West Oaks 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: 35028 . Based on observation, interview, and record review, the facility failed to maintain a safe environment in the Intake Department by having 2 of 2 wheelchairs with removeable arm rests. Once removed, the arms can be wielded as weapons by patients. Findings included: During a tour of the Intake Department on 7.23.2026 at 10:05am, 2 wheelchairs were found that had removable wheelchair armrests. Each armrest had a locking release mechanism that secured into the front sockets on the wheelchair frame. The surveyor easily removed the armrest by pressing the push button lock. A third wheelchair was taken to the Intake Department by Staff P from another area of the facility. That wheelchair had been modified such that the armrests were not removable. In an interview with Staff C (Intake Director), Staff R (DPO), and Staff P during the tour of the Intake Department, they each stated that the two wheelchairs with removable armrests were not safe for psychiatric patients that might have homicidal thoughts and tendencies.”

“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: 38015 Based on record review and interview, the facility failed to ensure registered nurses fully evaluated a patient’s health status, as shown by multiple inaccurate assessments of a patient’s condition (Patient #2) after he had sustained injuries to his face. More specifically, after Patient #2 injured his face on a chair and sustained bruises, all nursing skin assessments showed skin was normal with no bruises, redness, swelling, or scratches. The patient also had a bloody nose and scrapes to his toe which were not addressed in his daily nursing skin assessments. Findings included: Review of TAC rule Title 22, Part II, Rule §217.11, last reviewed 1/9/24 showed that standards of practice applicable to registered nurses include performing comprehensive assessments of the client as well as accurately and completely documenting the client’s status, including signs and symptoms. In addition, review of facility policy #20608074 titled “Nursing Documentation”, last revised 7/2023, showed that registered nurses are responsible for performing comprehensive nursing assessments on all patients, then accurately documenting the findings. Record review of Patient #2’s nursing notes dated 4/10/26 at 9:10 am showed he was running in the children’s unit dayroom and hit his face on a stationary chair, sustaining injury to his right cheek. He was given Tylenol for pain and ice for the swelling. In addition, nursing notes dated 4/10/26 at 9:00 pm showed the patient slipped while jumping in his bed and sustained a scraped 2nd toe on his right foot. First aid was given to stop bleeding. Review of Patient #2’s physician progress notes from MD Staff #H showed the patient had a right cheek contusion that was “fairly significant”, with ecchymosis (bruising), erythema (redness), and edema (swelling) below right eye. The patient also had epistaxis (nosebleed). Review of Patient #2’s nursing assessment for the same day of injury on 4/10/26 for both day and evening shifts showed skin assessments as “WNL” (within normal limits) with no bruising, redness, swelling, or superficial scratches. Review of all other nursing assessments every day on every shift, until the patient discharged on 4/23/26, 13 days later, showed skin was within normal limits with no bruising, swelling, redness, or scratches, and no mention of the patient’s significant facial injury. Also, although there was one brief written narrative nursing note on 4/10/26 describing the patient injuring himself, there were no other follow up nursing notes addressing the patient’s injury status, no further evaluation of his injuries, no responses to any treatment already administered, and no progress notes describing signs and symptoms. In an interview on 5/13/26 at 3:00 pm, ACNO Staff #C and DPI Staff #A both acknowledged the inaccurate nursing assessments and documentation regarding the patient’s injuries, stating that this type of issue had been recognized already by administration and the facility was currently working to improve compliance with nursing.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to inform 1 of 1 patients’ representative (Patient #2) of a change in health status, as shown by the facility’s failure to notify the guardian after the patient was assaulted and injured by another patient, resulting in an injury. Findings included: Record review of Patient #2’s clinical chart showed Nursing Progress notes dated on 11/4/24 at 6:47 with the entry “the patient was attacked by another patient and sustained a minor lip injury”. His lip was “dried” and an ice pack was applied for treatment. Medical multidisciplinary progress notes dated 11/4/24 at 9:15 am made by the patient’s doctor, Staff #F, showed that the patient had an “altercation” in the morning and was hit in the mouth, sustaining a “busted” left lower lip. His lip was swollen and presented with old, dried blood on it. Vaseline and ice were prescribed. Further review of all Patient #2’s medical records failed to reveal the patient’s guardian was ever notified of the incident that resulted in the patient being injured. In an in interview on 3/6/25 at 2:30 pm while reviewing Patient #2’s records, CEO-Staff #A confirmed there was no evidence the patient’s guardian was ever informed of the patient’s injuries.”

