Red River Hospital

“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: 33579 Based on Record Review, and Interview, the hospital failed 1 of 1 Patient (Patient #1), by failing to provide care in a safe setting. The patient had a change of condition. The communication was not shared with the RN on duty. The RN on duty did not properly complete a nursing assessment and document on Patient #1. Findings Include: During the record review of the RN Assessment on the overnight shift on the early morning of 11/18/2025, reflected that the Patient slept 8 hours. The video footage shows the patient was up at the nursing station waiting to speak with the RN at 1:09 AM. The video shows that the Patient was there for three minutes. When the patient departed from the nursing station, he walked into another patient’s room and was quickly redirected by Staff #7, Behavioral Health Associate. At 1:37 AM, Patient #1 was observed in the hallway again but was returned to his room by the Staff # 7, BHA, and at 2:24 AM, he was standing in his doorway talking to the RN #8. At 2:30 AM , Patient #1 was said to be sleepwalking, on behalf of the BHA. There is no history of sleepwalking. The BHA failed to report that to the RN on duty for evaluation. The RN on duty did not witness sleepwalking. The video footage did not reveal the Patient was sleepwalking. During a Staff #7 interivew by the hospital Staff #5, it was reported that Staff #7 entered the assigned room of Patient #1 at 7:45 AM, to complete vital signs. Patient #1 was cold to the touch upon completing vitals check. So Staff #7 rubbed the hands in effort to warm them up with hopes of obtaining an accurate reading of vital signs. Staff #7, stated that Patient #1 only grunted and did not speak during this time. Staff #7 reported not being able to identify when the Patient’s last bowel movement was. Staff #7 reports this information to another BHA (BHA #9) and not to Staff #8 the RN on duty. During an interview with hospital Staff #2, on 12/29/2025 at 2:15 PM, it was reported that Patient #1 was pronounced deceased at 9:00 AM by the county judge and coroner’s office to take the patient out. Policy The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Neglect, 03/2025, “It is the policy of Red River Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and Human Services and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the Intake Screening and has cause to suspect abuse has occurred is legally responsible for reporting.” The hospital Nursing Staff and Staffing Plan, POC 155 03/2025, “The governing body of Red River Hospital adopts, implements, and enforces a written nurse staffing policy and plan to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The nurse staffing plan is recommended by the hospital’s nurse staffing committee and given significant consideration to those recommendations. The Chief Nursing Officer/Director of Nursing assumes oversight and responsibility for the provision of effective, high-quality, and safe nursing care throughout the hospital.” The Hospital Policy on Observation 03/2005, “All patients will be routinely observed in compliance with physician orders and prescribed protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight, and intervention to provide for their safety and security. Patient observation and the frequency of documentation will be commensurate with the assessed level of risk.” The hospital Policy on re-assessment during Hospitalization 12/2025, “The patient’s condition is re-assessed throughout hospitalization. Additionally, and/or new needs may be recognized by the treatment team. New and/or additional needs are documented, addressed, and included in the multidisciplinary treatment plan and the multidisciplinary treatment plan reviews. a. Reassessments are conducted by all disciplines as indicated, with documentation provided through a variety of formats including but not limited to progress notes, nursing reassessment forms and medical staff directions. b. Reassessments are completed by the registered nurse on day and evening shifts and documented on the nursing reassessment form. The Hospital Policy on Sentinel Events, All.ACHC. Qual.0400, 05/2025, “Acadia Healthcare and its facilities will provide appropriate notice internally and externally regarding certain events and close calls that happened in Acadia’s facilities.””

