Harris County Psychiatric Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by the facility’s failure to ensure that the health and safety of patients were protected by providing care in a safe setting. The potential risks that were identified included ligature anchor points in bathrooms and a bedroom, as well as accessibility to aluminum cans/sharps, plumbing and electrical features, large plastic bags, a broom with wooden handle, fitted sheets with elastic bands, and hard plastic markers with sharp conical tips. Additionally, there were significant safety/security issues because of improper training and language barriers. Collectively, these potential risks put all patients throughout the hospital at risk for the likelihood of harm, serious injury, and possible death. More specifically, the facility failed to ensure that patients were provided care in a safe setting. This failure was evidenced by: A) 4 of 4 bathrooms on Unit 1-E, a child and adolescent unit, had handrails behind the toilets and in the showers that were not flushed against the wall thus creating gaps. Fabric could be pushed through the 3-4mm gap, creating a ligature anchor point for hanging self. In the male bathroom, there was a metal door on the wall next to the toilet. It did not close properly. One edge was loose enough to pull out, creating a gap that could be used as a ligature anchor point for self-harm. Additionally, plumbing features were housed behind this metal door. These ligature findings were not in alignment with the environmental risk assessment. 12 of the 19 child and adolescent patients on Unit 1-E were on suicide precautions (Patients #11 - #22), many of them with poor impulse control, well documented in their medical records. See A-0144 - Care in Safe Setting. B) 19 beds on Unit 1-E had fitted sheets with a 1.5cm elastic band that ran the entire border of the sheet. The elastic band could be removed (as was evidenced by the surveyor) and used as a ligature for hanging self or strangulation. 12 of the 19 patients on Unit 1-E were on suicide precautions (Patients #11 - #22). It was also noted that all hospital beds throughout the facility had the same fitted sheets potentially impacting 538 patients. See A-0144 - Care in Safe Setting. C) 1 of 11 bedrooms (Room 1-E 71) had a bed that was anchored to the floor. The bed was adjacent to a built-in shelving unit and positioned such that a 1-2-inch gap was created between the bed and one of the shelves of the unit. A knot was tied in one corner of bedding and wedged in the gap. This created a ligature anchor point. The bedding was then draped over the bed to the opposite side. This created a ligature risk. Patient #12, a patient on Suicide Precautions, had been assigned this bed. See A-0144 - Care in Safe Setting. D) A cleaning cart and a large round commercial trash can on wheels were outside the door of bedroom #70 on Unit 1-E. Staff R (housekeeper) was in the bedroom cleaning. She was turned away from the door, thus leaving the equipment behind her unattended. The trash can was lined with a large plastic bag. Additionally, there was a roll of the same plastic bags in one of the pockets of a trash can apron attached to the trash receptacle. Suicidal suffocation can occur using plastic bags. Inside the trash can were two aluminum cans: a Monster Energy drink and a Celsius drink. Aluminum cans are considered high-risk contraband because they can be easily manipulated into dangerous weapons for self-harm or to harm others. When ripped apart, aluminum cans create extremely sharp, jagged edges that can be used for cutting or stabbing. The unattended cleaning cart housed a broom with a 4-foot wooden handle. See A-0144 - Care in Safe Setting. E) Staff R (housekeeper) did not understand English when the surveyor attempted to speak with her about issues regarding her inattention to her cleaning equipment and the aluminum cans. Further discussion with Staff S (Housekeeping Supervisor) revealed that Staff R spoke Swahili and had not been properly trained, creating potential safety and security issues on Unit 1-E, an inpatient psychiatric unit. See A-0144 - Care in Safe Setting. F) 5 hard plastic markers with sharp conical points were found on Unit 1-E: four in patient bedrooms and one in a commons area. These markers can be used as a weapon. 8 of 19 patients (Patient #11, 13, 17, 21, 23, 24, 25, and Patient #26) were on Combative & Destructive Precautions. See A-0144 - Care in Safe Setting. G) On Unit 1-D, there was a metal access door into the space above the ceiling of room 34, a bathroom. The door had a gap that could be forced open potentially exposing plumbing that could be used as a ligature anchor point for hanging of self. See A-0144 - Care in Safe Setting. H) On units 1-D and 1-C, there was a tiled ledge/half-wall/pony wall separating the shower from the rest of the bathroom area in 6 bathrooms. The walls, about 5 feet high, acted as a long, continuous shelf. At the end of the ledge/shelf (at the doorway) the edges were not rounded, thus creating two sharp points. These points were identified as a safety hazard, first by Patient #27, during a tour of 1-D. .”