“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: 38015 Based on record review and interview, the facility failed to provide a safe environment for 6 of 16 patients (Patient #’s 1, 5, 7, 8, 9 & #10) from 2/24/25 through 2/26/25, as evidenced by staff not effectively monitoring and preventing patient-on-patient aggression. This failure resulted in patient injury (Patients #1 and #11). Findings included: Review of facility policy #POC-N149 titled “Levels of Observation”, last revised 5/2000, showed patients will be closely observed and monitored for safety. Level of patient observation is based on assessment, which includes assessing for potential assault and aggression. The various levels include “One-to-One”, with staff member constantly within arm’s reach of patient; “Q5 Minute Observations”, with staff member monitoring patient every 5 minutes, or “15 Minute Observations”, the minimum level for all patients, where a patient is monitored every 15 minutes. The policy also states that staff may consider the need to move an aggressive patient or intended victim to another unit for safety. In addition, the patient at risk should be assessed for room monitoring, where staff sit outside a patient room to ensure patient safety. Record review of Patient #1’s clinical records showed the following: 14-year-old male, admitted 2/17/25, discharged 2/25/25. Diagnoses were Disruptive Mood Dysregulation disorder, Autism, Attention Deficit Hyperactivity disorder. Reason for admission; threatening peers, homicidal ideation towards others, punching walls, destroying property. He was placed on 15 Minutes Observations monitoring. Review of Restraint/Seclusion orders and accompanying nursing notes from the day of admission, dated 2/17/25 at 6:56 pm, showed the patient became violent, provoking peers, pushing chairs, banging on doors, banging on the nursing station. He was given an intramuscular injection (IM) of emergency psychoactive medications to control behavior-Thorazine 50 mg and Benadryl 50 mg. Review of Restraint/Seclusion orders and accompanying nursing notes dated 2/21/25 at 6:08 pm, showed patient had grabbed an object from the nursing station, hit Patient #5 with it, and was punching doors and windows. He was subsequently given IM emergency psychoactive medications again-Thorazine 50 mg and Benadryl 50 mg, then placed in seclusion (note; four days later, on 2/25/25, Patient #5 then physically attacked Patient #1-see below). Review of nursing progress notes dated 2/24/24 at 12:20 pm, showed the patient was then hit by a different peer, Patient #11. The notes read “punched him on the face and he started having nose bleeding”, after Patient #1 was talking loudly and banging on glass windows, apparently aggravating Patient #11. Dr-Staff #F was contacted and ordered a medical consult and first aid treatment. Patient #11 then complained of right hand pain from punching Patient #1, was x-rayed, and diagnosed with Right 5th Metacarpal (hand) Fracture. He was sent to Memorial Hermann Hospital Southwest on 2/25/25, treated, given a splint, then returned to facility. Further review of nursing progress notes dated 12/24/25 at 12:50 pm, just 30 minutes later, showed Patient #1 was punched again, this time by another different peer, Patient #8. Patient #1 was reportedly still loud, banging glass of door, and aggravated this other peer. When Patient #1’s guardian was called and informed of these incidents, she requested that Patient #1 be moved to another unit but her request was denied: Nursing progress notes from RN-Staff #G showed “[Guardian] requested patient moved to another unit but informed is the only adolescent boys unit. Requested to move him to girls unit will continue to monitor”. (Note: Patient #8 also had a previous physical altercation with another different peer, Patient #12, the day prior, 2/23/25 at 7:20 pm, and had sustained a bloody nose). The next day, Patient #1 was punched again (the third time in two days, from three different peers). Nursing progress dated 12/25/25 at 7:52 am showed that Patient #5 (who Patient #1 had previously hit on 12/21/25) walked into Patient #1’s room “and started punching him”. Record review of Patient #5’s clinical chart showed he also had a history of violence and he was involved in at least two other incidents with two other patients: On 2/24/25 at 9:00 am, he has a physical confrontation with Patient #9, and on 2/26/25 at 1:25 pm, he had another physical aggression incident with Patient #7, who needed first aid as a result. In an interview on 3/6/25 at 12:20 pm, RN-Staff #G was questioned about her knowledge regarding Patient #1. She stated he was autistic, violent, and very difficult to redirect because he would not listen to staff. He did not like to be with other children and acted immature at times, and would ask for his stuffed animal. She added that the first boy who hit him “really hurt himself” (he broke his hand) and the second boy who hit him just 30 minutes later gave the patient a bloody nose. The third boy who hit the patient the following day just entered his room and started punching him after Patient #1 allegedly called him a derogatory name and aggravated him. Staff #G also stated that Patient #1 was never on One-to-One or Q5 Minutes Observations for added safety, just on Every 15 minutes Observations like most patients. Staff #G never asked the patient’s doctor to move him to a different unit or increase close observation monitoring, even after the patient’s guardian made the request to move the patient to another unit.”