“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: 33579 Based on the interview and record review, the hospital failed 1 of 1 Patient (Patient #1). The hospital failed to provide a nursing assessment for Patient #1 and document the care Patient #1 received. Findings Include: During the record review Staff #8, RN noted Patient #1 slept for 8 hours. During record review hospital Staff #4, reported Patient #1 was up at 1:09 AM, standing at the nurses’ station. It is reported Patient #1 stood there until 1:12 AM. When the Patient stepped away from the nursing station, the Patient entered the incorrect room. During interview it was discovered that Staff #6 witnessed Patient #1, and redirected the Patient back to the assigned room, at 1:37 AM. At 2:00 AM, Patient #1 appeared in the assigned room doorway, but does not exit the room. At 2:24 the Patient is talking to the RN in the doorway of the assigned room until 2:25 AM. It is reported for Staff #4 from 2:30 AM until 7:15 AM Patient Observation Rounds are consistent with round sheets, staff #6 entered the room to complete rounds. In record review Staff #6 did not report the incidents of Patient # 1 being awake, and allegedly sleepwalking to the RN Staff #7 during the shift. Staff #6 reported that Patient #1’s hands were cold upon attempts to take vitals symptoms and rubbing the hands to try and warm them up. Staff #6 advised another Tech Staff #8, on the oncoming shift at 7:45 AM of change in condition. During Record Review Staff #8, Tech failed to properly complete Patient Observation Rounds, by entering the room and witnessing the rise and fall of the chest. Staff #8 on walked by the room and looked at the patient from the doorway from 7:59AM through 8:41 AM. During Interview Staff #2 reported that Patient #1 was pronounced deceased at 9:00 AM by the coronor and County Judge. Policy The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Neglect, 03/2025, “It is the policy of Red River Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and Human Services and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the Intake Screening and has cause to suspect abuse has occurred is legally responsible for reporting.” The hospital Nursing Staff and Staffing Plan, POC 155 03/2025, “The governing body of Red River Hospital adopts, implements, and enforces a written nurse staffing policy and plan to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The nurse staffing plan is recommended by the hospital’s nurse staffing committee and given significant consideration to those recommendations. The Chief Nursing Officer/Director of Nursing assumes oversight and responsibility for the provision of effective, high-quality, and safe nursing care throughout the hospital.” The Hospital Policy on Observation 03/2005, “All patients will be routinely observed in compliance with physician orders and prescribed protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight, and intervention to provide for their safety and security. Patient observation and the frequency of documentation will be commensurate with the assessed level of risk.” The hospital Policy on re-assessment during Hospitalization 12/2025, “The patient’s condition is re-assessed throughout hospitalization. Additionally, and/or new needs may be recognized by the treatment team. New and/or additional needs are documented, addressed, and included in the multidisciplinary treatment plan and the multidisciplinary treatment plan reviews. a. Reassessments are conducted by all disciplines as indicated, with documentation provided through a variety of formats including but not limited to progress notes, nursing reassessment forms and medical staff directions. b. Reassessments are completed by the registered nurse on day and evening shifts and documented on the nursing reassessment form. The Hospital Policy on Sentinel Events, All.ACHC. Qual.0400, 05/2025, “Acadia Healthcare and its facilities will provide appropriate notice internally and externally regarding certain events and close calls that happened in Acadia’s facilities.””

“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: 33579 Based on Interview and Record Review the hospital failed 2 of 2 Patients (Patients #1, and Patient #2), by failing to ensure the patients are receiving care in a safe setting. Patient #1 and Patient #2 reported they engaged in inappropriate sexual intercourse. The hospital staff confirm the Patients engaged in inapropriate physical contact and failed to place precautions in place. Findings Include: During Interview with hospital Staff #2, Patients #1 and #2 were observed touching one another over their clothing in the milieu and told to stop. The Patients were observed kiss in the milieu and informed to stop. There was nothing put in place to stop the patients or relocate Patients #1 and Patient #2. During Interview with hospital Staff #6 it was reported she was transferred to another unit at 11:00PM. This left the unit to be monitored by Staff #7 alone. During Interview with hospital Staff #2 it is reported during video footage three Staff #6, #7 and #8 were in the nursing station, while Patient #1 and Patient #2 were in the hallway underneath their own individual blankets. Staff #1 agreed that blankets should remain in room on beds and not in the hallways or milieu. Staff #6 indicated that the patients were told not to be touching one another when taking one item to the laundry room. Policies: The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Provision of Care, Treatment and Services Sexually Acting Out/Sexual Victim Prevention 04/2023, “It is the policy of Red River Hospital to implement protective measures for those patients vulnerable to sexual victimization by other patients in the facility. Patients are assessed for risk of sexually acting out behavior and/or being sexually victimized. Patients shall not have sexual contact with one another.” The hospital Policy on Abuse and Neglect, 03/2025, “It is the policy of Red River Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and Human Services and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the Intake Screening and has cause to suspect abuse has occurred is legally responsible for reporting.” The hospital Nursing Staff and Staffing Plan, POC 155 03/2025, “The governing body of Red River Hospital adopts, implements, and enforces a written nurse staffing policy and plan to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The nurse staffing plan is recommended by the hospital’s nurse staffing committee and given significant consideration to those recommendations. The Chief Nursing Officer/Director of Nursing assumes oversight and responsibility for the provision of effective, high-quality, and safe nursing care throughout the hospital.” The hospital Policy on Quality Care and Treatment 01/2024 Acadia Healthcare Quality Management Plan, “The Quality Department provides oversight for the enterprise Quality Management functions by supporting processes, practices and improvements. The Quality Department informs decisions for improving quality, providing expertise in quality improvement, improving patient safety, supplying timely measurement and leveraging Acadia’s data and informatics to support the Quality Management Plan.