient #A. Findings included: Review of Patient #A medical record of the physical assessment from 02/11/2026 to 02/21/2026 indicated the following days when Patient #A had a catheter change: 02/09/2026; 02/16/2026, 02/20/2026. Review of Patient #A record revealed no documentation of the doctor’s order for the above catheter changes In an interview with Staff #14 on 04/22/2026 at 1:30 PM, he stated that as a quadriplegic, Patient #A having a cloudy urine was not a concern. He confirmed that a catheter change requires a doctor’s order. Review of the facility policy Bladder Scanning and Residual Care for Adults (last revised 12/01/2022), it stated, “the nurse will update the patients plan of care and medical record, and may include the following details: indication for bladder scan and date/time of bladder scan; pre-bladder scan voiding, if relevant; results of bladder scan in mL of urine within bladder; patients response/tolerance of the procedure; name of provider notified; comfort measures and patient education.” In review of Patient #A medical chart included the following nursing note (dated 02/21/26 at 8:53 AM) that indicated he had a bladder scan: “(2/20/26) Per report from [Staff # 10] pt [patient] has low urine output of about 350mls for her shift, BP and other vitals signs had been stable. On examination of pt at shift change, pt AAO x4, trach to vent, foley flushed, very turbid urine with creamy sediments seen in foley tube, bladder scan did not show urine retention. Vitals taken, BP 89/55, HR 106, Temp 98.3F, SAT 99% on Vent(AC). Notified [Staff #11] of patient’s low BP and low urine output with generalized edema. 98.9, SAT 97% on vent, pt easily rousable, BOLUS of one Liter 0.9% NS given intravenously via newly inserted midline (Right arm). Pt Still AAOx4. Bladder scan shows no urine, foley bag has about 50mls of amber colored urine with sediments” Review of Patient #A medical record revealed there were no documentation of the results of bladder scan in mL and/or any update to patient plan of care for the above bladder scan per facility policy. In an interview with Staff # 8 on 04/22/2026 at 1:30 PM in the conference room confirmed the above findings.”

“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: 38387 Based on review of facility policy, record review, and confirmed in interview, the facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility’s policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of six sampled patient (Patient #A), had renal kidney failure and the facility did not initiate their sepsis protocol and transfer the patient timely. Review of the facility policy Escalation of Medical Concerns (last revised 03/31/2026), it stated “because sepsis can progress rapidly, any concern for sepsis must trigger the escalation of medical concerns process without delay ...the NP [nurse practitioner] (if involved) should then document in the medical record the nature of the medical concern and the plan of care implemented to address the medical concern. If the NP cannot resolve the medical concern independently the NP shall call an appropriate physician for specific recommendations. If the patient cannot be stabilized after the recommendations of the appropriate physician are implemented, then an acute care transfer may be initiated under the direction of the physician overseeing the care of the patient during this acute change in medical condition ...patients meeting one or more of the following clinical criteria, including but not limited to those listed below, are presumed to require a level of care that is not available at Nexus ...sepsis with hemodynamic instability, rising lactate, or evidence of end-organ dysfunction requiring escalation beyond on-site capability.” In review of Patient #A medical chart included the following nursing note (dated 02/21/26 at 8:53 AM): “(2/20/26) Per report from [Staff # 10] pt [patient] has low urine output of about 350mls for her shift, BP and other vitals signs had been stable. On examination of pt at shift change, pt AAO x4, trach to vent, foley flushed, very turbid urine with creamy sediments seen in foley tube, bladder scan did not show urine retention. Vitals taken, BP 89/55, HR 106, Temp 98.3F, SAT 99% on