Nexus Childrens Hospital Dallas

“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: 37325 Based on record review and interviews, the hospital failed to have an organized nursing service for one of one patients (Patient #1) when two nurses on two consecutive days administered a dosage of Patient #1’s muscle relaxant that came close to three times the daily recommended amount. On the third day, nursing administered a dose almost double the daily recommended amount before the excessive medication doses were discovered. Patient # 1 experienced very low respiratory rates with physician observed increased respiratory efforts, increased sleepiness, and seizure-like activity that required an increase in the patient’s anti-seizure medication. Cross refer: A0405.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37325 Based on record review and interview, the facility failed to provide drugs and biologicals in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. for 1 of 1 (Patient #1) patients when nursing staff administered a muscle relaxant medication close to three times the daily recommended dose on two consecutive days and almost doubled the daily dose on the third day. During those days, Patient #1 was noted with a very low respiratory rate and required an increase in his antiseizure medication. Findings included: Patient #1 was an 18-year-old male who had suffered a traumatic brain injury. The patient had undergone surgery at an outside hospital and was re-admitted to the facility on 01/31/26. The Discharge Medication List from the transferring facility listed the patient’s Baclofen, a muscle relaxant, dose as 50mg every six hours (Q6H). Upon re-admission to the facility on 01/31/26 at 06:35 PM, Personnel #11 wrote an order to give Patient #1 Baclofen 50mgs Q6H. Record review of Patient #1’s Medication Administration Record reflected Personnel #7 reviewed the order on 01/31/26 and cleared the medication to be administered by nursing services. Record review of Patient #1’s Medication Administration Record reflected Personnel #10 acknowledged the order on 01/31/26 at 09:00 PM. According to Patient #1’s Medication Administration Record review, Patient #1 received Baclofen 50mgs on 01/31/26 at 11:53 PM, on 02/01/26 at 05:45 AM, 12:19 PM, 06:04 PM and 11:35 PM. Patient #1 received Baclofen 50mgs on 02/02/26 at 05:20 AM, 12:47 PM, and 06:08 PM. Patient #1 received Baclofen 50 mgs on 02/03/26 at 12:29 AM, 05:39 AM, and 12:24 PM. Patient #1 received a total of 200mgs of Baclofen on 02/01/26, 200mgs of Baclofen on 02/02/26, and a total of 150mgs of Baclofen on 02/03/26. The high doses were administered by Personnel #8, #9, and #10. The Attending Progress Note dated 02/03/26 at 06:40 PM reflected ...”Appears more sleepy with hyperventilation noted on exam. Over the last 48 hours, family reporting more sleepiness with intermittent hypotension ...as well as possible twitching episodes that resolved without clinical intervention. Keppra was increased from 500mg BID [twice daily] to 750mg BID yesterday given concern for possible seizure activity ...Close evaluation of medication list revealed high Baclofen dose at 50mg q6h ...” A review of Patient #1’s vital signs reflected the patient had a respiratory rate of 11 breaths per minute on 02/02/26 at 08:00 AM; his respiratory rate had decreased to 6 breaths per minute. The following day, on 02/03/26, Patient #1 had continued low respiratory rates of 7 breaths per minute at 08:00 AM, 6 breaths per minute at 12:00 noon, 6 breaths per minute at 04:00 PM and 08:00 PM, and 7 breaths per minute at 11:59 PM. The Cleveland Clinic (2023) noted that adults aged 18-50 have a typical respiratory rate of 12 to 20 breaths per minute, and rates below the typical rate, bradypnea, meant that body cells “may not get enough oxygen ...” (Bradypnea: Causes, Symptoms, Diagnosis & Treatment). During an interview on 03/19/26 at 12:16 PM Personnel #4 stated the Nurse Practitioner came to him after the patient seemed strange and more sedated. Personnel #4 stated that they “ran through the patient’s medications” and noticed the order for Baclofen “was high.” Personnel #4 stated that a patient should not get more than 80mg of Baclofen per day denied awareness of any reason for that high of a dose. During an interview on 03/19/26 at 11:57 AM Personnel #7 stated that, according to standard patient hospital admission procedure, the practitioner would write orders, and a pharmacist would review the order entry. Personnel #7 stated that when Patient #1 was admitted the Nurse Practitioner wrote the orders, the on-call Pharmacist reviewed the orders but “did not catch” the error. During a medical record review on 03/19/26 ending at 03:35 PM Personnel #1 confirmed the above findings. The policy titled Medication Administration dated 05/02/23 reflected ...” Procedure C. The pharmacist determines if a medication order is appropriate ... IV. Administration Process ...v. Verifies that the medication is administered in the correct dose and that the dose does not reflect an unsafe dosage level ...” The Food and Drug Administration (2021) Baclofen Label reflected ... “The maximum dosage is 80 mg daily (20 mg four times a day) ... 