“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: 35028 Based on observation, interview, and record review, the facility failed to deliver nursing care that demonstrated competence in the documentation of dietary intake on the observation rounds. This negligence was evidenced by the facility’s failure to ensure staff consistently documented the dietary intake on 9 of 10 adolescents and children (Patient # 1, 3, 4, 14, 15, 16, 17, 18, and Patient # 19). Findings were: Patient #4. Review of the Psychiatric Evaluation for Patient #4 by Staff N (MD) dated 12/14/2024 at 12:20 PM showed: “picky” appetite, “he only eats what he wants,” high energy level, sleep is not good. Impression: Disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, Von Willebrand’s Disease [a genetic bleeding disorder]. Review of Nursing Admission Assessment - Youth for Patient #4 by Staff O (RN) on 12/13/2024 at 7:30 PM showed: Weight 47 lbs. Height 59 inches. Review of Observation Sheets showed the documentation of dietary intakes was missing for the following 9 patients on these days. Patient #1 - Incomplete 2/17, 18, 19, 20, 21, 22, 23, 24, and 2/25/2025. Patient #3 - Incomplete 12/9, 11, 12, and 12/13/2024. Patient #4 - Incomplete 12/14, 15, 16, and 12/17/2024. Patient #14 - Incomplete 3/3 and 3/5/2025. Patient #15 - Incomplete 3/3 and 3/5/2025. Patient #16 - Incomplete 3/5/2025. Patient #17 - Incomplete 2/27, 2/28, 3/1, 3/2, 3/3, 3/4, and 3/5/2025. Patient #18 - Incomplete 3/3, 3/4, 3/5/2025. Patient #19 - Incomplete 2/10 and 2/11/2025. Further breakdown of this data showed that 34 of 48 meals (70%) were not documented on the Observation Sheets. There were: 19 instances in which dietary intake for all three meals was not documented. 3 instances in which dietary intake for two meals was not documented. 13 instances in which dietary intake for one meal was not documented. In an interview with Staff A (CEO) on 3/6/2025 at 3:00 PM, she stated staff are to document on the Observation Sheets the percent of meals eaten for breakfast, lunch, and dinner on all patients. In an interview with Staff G (RN - Youth Services) and Staff I (LVN - Youth Services) on 3/6/2025, 11:35 AM - 11:55 AM, they stated that it is the Mental Health Technicians (MHT) that usually monitor the percent of meals eaten, documenting that percent on the Observation Sheets. They also stated the staff members escorting the patients to the cafeteria take the Observation Sheets with them. The plates are checked by staff members before being discarded. Staff I (LVN) explained that some patients do not have cafeteria privileges and eat their meals on the unit. Staff follow the same protocol of assessing the percent of food eaten and documenting this on the Observation Sheets. Staff G (RN) stated it is her expectation that the staff she oversees document the percent of meals eaten on the Observation Sheets. She concluded by stating she did not know that completion of this section of the Observation Sheets was being neglected.”