Vent(AC). Notified [Staff #11] of patient’s low BP and low urine output with generalized edema. [Staff #11] gave orders to give IVF 0.9% NS x one Liter STAT, and continue monitoring 2205hrs (2/20/26)- After several attempts to insert an IV but nurses failed, [Staff #11] notified there is no IV access to administered IVF ordered. [Staff #11] gave new order to place a Midline STAT for IV access and for bolus fluid ordered. BP 85/59, HR 105, Temp 98.8, 97% SAT on Vent. One liter bolus of water was given over 2.5hrs via PEG tube. 2310hrs- BP 80/52 MAP 61, HR 108, Temp 98.8.97% SAT on vent, pt still AAO x4 and respond[ed] to commands appropriately. Requested order for Midodrine to help stabilize BP while waiting for midline placement. Midodrine order received and was administered 0100hrs (02/21/26) BP 81/47 MAP 59, HR 104, Temp 98.7, 98% on Vent. House Supervisor notified pt’s mother of current clinical status, also briefed pt’s mother about the requirement to insert a midline for planned clinical interventions. Patient’s mother gave telephone consent to insert midline. Pt still easily rousable but extremities are bit cold with weak pulse volume. Pt not confused, not disoriented 0400hrs(2/21/26) Midline inserted on right upper arm, procedure well tolerated. BP 76/42 MAP 55, HR 99, Temp 98.9, SAT 97% on vent, pt easily rousable, BOLUS of one Liter 0.9% NS given intravenously via newly inserted midline (Right arm). Pt Still AAOx4. Bladder scan shows no urine, foley bag has about 50mls of amber colored urine with sediments 0620hrs on 02/21/2026 -Notified [Staff #11] again about pt’s response to total of 2 Liter Bolus given, namely, BP still low 79/49 after interventions, HR 108, emphasis made about pt’s propranolol and NP [Staff #11] gave order to HOLD PROPRANOLOL for now, urine output in last 12 hrs was 120mls Dark amber turbid urine with creamy sediments, Temp now 99.1, SAT 94% on vent, limbs extremities are a bit cold with weak volume pulses but pt still AAO x4. No change in baseline of pt’s sensorium. [Staff #11] gave new orders, STAT CBC, CMP, hold propranolol, start new 0.9% NS at 100cc/hr Orders executed 0713hrs on 02/21/2026, House supervisor removed hold foley, inserted new foley (18FR), urine sample collected for urinalysis and reflex culture. Suprapubic fullness noted at this time, about 500mls of red colored urine was collected in new foley bad and suprapubic fullness/tightness was relieved/softened.” Further review of Patient #A chart revealed another nursing note (dated 02/21/2026 at 12:00 PM): “[Staff #12] assumed care from 7a-7pm, received report from nightshift nurse that patient hypotensive and decreased urinary output overnight with covering provider and Charge nurse/NOA notified, Respiratory Therapist, NOA and writer at bedside for ongoing assessment. Foley catheter changed twice due to decreased urinary output, and large amount of serosanguinous blood observed during catheter change. Received new order for Sepsis work up protocol, collected blood cultures, urine culture and lactic acid and sent to lab. Received critical lab result for Creatinine: 4.67 and Lactic Acid: 38.7, covering provider and NOA notified. Received new order for patient to start on levophed r/t hypotension, hung by NOA. Received new order from [Staff #11] to transfer patient Texas Children’s Hospital, The Woodlands Campus related to hypotension and decreased urinary output. Report called to TCH ED and given to EMS paramedics at bedside” Review of Patient #A chart revealed the following critical labs and times that providers and/or nurse were notified. ABG pH of 7.262 (critical <7.3) on 02/21/26 at 7:50 AM to Staff #13 Creatinine of 4.67 mg/dL (normal range 0.60-1.30 mg/dL) and a lactic acid of 38.7 mg/dL (normal range 4.5-19.8 mg/dL) on 02/21/26 10:46 AM and 02/21/26 11:12 AM respectively to Staff #12. In an interview with Staff #14 on 04/22/2026 at 1:30 PM in the conference room, he stated that Patient # A was assessed earlier in the day on 02/20/2026 and was stable for discharge with no medical concerns. He stated that IV antibiotics were ordered in the morning (02/21/26) after lab results from morning bloodwork. He stated that after Patient #A showed signs of renal failure that they could no longer treat