10.1 Symptoms of Baclofen Overdose: With overdose of baclofen, patients may present in coma or with progressive drowsiness, lightheadedness, dizziness, somnolence, accommodation disorders, respiratory depression, seizures, or hypotonia progressing to loss of consciousness ...” https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215422lbl.pdf”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37325 Based on record review and interview the facility failed to provide care in a safe setting for 16 of 16 (Patients #1, #2, #3, #4, #5, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, and #19) patients in that the facility failed to implement and train staff on the temporary emergency evacuation action plan prior to shutting down all elevators in the facility on 07/17/25. Cross refer: A144”

“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: 37325 Based on record review and interview the facility failed to provide care in a safe setting for 16 of 16 (Patients #1, #2, #3, #4, #5, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, and #19) patients in that the facility failed to implement and train staff on the temporary emergency evacuation action plan prior to shutting down all elevators in the facility on 07/17/25. Findings included: Observations on 07/30/25 at 10:50 AM reflected ....The facility consisted of three floors and included a lower floor, a first-floor rehabilitation and transition care unit, and second floor behavioral health unit. The facility had two elevators that serviced the patient care areas. Both elevators were nonfunctional as observed during a previous visit on 07/03/25. On 07/17/25 both elevators for the patient care areas were taken out of service per Personnel #5. The Alternative Life Safety Measure document reflected ...”Date Deficiency Identified: 07/03/25 ... Deficiency Description ...facility elev.(elevator) Currently out of service ...Corrective Action Plan ...Estimated Date of Repair/Resolution” 6/8 weeks ...As part of our ongoing commitment to safety and facility improvements, the elevator in question Has already been approved for full modernization. The project is currently in progress and is expected to take approximately 6 to 10 weeks ...” The Temporary Emergency Evacuation Action Plan (no date) reflected ...”2. Alternative Evacuation Methods: Emergency Evacuation Sleds (for patients and staff needing assistance) Bed Mattress Drag Method (last resort in life-threatening situations) ...3. Staff Education and Training Plan: A. Initial Training: -All clinical and support staff will undergo mandatory in-service training on: -Location and proper use of evacuation sleds-Mattress evacuation technique (drag and carry methods) ...” During a tour of the facility on 07/30/25 at 10:50 AM Personnel #6 and Personnel #7 were asked if they had received training on how to evacuate a non-ambulatory patient in the case of an emergency.? Personnel #6 and Personnel #7 both stated they had “not received any training since the elevators had been taken out of service.” During an interview on 07/30/25 at 11:05 AM Personnel #1 stated all current patients on the second floor were ambulatory. Personnel #1 stated “the facility developed a plan to evacuate a non-ambulatory method using a mattress if needed prior to the evacuation sleds that were ordered being delivered.” When asked if the staff had received training on the mattress method, Personnel #1 stated “not yet.” During an interview on 07/30/25 at 11:53 AM Personnel #5 stated” the facility had ordered a sled for evacuation” but it had not arrived at the facility yet. Personnel #5 stated the facility had not provided staff training on how to evacuate a patient via the mattress method. During an interview on 07/31/25 at 10:14 AM Personnel #5 stated all elevators were out of service on 06/11/25, 06/14/25, 06/15/25, 06/16/25, 06/17/25, and 06/18/25. The facility made the decision to “take all elevators out of service on 07/17/25 after the Action Plan had been developed.” During a telephone interview on 07/30/25 at 05:28 PM Personnel #8 stated they “had not received training on how to evacuate a non-ambulatory patient in case of an emergency.””