“Social Service Records CFR(s): The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history. This Standard is not met as evidenced by: 35028 Based on observation, interview, and record review, the facility failed to ensure Clinical Services staff members documented factual and historical information in the development of the Psychosocial Assessment. This omission was evidenced by the facility’s failure to ensure: a) A parent or legal guardian was contacted to provide significant aspects in the development of the Psychosocial Assessment for 3 of 8 children (Patient #4, 19, and Patient #21). b) An Individual Therapy session was conducted for 8 of 8 patients (Patient #4, 19, 20, 21, 22, 23, 24, and Patient #25.) c) A Family Therapy session was conducted for 2 of 8 patients (Patient #4 and Patient #19). d) Members of the Clinical Services Department were properly trained in the development of the Psychosocial Assessment. Findings were: a) Psychosocial Assessment Record review of the policy “Procedure on Psychosocial Assessments” policy number POC - C112, last review 2/2024, showed the following. Purpose ... To provide current background data on the patient which includes stressors contributing to dysfunction and strengths or supports contributing to recovery ... A regular or updated Psychosocial Assessment shall be completed within 72 hours of admission ... All Psychosocial Assessment shall be completed only by staff credentialed in this area, or by staff supervised by credentialed staff ... All psychosocial [assessments] will be signed by an LMSW or LCSW. Review of an educational handout (not dated or timed) that was provided by Staff L (Director of Clinical Services - DCS) on 3/6/2025 at 3:00 PM showed: In accordance with the psychosocial assessment (PSA) process. Families are contacted within 48 hours of admission to schedule a time to complete the PSA, schedule family therapy session an address weapon safety. In the event a guardian is unreachable, the clinician must leave a message, document in a progress note and reattempt prior to the end of day. After several attempts and no contact has been made, clinician must document on a progress note and then seek guidance from the Clinical Director ... PSA is completed with the guardian or family member authorized to provide collateral information regarding the PSA. Review of the Psychiatric Evaluation by Staff N (MD) on 12/14/2024 (dictated at 12;20 PM and transcribed at 4:40 PM) showed that the adoptive mother reported that the biological mother used alcohol while pregnancy with Patient #4 and had been diagnosed with a bipolar disorder and “other mental health issues.” She also abused drugs. The biological father was “a heavy drug user” as well as alcohol abuse. Review of the Psychosocial Assessment completed by Staff K (Licensed Professional Counselor Associate - LPCA) on 12/14/2024 at 10:53 AM for Patient #4 showed that the Psychosocial Assessment was completed from information collected from the 7-year-old patient and the Intake Assessment. The patient’s mother was not contacted. Staff K (LPCA) documented that it was “unknown” if the biological father and mother had a history of alcoholism, drug abuse, and mental illness. This documentation was not consistent with the documentation found in the Psychiatric Evaluation by Staff N (MD) - documented above. The Psychosocial Assessment was co-signed by Staff P (LMSW). Additionally, review of two other Psychosocial Assessments (Patient #19 and Patient #21) showed that Staff K (LPCA) made one unsuccessful attempt to reach a parent or legal guardian. There was no documentation of a follow-up phone call. Finally, each of these Psychosocial Assessments showed that the family was not a source of the information used to write the assessments. In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated the following. 1) The Psychosocial Assessment is to be completed within 72 hours. 2) For children and adolescents, the parent must be contacted. 3) If the therapist is unable to reach the parent, several attempts are to be made “throughout the day,” with attempts “every single day” until the parent is reached. 4) She is to be notified by the therapist if the parent cannot be reached by phone. In an interview with Staff M (Associate Director of Clinical Services - ADCS) on 3/6/2025 at 10:20 AM - 10:35 AM, Staff M stated parents should be involved in the development of the Psychosocial Assessment. He also stated that multiple phone calls should be made to reach a parent. In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following. 1) The Psychosocial Assessment is to be completed within 72 hours. 2) She reviews the Standardized Intake Assessment and interviews the patient in the development the Psychosocial Assessment. 3) She seeks additional information for the completion of the Psychosocial Assessment - information that is not found in the Standardized Intake Assessment, such as “strengths and limitations, weapons in the house, and current abuse.” A child’s parent or legal guardian would need to be contacted to obtain this information. 4) Her attempt to reach Patient #4’s adoptive mother on 12/14/2024 was unsuccessful, as were her attempts to reach a parent for Patient #19 and Patient #21. 