him at their facility. “He needed to be transferred out.” Review of the ambulance run record revealed a 911 call was placed to them on 02/21/2026 at 11:34 AM and was on site 11:48 AM. EMS assessment at 2/21/26 at 11:53 AM revealed Patient # A skin “cold’ and mental status “unresponsive”. Review of the EMS run record included the following narrative: “Upon arrival to scene, pt [patient] was laying semi fowlers in a hospital bed at the facility. Staff reports pt is a GSW victim from 2025 and is a quadriplegic with a tracheotomy. Staff reports pt has been hypotensive since this morning around shift change, but staff wasn’t able to provide an accurate timeline prior to shift change when pt was at baseline. Staff reports pt is normally GCS 15 and is able to mouth answers. Staff reports a decrease in urine output over night which caused them to replace pt’s foley and then they noticed blood in the foley. Staff had pt on 4 mcg/min Norepi. Pt’s vitals were assessed and pt was tachycardic, but no blood pressure was able to be obtained. Pt was moved to EMS vent and Norepi pump. Pt was transferred to stretcher via sheet Lift. Pt was secured to stretcher per protocol. Treatment: PE was placed on EMS vent with identical settings. Norepi was started at 4 mcg/min but was increased over the transport time to 30 mcg/min with additional push doses administered due to multiple hypotensive or no reading of blood pressure. Fluids were administered as well. Pt’s vitals were monitored enroute and pt remained severely hypotensive. Upon arrival to ER, pt was triaged and assigned to MTR B. Pt was transferred via sheet lift to ER bed. Pt report was given to ED staff and care was transferred.” Review of the ED records revealed Patient # A arrived on 02/21/2026 at 12:45 PM. He was diagnosed with hypotension, hematuria and “critically ill due to fluid-refractory shock, likely sepsis” with vitals BP 96/51 | Pulse (!) 129 | Temp 98.7 °F (37.1 °C) (Axillary) | Resp 16 | Wt 124 kg (273 lb 5.9 oz) Comment: with SCDs | SpO2. After a few hours of medical interventions, facility attempted to life flight him to the sister ED facility in Med Center for higher level of care. During transfer, Patient #A was in V-tach without a pulse. They continued compressions but were unsuccessful. Patient # A died on 02/21/26 at 4:24 PM. In an interview with Staff #8 on 04/22/2026 at 10:40 AM in the conference room, she stated that she is unsure of why there was a delay in Patient #A transfer. She confirmed that if a patient required transfer to an acute care facility, they simply call 911 and the ambulance comes right away.”

“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: 38387 Based on review of facility policy, random record review, and confirmed in interviews, the facility’s nursing services failed to supervise and evaluate the nursing care for each patient for one of six patients reviewed (Patient #A). Facility nursing failed to assess and promote healing of bruising found for Patient #A. Findings included: Review of Patient #A chart revealed he is a 14-year-old male with a complex medical and neuropsychiatric history, including hypoxic ischemic brain injury, septic shock, cerebellar ischemia, epilepsy, and severe behavioral dysregulation. He admitted to the facility with a plan for medication management of severe behavioral aggression and rehab. Review of the facility policy Wound and Pressure Injury Prevention and Management (revised 10/30/2023) and Wound Care Team Protocols (SOP/WOU-012 reviewed 04/2019) revealed no procedure for assessing and reassessing for bruising. Further review of Patient #A chart revealed a nursing assessment on 03/01/2026 at 8:05 PM that included bruising in the left and right eye. No further assessment was found as to what intervention was provided to promote healing for the bruising. No incident report was available for review to account for the injury. In an interview with Staff #2 on 03/09/2026 at 2:10 PM in the conference room, she confirmed the above 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: 35028 . Based on observation, interview, and record review, the facility failed to ensure that the emotional health and well-being of Patient #1 was protected. This failure resulted when