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 33579 Based on Interview and Record Review the hospital failed 2 of 2 Patients (Patient #1, and Patient #2) by failing to provide each patient to nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. Patient #1 and Patient #2 were already engaging in inappropriate activity, underneath blankets in the hallway. Staff #7 was left to monitor the unit total of 7 patients from nursing and monitoring standpoint. Findings: During Interview with hospital Staff #6 on 05/01/2025 at 2:00 PM., it was reported “at 11:00 PM I was being transfered to another unit to assist staffing the remainder of the evening.” During Interview with hospital Staff #8 on 05/02/2025 at 10:40 AM, “it was reported that there was no significant time spent on 1 particular unit that night. Staff #8 reported floating from unit to ensuring staffing needs are met and patient safety. There was no incident reported to Staff #8 that evening about patients engaging in inappropriate contact. Staff #8 inidcated learning of the incident when notified by hosptial staff on 05/01/2025.” During Interview Staff #5 inidicated not knowing about why “Staff #6 was transferred to another unit and or why Staff #6 was transferred to cover another unit.” This left the RN on the unit to cover nursing duties and patient monitoring of 7 patients in total. During Record Review the hospital Patient Preliminary Census report on 04/19/2025 indicated at 11:21 PM there was a total of 7 Patietns on the Magnolia Unit.” During Record Review the hospital Staffing Sheet indicated “Saturday April 19, 2025, two (2) Staff assigned to the Magnolia unit on the night shift 19:00 to 0700. Staff #6 and Staff #7 assigned to the unit.” Policy The hospital Provision of Care, Treatment and Services Observation Levels, POC 132, 11/2024, “In order to maintain patient health and safety the hospital staff encouraged patients to practice daily makes and documents routine safety observations on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. The level of observation can be increased by the RN at any time there is a concern, but only a psychiatric practitioner may decrease the level.” The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Provision of Care, Treatment and Services Sexually Acting Out/Sexual Victim Prevention 04/2023, “It is the policy of Red River Hospital to implement protective measures for those patients vulnerable to sexual victimization by other patients in the facility. Patients are assessed for risk of sexually acting out behavior and/or being sexually victimized. Patients shall not have sexual contact with one another.” The hospital Policy on Abuse and Neglect, 03/2025, “It is the policy of Red River Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and Human Services and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the Intake Screening and has cause to suspect abuse has occurred is legally responsible for reporting.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 33579 Based on Interview and Record Review the hospital failed 1 of 1 Patient (Patient #1) by failing, to incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital acquired conditions. The hospital nursing staff failed to complete Incident Reports, and Restraint and Seclusions packets after incidents occur. The hospital also administered medication prior to containing Consents to do so. Findings Include During Record Review the hospital failed to complete Incident Reports for Patient #’s behavioral issues on 02/15/2025, 03/20/2025, 03/25/2025, 03/31/2025, 04/15/2025, and 04/17/2025. During Interview with hospital Staff #1 the information of missing incident Reports was verified 04/21/2025 at 3:00PM. During Record Review there was no Restraint and Seclusion Packet for Patient #1 on 03/06/2025. During Interview on 04/21/2025 with hospital Staff #1 it was reported, “The Staff are failing to either obtain and complete Incident Reports or Restraint and Seclusion packets. Or they are giving medication without the proper order.” During Record Review it was noted by hospital Staff #5, in the hospital AHC Progress Note at 4:25 PM, “This writer was informed that they had administered medication without proper consent to Patient #1 on the Mockingbird unit on 03/24/2025 at 8:24 AM. The medication in question was Lithium Carbonate 300MG PO indicated for mood changes. Incident Report filed.” During Interview with hospital Staff #1 and Staff #5 it was verified that the medication administration record revealed that there were 20 opportunities to give the Lithium without obtaining proper consent. The medication was administered 9 times out of the 20. Policy The hospital Policy on Quality Care and Treatment 01/2024 Acadia Healthcare Quality Management Plan, “The Quality Department provides oversight for the enterprise Quality Management functions by supporting processes, practices and improvements. The Quality Department informs decisions for improving quality, providing expertise in quality improvement, improving patient safety, supplying timely measurement and leveraging Acadia’s data and informatics to support the Quality Management Plan.” The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Physician Services Provision of Care, Treatment and Services, Transcribing Physician Orders, 06/03/2024, “At Red River Hospital, only licensed nursing personnel (RN’s and :VN’s may transcribe physician’s orders, to assure that our patients receive their medications in a safe, accurate, and effective manner.”