5) If she is unsuccessful reaching a parent or legal guardian for information needed to complete the Psychosocial Assessment, the policy is to “make another attempt after 7 days,” adding that she “may” attempt again after 7 days. b) Individual Therapy. c) Family Therapy. In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following. 1) She did not conduct a Family Therapy session with Patient #4 and his adoptive mother because she did not reach the parent on 12/14/2024. 2) The Psychosocial Assessment is the Individual Therapy session. In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated the Psychosocial Assessment is not the Individual Therapy and that individual and family therapy sessions are to be completed on all patients. Review of a Progress Note by Staff K (LPCA) dated 12/14/2024 at 12:16 PM showed an unsuccessful attempt made on 12/14/2024 at 11:31 AM to contact the adoptive mother “to discuss a Discharge Safety Plan and conduct a Family Therapy session” for Patient #4. During further review of the medical record, the following items were not found: a follow-up phone call to the adoptive mother, an Individual Therapy session, and a Family Therapy session. Review of the medical records for Patient #19 and Patient #21 showed that a Family Therapy note was not found. Review of the medical records for Patients #4, 19, 20, 21, 22, 23, 24, and Patient #25. d) Staff training in the development of the Psychosocial Assessment. Review of TAC, Title 22 - Examining Boards, Part 30 - Texas Board of Examiners of Professional Counselors, Chapter 681 - Professional Counselors, Rule §681.91 - LPC Associate License shows: (5) (i) An LPC Associate must continue to be supervised after completion of the 3,000 hours of supervised experience and until the LPC Associate receives his or her license. Supervision is complete upon the LPC Associate receiving the LPC license. In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following. 1) LPCA is a Licensed Professional Counselor Associate. 2) As an LPCA, she is still under supervision of licensed counselors. In an interview with Staff L (DCS) on 3/6/2025 at 3:00 PM, she stated that new-hire orientation does not cover the completion of form “WHO-121,” The Psychosocial Assessment and that she is currently revamping that process. She also stated that Professional Counselor Associates are hired by the facility and that licensed counselors provide oversight and sign off on their assessments. In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated Staff K (LPCA) will need to be removed from the children’s unit because she is “too green.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient records, and confirmed in interview, the facility failed to ensure four of ten patients (Patient #K, L, M, P) were provided with an environment which promoted personal privacy and dignity. Patient #K, L, M, P were assigned alternative sleeping arrangements for greater than 24 hours. Findings included: Review of facility policy Admission/Intake (Policy AIM 105, revised 07/23) under Room Assignments it stated “Patient unit and room assignments and levels of monitoring shall be made on the basis of: a) the needs of the patient; b) the needs of other patients on a unit; c) the attending physician’s request or approval; d) space available. Patients may be admitted to a unit and transferred to another unit based upon the patient’s needs and other patient’s needs. Patients may consent to alternative sleeping arrangements and transferred to another available bed by the next day.” In an interview with Staff # 2 on 09/04/2024 at 11:00 AM in the conference room, she described the alternative sleeping arrangements as temporary and less than 24 hours. The facility would provide the patient with a mattress on the floor in either the seclusion room and/or day room at night to sleep. During the day, the mattress will be stored away. The patient may or may not have access to a private room during the day depending on the room availability. The patients still participate in the programming. Random review of patient records from August 2024 revealed the following four of ten patients who were assigned an alternative sleeping arrangements for longer than 24 hours. Patient #K Review of observation rounds revealed Patient # K slept in the TV room on 08/16/2024, 08/17/2024, 08/18/2024, 08/19/2024. Patient #K was assigned Room 808B on 08/20/2024. Patient # L Patient #L was originally assigned Room 801A at admission on 08/13/2024. Review of observation rounds revealed Patient # L slept in the Quiet Room 08/16/2024, 8/17/2024, 8/18/2024. She discharged on 08/19/2024. Patient # M Review of observation rounds revealed Patient # M slept in the Quiet Room 08/16/2024, 8/17/2024, 8/18/2024, 08/19/2024, 08/20/2024 . Patient # M was assigned Room 703B on 08/21/2024. Patient # P Review of observation rounds revealed Patient # P slept in the TV Room 8/17/2024, 8/18/2024, and 08/19/2024. Patient # P was assigned Room 702B on 08/20/2024. No doctors orders were available for review to indicate the alternative sleep arrangements were for patient safety. In an interview with Staff #1 via Teams on 09/10/2024 confirmed the above findings. She stated that the above patients consented to the alternative sleep arrangements but it was not clear that it could be greater than 24 hours.”