Patient #1, a 12-year-old patient, who shared a “Jack and Jill” bathroom with Patient #2, a 20-year-old patient, was touched inappropriately by Patient #2. Findings were: Review of the facility’s website, Nexus Health Systems, showed: “Inpatient pediatric specialty care for profound autism ... Nexus Children’s Hospital - Houston provides ... structured, inpatient care for children ages 4 up to 18 with severe autism and other intellectual or developmental disabilities.” https://nexushealthsystems.com/locations/nexus-childrens-hospital-houston/ Review of policy “Abuse, Neglect & Exploitation” last revised 01.2025 showed, “Patients have a right to be free from abuse, neglect, and exploitation, and feel safe in their care setting.” Review of “Patient Rights and Responsibilities” showed, “Rights Related to Care ... Receive physical and emotional care in a safe setting, which includes environmental safety ... to the extent the facility can control that environment.” During a tour of the North Unit on 9.10.2025 at 10:22am, it was observed that the North Unit had 10 beds. CCO Staff B explained during the tour that the North unit programmed patients with very limited to no communication. It was observed that bedrooms 309 and 310 had a shared common bathroom. The bathroom had two separate entrances, one for each of the adjoining bedrooms, allowing the patients to use the facilities privately from their rooms. Each bedroom had a door to the hallway. Other “Jack & Jill” bathrooms on the North Unit were observed, and included bedrooms 303 - 304, 305 - 306, and 307 - 308. Bedrooms 301 and 302 were private bedrooms with private bathrooms. Review of the Staff Assignment for 8.28.2025 showed that Patient #1 was assigned to bedroom 310 and Patient #2 was assigned to bedroom 309. (As noted above, bedrooms 309 and 310 were adjoining bedrooms with a shared common bathroom.) Record review of the “Pre-Admission Evaluation” for Patient #1 by RN Staff T and LMSW Staff U dated 3.21.2025 showed an 11-year-old male. Admitting Diagnoses: Autism Spectrum Disorder, Intellectual Development Disorder, Full Incontinence of Feces, Fecal Smearing, Non-suicidal Self-Harm, Attention Deficit Hyperactivity Disorder, Cognitive Delays, Urinary Incontinence, Child in State Custody, and Wandering. Record review of the “Pre-Admission Evaluation” for Patient #2 by MD Staff V dated 11.20.2023 showed an 18-year-old male with increasing agitation, dysregulation and impulsivity. Admitting Diagnoses: Autism Spectrum Disorder, Obsessive Compulsive Disorder, Tourette’s, Intellectual Disability, Anxiety, Agitation, Disruptive Moo Dysregulation Disorder, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection, Seasonal Asthma, Expressive Language Delay, Chronic Vocal or Motor Tics, and Severe Elopement. In an interview with Quality Director Staff K on 9.10.2025 at 12:09pm, she stated that Behavioral Manager Staff L reported on 8.27.2025 that she observed Patient #2 attempting to go into Patient #1’s bedroom. Patient #2 ran from his bedroom through the adjoining bathroom into Patient #1’s bedroom. Staff K further stated she saw Patient #2 “attempting to pull Patient #1’s pants down.” In an interview with Quality Director Staff K on 9.10.2025 at 12:10pm, she stated that CNA (Certified Nursing Assistant) Staff M reported on 8.27.2025 that Patient #2 went into Patient #1’s bedroom through the bathroom. “Earlier before this incident, Patient #1 had his shirt off and when asked what happened, he pointed at Patient #2.” She also stated she saw Patient #2 “attempting to pull the pants [of Patient #1] down.” Review of a progress note in Patient #2’s medical record by RN Staff P on 8.26.2025 at 7:30pm showed documentation that supports the above interview with CAN Staff M. RN Staff P further wrote, “Provided numerous redirections to prevent the patient [Patient #2] from entering the other patient’s room [Patient #1] and from touching the other patient inappropriately.” This information was also captured in an occurrence report completed by RN Staff P, dated 8.28.2025. Review of progress note in Patient #2’s medical record by RN Staff Q on 8.26.2025 at 10:40pm showed, “This nurse told the patient’s mother what the day nurse told her in report