“ORDERS FOR RESPIRATORY SERVICES CFR(s): 482.57(b)(3) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 37325 Based on record review and interview the facility failed to provide services under the orders of a qualified and licensed practitioner for 1of 1 (Patient #1) patients in that a respiratory therapist applied oxygen to Patient #1 without a qualified practitioners order twice within approximately five hours the night of 07/12/2025 and 07/13/2025 Findings included: Patient #1 was 15-year-old with a history of obstructive sleep apnea. The record titled Edit Oxygen Delivery dated 07/12/25 at 11:48 PM reflected ...”RN (Registered Nurse) called for RT [Respiratory Therapy] for lower O2 sats [oxygen saturation]. Patient 90-91% when RT arrived. Placed on 1 L (liter) O2 patient came up to 99” Patient #1’s record titled Edit Oxygen Delivery dated 07/13/25 at 05:12 AM reflected ...”RT came to reassess patient ...Liter flow turned up to 3L ...” During an interview on 07/30/25 at 11:43 AM Personnel #4 stated the hospital policy allowed the Respiratory Therapist to stabilize the patient and then call for an order for oxygen. Personnel #4 stated he did not see an order for oxygen in the record until 07/14/25, approximately 24 hours later. The policy titled Oxygen Therapy dated 12/02/2024 reflected ...”Respiratory care staff and/or qualified nursing staff may set up and discontinue oxygen therapy as per physician or NP (Nurse Practitioner) order. In the event, when a physician is not at bedside, staff may provide sufficient FiO2 to resolve cyanosis and immediately notify the physician or NP of the patient’s condition and obtain further orders ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37325 Based on record review and interview the facility failed to administer drugs in accordance with the order of the practitioner and accepted standards of practice for 1 of 1 (Patient #1) patients. Findings included: Patient #1 received an order for Haldol 2.5mg PO (by mouth) Q6HR (every 6 hours) PRN (as needed) for agitation/Aggression. Patient #1 was administered Haldol 2.5 mg on 01/08/25 at 05:34 PM, 01/10/25 at 09:06 AM, 01/12/25 at 06:06 PM, 01/13/25 at 06:50 PM, 01/16/25 at 06:46 AM, 01/25/25 at 06:03 AM, 01/29/25 at 06:28 AM, 01/30/25 at 10:56 AM and 02/25/25 at 08:19 AM. Based on record review there was no documentation to justify the reason the medication was administered and no documentation of the effectiveness of the medication. Patient #1 received an order for Ativan 1mg PO Q8HR PRN for agitation/Aggression. Patient #1 was administered Ativan 1mg on 03/04/25 at 06:34 AM, 03/05/25 at 07:11 AM, 03/06/25 at 06:43 AM, 03/09/25 at 12:30 PM, and 03/10/25 at 12:45 PM. Based on record review there was no documentation to justify the reason the medication was administered and no documentation of the effectiveness of the medication. During a record review ending at 12:15 PM on 07/03/25 Personnel #2 verified the above information. The policy titled Medication Administration last revised 05/02/23 reflected...”B...xiv Monitor the effects of the medication to ensure effective patient response...””