“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: 38387 Based on review of facility records, patient charts, and confirmed in interview, the facility failed to provide care in a safe setting for one of ten patients reviewed. The facility failed to ensure Patient # G who had a history of peer and staff violence did not have an opportunity to injure Patient # C. Findings included: Patient #G chart In review of Patient #G chart, she was admitted on 07/11/2024 for suicidal ideation with plans to overdose. Random review of nursing, progress, and therapy notes from July 2024 included the following five incidents of aggressive behaviors with no change in her level of observations. Nursing Notes on 07/11/2024 “Patient [G] got into a brawl fight with another patient on the unit refusing multiple redirections and became uncontrollable making the unit chaotic and triggering other patient danger to self and other. Staff initiated a code green.” Nursing Notes on 07/13/2024 “Patient [G] is visible in the unit. She is very disruptive. She was trying to attack [patients] most of the time. Patient received haldol/benadryl to help with her aggressive behavior.” Nursing Notes on 07/17/2024 “[Patient G] became agitated and verbally and physically aggressive to peers and staff. Required emergent IM med to assist her...” Nursing Notes on 07/19/2024 “[Patient G] was trying to fight another [patient] without any provocation. She was redirected multiple times but refused redirections. She became uncontrollable climbing tables, threatening and swearing other peers, throwing things on the floor, becoming disruptive on the unit.” Physician progress note 07/20/2024 “Threatening to cut her arm if she does not get her green band back today. [Patient G] lost her green band yesterday due to increased aggressive behaviors. Per report patient became very disruptive yesterday climbing tables and threatening peers.” Nursing Notes on 07/21/2024 “At 1423 report received from recreational therapist that [Patient G] ran towards therapist during recreational therapy. Therapist paused for a second kicked her shoes off and then [Patient G] attacked the therapist. [Patient G] hit therapist three times and then started pulling her hair and would not let go. The recreational therapist and two techs had to pull [Patient G] off the therapist..” Physician progress note 07/22/2024 “remains hyperactive and impulsive. poor boundaries, reports mood swings. stated ‘I beat up the therapist because she was rude’ less irritable but still anxious and unpredictable.” Therapy Notes on 07/22/2024 “[Patient G] on 07/19/2024 was trying to fight another [patient] without any provocation, [patient] was climbing table, threatening and scaring other [patients]. On 07/21/2024 [Patient G] ran towards therapist and attacked her. [Patient G] hit therapist in the head and pulled her hair. On 07/21/2024 [Patient G] became defiant, aggressive towards unit, and disrupt the unit.” Nursing Notes on 07/23/2024 “at 1823 [Patient G] attacked peer unprovoked. She came up behind peer and threw her on the ground and would not let go of her. Staff intervened. [Patient G] escorted to seclusion. No injury to this patient.” Patient #C In review of Patient #C chart, she was admitted on 07/22/2024 for DMDD (disruptive mood dysregulation disorder). In review of the nursing and ER (emergency room) notes stated the following: nursing notes on 07/23/2024 at 1100 “[Patient C] awake, alert, oriented. Denies suicidal/homicidal ideation and hallucinations. Reports depression 8/10 and anxiety 7/10. Reports ‘staying to myself’ to avoid drama with others. No thoughts of hurting herself....” Nursing notes on 07/23/2024 at 1920 “at 1823, [Patient C] was attacked by a peer. The peer came up from behind threw patient down causing her to hit head and [left] hand on the floor...order received to send to [ER located on 6621 Fannin] for evaluation. Review of ER records on 07/23/2024 “Physical Assault (coming from [facility]/ she was slapped on yesterday, her face slammed to tile floor, and hair pulled by another patient there yesterday. Today while trying to report and file charges the same patient assaulted her again and while the staff was trying to get the other patient off of her the patient fell to the floor with right being caught under her body. [Patient C] is complaining of pain in her right arm and hand. PMS intact/2nd digit swollen, and 3rd, 4th digit is painful to move.” “Patient is a 14 year old female with PMH bipolar type 2, anxiety, depression who presents from [facility] for physical assault. Patient with a negative Ct head and negative XRs of the RUE. Little concern for intracranial bleed or skull fracture, patient likely has a concussion given head trauma and symptoms of nausea, light-headedness and headache. Patient likely has contusions to right wrist, hand and digits given pain, swelling, bruising and negative Xrs. Medical clearance labs unremarkable, mildly elevated WBC likely reactive given no infectious symptoms. Given that patient has been assaulted multiple times at [facility] and does not feel safe, social work consulted and plan to move patient to a different inpatient psychiatric facility. Patient is medically cleared.” An interview with Staff #1 via teams on 09/10/2024 at 4:15 PM confirmed the above findings. She stated that Patient G was placed on unit restrictions after her incident on 07/21/2024. However, unit restrictions did not prevent her from injuring another patient in the unit.”