about” Patient #2 taking off Patient #1’s shirt, and trying to take off a Patient #1’s pants while Patient #1 was “sitting on the toilet.” In an interview with Quality Director Staff K on 9.10.2025 at 12:15pm, she stated that NP (Nurse Practitioner) Staff O reported on 8.27.2025 that prior to the incident between Patient #1 and Patient #2 on 8.26.2025, she provided a safety plan for Patient #2 when he transferred to the North Unit. She went on to say that she recommended that Patient #2 NOT be placed in the bedroom that shared a bathroom with Patient #1 because Patient #2 “tends to pick on younger patients.” Her recommendation was that Patient #2 be placed in a bedroom that did not have a shared bathroom. She concluded by saying that MD Staff H stated it was okay for Patient #1 and Patient #2 to be in bedrooms that shared a common bathroom. Review of an occurrence report by Case Manager Staff R dated 8.27.2025 showed that NP Staff S notified Staff R of the documentation in Patient #2’s chart of the incident between him and Patient #1. NP Staff S was concerned that this information was not documented in Patient #1’s medical record. Case Manager Staff R wrote following the incident that she observed Patient #1 on the unit, in his bed asleep and would not get up when asked to ... [He] appeared to get upset” with staff attempting to wake him up. This was not Patient #1’s “usual time to nap” nor was it “typical behavior.” Patient #1’s “behaviors have been escalating again over the last week or so including disrobing, “behavior that had almost gone away.” .”

“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: 38387 Based on review of facility policy, patient record review, and confirmed in interview, the facility failed to ensure the rights of one of five patients (Patient #A) to be free from all forms abuse, as shown by facility’s failure to investigate sexual allegations. Findings included: Review of facility policy Abuse, Neglect, Exploitation dated 05/2005 stated that “...The investigation will be initiated immediately upon receipt.... identify the victim, the suspected perpetrator, witnesses and others who may have knowledge of the alleged incident...take steps to prevent further potential abuse..protect the victim by providing a safe location, provide medical care as ordered and increase clinical assessments as needed “ Review of Patient #A record revealed the following nursing note from Staff #6 on 12/24/2024, “By morning nurse patient was concerned about someone been entering her room and presumably been touching doing something to her during nightshift, morning nurse also stated that, the patient was complaining about having pain in her private parts and she [hear] from other peers that maybe someone at night was raping her or doing something.” Review of Patient #A record revealed a psychiatry (Staff #3) progress note on 12/26/2024 that included an assessment “she endorsed groin pain and which requires further investigation and has been relayed to her medical team.” In an interview with the Staff #4 on 02/12/2025 at 10:40 AM, she stated that she vaguely remembers an assessment with Patient #A performed by another provider that Patient #A mentioned that that incident had been a dream. No documentation of the above assessment was available for review. In an interview with Staff #1 on 02/12/2025 at 10:00 AM, she stated that there had been an investigation into her allegations where the facility reviewed video and conducted interviews of staff and patients. However, review of incident reports available revealed no documentation of an investigation from the 12/24/2024 Patient #A outcry.”

“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: 37322 Based on observation, record review and interview the facility failure to ensure the crash cart and defibrillator were checked daily per hospital policy. Findings include: The hospital policy revised on 10/17/23 titled “Crash Cart”, stated “the House Supervisor will check the crash cart/defibrillator monitor every 24 hours.” Observation on 05/23/2024 at 1109 of the North Unit revealed the crash cart had not been checked on 05/14,5/18, and on 5/19/2024. Interview with the nurse manager (ID#2) during the observation, verified the findings.”