“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: 33579 Based on Interivew and Record Review the hospital failed 1 of 1 Patient (Patient #1) by the registered nursing not supervising and evaluating the nursing care of each patient. Patient #1 was administer Haldol after it was discontinued and determined to cause Dystonia (lockjaw) to the Patient #1. Patient #1 also received 9 doses of Lithium out of 20 opportunities. Findings During Record Review the hospital Medication Administration Transaction 02/28/2025 at 8:28PM, “Patient received Haloperidol 5ML, 5MG/ML SOLN.” During Record Review the hospital History of Present Illness 03/06/2025, 9:20 AM, “This is a 16 year old with a follow-up visit (jaw pain). He reports no complaints and no reports of jaw pain ....Plan; Highly suspicious that jaw pain with locked jaw was from Haldol and will add Haldol as an allergy.” During Interview with hospital Staff #1 on 04/21/2025. It was reported that Patient #1 received the order to discontinue the Haldol medication as the patient is allergic to it on March 06, 2025. During Record Review the hospital Medication Administration Transaction 04/07/2025 at 10:47 PM. “Patient received Haloperidol 5ML, 5MG/ML SOLN.” During Record Review the hospital History of Present Illness/Clinical Status 04/08/2025, “Patient received emergency medications for disruptive behavior and agitation last night. He is currently drowsy but arousable. Sedation likely secondary to Haldol administration. No safety concerns at this time. He maintains orientation and adequate oral intake.” During Interiview on 04/21/2025 with hospital Staff #1, it was reported, “Nursing Staff did not review the medical records and notice Haldol was listed as an allergy. It was listed on 03/06/2025. During Record Review Paitent #1 received Medication Lithium 9 times out of 20 opportunites. The hospital Staff failed to obtain consent to administer Lithium from Patient #1’s Caseworker. During Interview with the hospital Staff #5 on 04/21/2025, it was reported in the AHC Progress Note 03/24/2025 at 4:25 PM, “This writer was informed that they had administered medication without proper consent to Patient #1 on the Mockingbird unit on 03/24/2025 at 8:24 AM. The medication in question was Lithium Carbonate 300MG PO indicated for mood changes. Policy The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Physician Services Provision of Care, Treatment and Services, Transcribing Physician Orders, 06/03/2024, “At Red River Hospital, only licensed nursing personnel (RN’s and :VN’s may transcribe physician’s orders, to assure that our patints receive their medications in a safe, accurate, and effective manner. The hospital Policy on Quality Care and Treatment 01/2024 Acadia Healthcare Quality Management Plan, “The Quality Department provides oversight for the enterprise Quality Management functions by supporting processes, practices and improvements. The Quality Department informs decisions for improving quality, providing expertise in quality improvement, improving patient safety, supplying timely measurement and leveraging Acadia’s data and informatics to support the Quality Management Plan.” The hospital’s Policy on Advanced Pharmaceutical Consultants, Inc. Medication Management. “An adverse drug reaction (ADR) is defined at the facility in broad terms as. ‘Any unintended, undesired, or unwanted effect of the administration of a drug that results in a change of therapy.’ A more technical definition is: An undesired or unexpected side effect, allergy, or toxicity that occurs with the administration of medication. ADR’s can range from mild side effects to very severe reactions including death. ADR’s are unwanted and can be unpleasant, noxious, or potentially harmful. Onset may be sudden or take days to develop. ADR’s may require discontinuation of the medication, modification of the dosage, hospitalization, and/or supportive treatment.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 33579 Based on Interview and Record Review the hospital failed 1 of 1 Patient, (Patient #1) by providing nursing services in the hospital that are not adherence to the policies and procedures of the hospital. Three of four nurses were contracted and failed to identify there were no consent in the medical record Lithium for Patient #1. Patient #1 had received Lithuim 9 of 20 times it was made available. Findings include During Record Review the hospital History of Present Illness/Clinical Status 03/13/2025, “Patient #1 is a 16 year old with a history of MDD. Patient #1 continues to exhibit mood instability, requiring ongoing evaluation and monitoring. Consent for Lithium is pending. “ During Record Review the hospital Medication Administration Transcition reflected the Patient was administered the Lithium Carbonate 300 MG, oral in 9 out of 20 opportunities.. During interview with hospital Staff #5 on 04/21/2025, indicating informing administration “I reported administered medication without proper consent to Patient #1 on the Mockingbird unit on 03/24/2025 at 8:24 AM. The medication in question was Lithium Carbonate 300MG PO indicated for mood changes. Staff #5 indicated as it was time to administer the medications the medical record was reviewed by themselve to ensure consent was in place. During interview with hospital Staff #1 on 04/21/2025, “The staff that were involved in the incidents have been identified by 3 of them being (Turnkey employees) contracted nursing staff and one of them is a employee of the hospital. Staff #1 indicated they are just not doing what they have been taught, and will require retraining and perhaps other consequences. Policy The hospital policy Patients’ on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities.” The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.” The hospital Policy on Physician Services Provision of Care, Treatment and Services, Transcribing Physician Orders, 06/03/2024, “At Red River Hospital, only licensed nursing personnel (RN’s and :VN’s may transcribe physician’s orders, to assure that our patints receive their medications in a safe, accurate, and effective manner. The hospital Policy on Quality Care and Treatment 01/2024 Acadia Healthcare Quality Management Plan, “The Quality Department provides oversight for the enterprise Quality Management functions by supporting processes, practices and improvements. The Quality Department informs decisions for improving quality, providing expertise in quality improvement, improving patient safety, supplying timely measurement and leveraging Acadia’s data and informatics to support the Quality Management Plan.””