“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: 33589 BASED ON observation, record review, and interviews, the facility to ensure all patients recieve care in a safe setting. One of 20 patients (Patient #1) on 2/09/2025 suffered a fall from the crib when the side rail of the crib was left in the down position by the Registered nurse (RN). FINDINGS Patient #1 is a 5 year old little girl brought by a family member to the boarder for medical care. During an observation of Patient #1’s diaper change in room 117 on 2/13/2025 at 10:56 AM with Personnel #1: Personnel #7 prepared supplies for the change. Personnel #8 was present. The supplies were placed on the crib mattress. The crib rail was lowered. Patient #1 opened her eyes and moved her mouth spontaneously to touch and throughout care. Patient #1 did not cry but made small little noises. Personnel #7 stayed with Patient #1 at all times. Patient #1 was rolled to see there was no bruising to the hip/thigh/ischial areas. When the diaper change was complete, Personnel #7 propped the patient into a right sided turn with pillows. Once the positioning was complete, Personnel #7 raised the crib side rail. Patient #1 squirmed and tensed/arched her back throughout the change and positioning. Patient #1 squirmed and tensed/arched until she returned unassisted to her back. During record review and interview on 2/13/2025 at 11:08 AM, Personnel #5 navigated the record and confirmed the findings. The fall and post fall information was documented by the nurse, respiratory therapy, and the physician. ~ History and Physical by Physician #6 noted, “1/21/2025...She did not meet any of the developmental milestones, is unable to sit, stand, or walk, is nonverbal...stiff limbs from contractures, spasticity...incoordination...Physical Exam...extremely underweight and malnourished...atraumatic microcephalic...dysconjugate gaze, does not appear to track...aphasia expressive, aphasia receptive, spastic quadriplegia with limbs held in extension and contractures of all four extremities...a complex medical history including congenital microcephaly, spastic quadriplegia, global development delay, seizure disorder, feeding difficulties with concern for dysphagia and severe malnutrition...Problem List: CP (Cerebral Palsy)/Microcephaly ...” ~ Nurse Notes by Personnel #4 noted, “2/10/2025 7:24 AM...2225 (10:25 PM) upon changing the patient diaper, nurse turn and reach over to grab the patient’s diaper bed rail in down position and patient rolled to her left side falling in between bed and seizure padding...” ~ Physician Progress note by Physician #6 noted, “2/10/2025... fell out of bed last night when the side of the crib was left down. Per nurses report she landed on her feet with her legs straight due to chronic hyperextension from her CP (Cerebral palsy/Microcephaly) contractures. Long bone films showed no fractures...” During an interview on 2/13/2025 at 8:55 AM in the board room, Personnel #3 (Personnel #1 and #2 were present) was conferenced on video via computer. They were asked about the incident. Personnel #3 confirmed and discussed the fall, post fall actions, and the in-process investigation. Personnel #3 stated, “After the fall on South (unit), the doctor came in and assessed the patient. Patient #1 was stable and fine. Skeletal series (x-rays) were completed to make sure. They (staff) said she fell from the crib. Fell on the side. Post assessment was good. No head strike but hip and leg. The post fall assessment, and incident report were completed. We are not completed with the investigation yet.” During a telephone interview on 2/13/2024 ending at 2:24 PM, Personnel #4 stated, “I came back in and started changing her. I realized I had grabbed the smaller size (diaper.) I turned around to get the bigger one on the chair. She (Patient #1) tends to like the left side and had squirmed off to the left. She fell down...” The facility’s 9/19/2022 Patient Rights and Responsibilities Policy required, “Receive physical and emotional care in a safe setting, which includes environmental safety, infection control and access to protective/security services; to the extent the facility can control that environment...Be free of all forms of abuse, neglect, exploitation, and harassment...” The facility’s 2/06/2024 last revised Assessment and Re-assessment Policy required, “The assessment of the patient is an ongoing process from the start of care through discharge. Each patient admitted to Nexus Children’s Hospital-Dallas (NCHD) shall receive a complete assessment by a qualified individual so that a plan of care may be developed to best meet the needs of the patient...” The facility’s 6/19/2023 Fall Prevention Policy required, “identify patients who are at risk for falling and to outline strategies used to develop patient specific or individualized plans of care to reduce falls and fall-related injuries...Beds will be in low position with brakes on unless treatment needs require otherwise. After procedures, the bed will be returned to the low position...Assess your patient ’ s need for 1:1 supervision...Consider fall prevention in nursing care plan...Modify patient’s plan of care based on risk factors leading to fall...””

“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: 33589 BASED ON observation, record review, and interviews, the facility registered nurse (RN) failed to supervise the nursing care of Patient #1 on 2/09/2025 in accordance with the patient’s needs. Patient #1 suffered a fall from the crib when the siderail of the crib was left in the down position. FINDINGS Patient #1 is a 5 year old little girl brought by a family member to the boarder for medical care. During an observation of Patient #1’s diaper change in room 117 on 2/13/2025 at 10:56 AM with Personnel #1: Personnel #7 prepared supplies for the change. Personnel #8 was present. The supplies were placed on the crib mattress. The crib rail was lowered. Patient #1 opened her eyes and moved her mouth spontaneously to touch and throughout care. Patient #1 did not cry but made small little noises. Personnel #7 stayed with Patient #1 at all times. Patient #1 was rolled to see there was no bruising to the hip/thigh/ischial areas. When the diaper change was complete, Personnel #7 propped the patient into a right sided turn with pillows. Once the positioning was complete, Personnel #7 raised the crib side rail. Patient #1 squirmed and tensed/arched her back throughout the change and positioning. Patient #1 squirmed and tensed/arched until she returned unassisted to her back. During record review and interview on 2/13/2025 at 11:08 AM, Personnel #5 navigated the record and confirmed the findings. The fall and post fall information was documented by the nurse, respiratory therapy, and the physician. ~ History and Physical by Physician #6 noted, “1/21/2025...She did not meet any of the developmental milestones, is unable to sit, stand, or walk, is nonverbal...stiff limbs from contractures, spasticity...incoordination...Physical Exam...extremely underweight and malnourished...atraumatic microcephalic...dysconjugate gaze, does not appear to track...aphasia expressive, aphasia receptive, spastic quadriplegia with limbs held in extension and contractures of all four extremities...a complex medical history including congenital microcephaly, spastic quadriplegia, global development delay, seizure disorder, feeding difficulties with concern for dysphagia and severe malnutrition...Problem List: CP (Cerebral Palsy)/Microcephaly ...” ~ Nurse Notes by Personnel #4 noted, “2/10/2025 7:24 AM...2225 (10:25 PM) upon changing the patient diaper, nurse turn and reach over to grab the patient’s diaper bed rail in down position and patient rolled to her left side falling in between bed and seizure padding...” ~ Physician Progress note by Physician #6 noted, “2/10/2025 17:33 (5:33 PM) fell out of bed last night when the side of the crib was left down. Per nurses report she landed on her feet with her legs straight due to chronic hyperextension from her CP (Cerebral palsy/Microcephaly) contractures. Long bone films showed no fractures...” During an interview on 2/13/2025 at 8:55 AM in the board room, Personnel #3 (Personnel #1 and #2 were present) was conferenced on video via computer. They were asked about the incident. Personnel #3 confirmed and discussed the fall, post fall actions, and the in-process investigation. Personnel #3 stated, “After the fall on South (unit), the doctor came in and assessed the patient. Patient #1 was stable and fine. Skeletal series (x-rays) were completed to make sure. They (staff) said she fell from the crib. Fell on the side. Post assessment was good. No head strike but hip and leg. The post fall assessment, and incident report were completed. We are not completed with the investigation yet.” During a telephone interview on 2/13/2024 ending at 2:24 PM, Personnel #4 stated, “I came back in and started changing her. I realized I had grabbed the smaller size (diaper.) I turned around to get the bigger one on the chair. She (Patient #1) tends to like the left side and had squirmed off to the left. She fell down...” The facility’s 9/19/2022 Patient Rights and Responsibilities Policy required, “Receive physical and emotional care in a safe setting, which includes environmental safety, infection control and access to protective/security services; to the extent the facility can control that environment...Be free of all forms of abuse, neglect, exploitation, and harassment...” The facility’s 2/06/2024 last revised Assessment and Re-assessment Policy required, “The assessment of the patient is an ongoing process from the start of care through discharge. Each patient admitted to Nexus Children’s Hospital-Dallas (NCHD) shall receive a complete assessment by a qualified individual so that a plan of care may be developed to best meet the needs of the patient...” The facility’s 6/19/2023 Fall Prevention Policy required, “identify patients who are at risk for falling and to outline strategies used to develop patient specific or individualized plans of care to reduce falls and fall-related injuries...Beds will be in low position with brakes on unless treatment needs require otherwise. After procedures, the bed will be returned to the low position...Assess your patient ’ s need for 1:1 supervision...Consider fall prevention in nursing care plan...Modify patient’s plan of care based on risk factors leading to fall...””