“A Life Safety Code (LSC) unannounced compliant survey was conducted at the facility on 3/04/2025. An entrance conference was conducted on the afternoon of 3/04/2025 with the CEO, Director of Quality, and Director of Plant Operations to discuss the purpose of the LSC compliant and the survey process. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. A LSC exit conference was conducted on the afternoon of 3/04/2025, with the CEO, Director of Quality, and Director of Plant Operations. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 28433 Exit door on the third floor’s patient unit’s wing was pinned closed.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33579 Based on Record Review and Interview the hospital failed 2 of 2 Patients (Patient #1, and Patient #2) by failing to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goal and the nrsing care to be provided to meet the patietn’s needs. the nursing care plan may be part of an interdisciplinary care plan. The nursing staff failed to complete Incident Reporting involving Patient #2 inapropriate behavior touching Patient #1 underneath Patient #1’s clothing. Findings Include: During Record Review of Patient #1 and Patient #2 there is no findings of documentation that Patient #1 was touched inappropriately by Patient #2. During Interview with Patient #1 on 11/21/2024 at 1:35 PM, Patient #1 reported Patient #2 touched underneath Patient #1’s clothing and the incident was reported to hospital Staff #9. During Interview with hospital Staff #9 on 11/21/2024 at 3:00 PM, Staff #9 confirmed that Patient #1 reported that Patient #2 touched Patient #1 inappropriately underneath Patient #1’s clothing’s. During Interview with hospital Staff #5 on 11/21/2024 at 12:05 PM, Staff #5 indicated being informed that Patient #2 touched Patient #1 inappropriately. Staff #5 reported having no recall about documenting any incident related to this incident. Staff #2 indicated I have only been employed almost 2 months and I am not knowledgeable of all the rules. During Interview with hospital Staff #1 at 3:45PM, Staff #1 indicated that we did not document an Incident Report. Policy The hospital policy Patient’s on Patient Rights 03/03/2023, “All employees of Red River Hospital and members of the medical staff are responsible for ensuring that patients’ rights are respected and honored throughout the course of care, and that our patients and their families/guardians are made aware of their responsibilities. The hospital Policy on Abuse and Neglect 02/14/2023, “It is the policy of Red River Hospital to report alleged and suspected abuse and neglect to the Texas Department of Health and Human Services and appropriate authorities in accordance with State and Federal Statues. The staff member who conducts the Intake Screening and has cause to suspect abuse has occurred is legally responsible for reporting. Abuse Includes all physical assault, sexual assault and domestic abuse of elders, spouses, and children. Abuse includes any act or failure to act by an employee, which was performed or which was failed to be performed, knowingly, recklessly, or intentionally, and which caused or may have caused injury or death to a patient.” Neglect An act or omission by any individual responsible for providing services in a hospital which caused or may have caused injury or death to a patient or which placed the patient a risk of injury or death. The hospital Policy on Sexually Acting out/Sexual Victim Preventions 04/11/2023, “It is the policy of Red River Hospital to implement protective measures for those patients vulnerable to sexual victimization by other patients in the facility. Patients are assessed for risk of sexually acting out behavior and/or of being sexually victimized. Patients shall not have sexual contact with one another. The hospital Policy on Nursing Services 03/03/2023, “Red River hospital provides assessments to determine what type of care is required to meet a patient’s initial needs as well as his/her needs as they change in response to care. The assessment process is individualized according to the patient’s age, developmental level, and needs. Information is obtained from the patient, and if appropriate and consent is obtained the family members significant others, referral source, and/or primary care physician.””