“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, staff interviews, and record review, the facility failed to provide care in an environment that a reasonable person would consider to be safe. More specifically, the facility failed to ensure that patients were provided care in a safe setting. This failure was evidenced by: A) 4 of 4 bathrooms on Unit 1-E had handrails behind the toilets and in the showers that created gaps that could be used as ligature anchor points. In one bathroom, there was a loose metal door on the wall that created a ligature anchor point. 12 of the 19 child and adolescent patients (Patients #11 - #22) were on suicide precautions. B) 19 beds on Unit 1-E had fitted sheets with a 1.5cm elastic band that ran the entire border of the sheet that could be easily removed and used for hanging self or strangulation. 12 of the 19 patients (Patients #11 - #22) were on suicide precautions. All patient beds throughout the facility had the same fitted sheets potentially impacting 538 patients. C) 1 of 11 bedrooms (Room 1-E 71) had a bed that was anchored to the floor. The 1-2-inch gap between the bed and a shelving unit created a ligature anchor point when a knot was tied in one corner of bedding and wedged in the gap. A patient on sucide precautions had been assigned this bed. D) An unattended cleaning cart and a large round commercial trash can were outside the door of bedroom #70 on Unit 1-E. The trash can was lined with a large plastic bag. There was a roll of large plastic bags in one of the pockets of the trash can apron attached to the trash receptacle. There was no policy on plastic bags on the unit. Inside the trash can were two aluminum cans - potential weapons. There was no policy on aluminum cans being on the unit. There was no policy or procedure addressing staff members bringing aluminum cans to their offices adjacent to or on the unit. The unattended cleaning cart housed a broom with a 4-foot wooden handle. E) Staff R (housekeeper) did not understand English and could not address issues regarding her cleaning procedures. Staff S (Housekeeping Supervisor) stated Staff R had language barrier and improper training, creating both safety and security issues on Unit 1-E, an inpatient psychiatric unit. Even with proper training, there are safety and security concerns with a staff member on a psychiatric unit that does not speak English. F) 5 hard plastic markers with conical tips (potential weapons) were found on Unit 1-E: four in patient bedrooms and one in a commons area. 8 of 19 patients (Patient #11, 13, 17, 21, 23, 24, 25, and Patient #26) were on Combative & Destructive Precautions. The markers were not monitored by staff. G) On Unit 1-D, there was a metal access door into the space above the ceiling of room 34, a bathroom. The door had a gap that could be forced open potentially exposing plumbing that could be used as a ligature anchor point. H) On units 1-D and 1-C, there was a tiled ledge/half-wall/pony wall separating the shower from the rest of the bathroom area in 6 bathrooms. The edges were not rounded, thus creating two sharp points. These points created a safety hazard. Findings were: A) Ligature anchor points behind grab bars on Unit 1-E. Literature review. Record review of “Impulsivity and Suicidality in Adolescent Inpatients” by R. Auerbach, J Stewart, and S Johnson in the Journal of Abnormal Child Psychology, 2017 Jan, 45(1):91-103, showed, “Suicide is the second leading cause of death among adolescents, and impulsivity has emerged as a promising marker of risk ... The precise relationship between impulsivity and suicidal behaviors remains unclear.” Record review of a previous investigation (TX00554826) of a suicide attempt by Patient #28, a 14-year-old adolescent on Unit 1-E, demonstrated the impulsiveness and suicidality found in this population. On 10.26.2025, Patient #28, walked from her bedroom carrying a pair of red pants. She walked through the commons area where many of her peers and several staff members were gathered around tables. She then entered the bathroom. She was found on the floor with the pants tied around her neck. A Code Blue was called. Later in the evening, she again tried to choke herself with a pair of pants. Review of an Environmental Risk Assessment of identified risks, risk reduction features, and current mitigation strategies, showed: Risk Reduction Features: Grab bars are non-loopable ... No features in the bathroom provide an opportunity for hanging ... Constant observation is required to ensure ligature points are not created. During a tour of Unit 1-E, a child and adolescent unit, on 2.10.2026 at 10:30am, it was observed that four bathrooms, used by all patients, had ligature anchor points thus creating ligature risks. (1) Bathroom #1, a male bathroom. This bathroom had a handrail/grab bar behind the toilet. The handrail was not flushed to the wall, thus creating a gap. Fabric could be pushed through the gap, creating a ligature anchor point that could be used for self-harm. Additionally, a metal door on the wall next to the toilet, identified by Staff Q as a “plumbing door,” did not close properly. One edge was loose enough to pull out, creating a gap that could be used as a ligature anchor point for self-harm. Staff Q (RN Unit Manager) also stated that forcing the door open could possibly expose an individual to plumbing pipes that could be used as a ligature anchor point for self-harm. (2) Bathroom #2, the children’s bathroom. This bathroom had handrails/grab bars behind the toilet and in the shower. The handrails were not flushed to the wall, thus creating gaps. (3) Bathroom #3, a female bathroom. This bathroom had handrails/grab bars behind the toilet and in the shower. The handrails were not flushed to the wall, thus creating gaps. (4) Bathroom #4, a female bathroom. This bathroom had handrails/grab bars behind the toilet and in the shower. The handrails were not flushed to the wall, thus creating gaps. Staff Q stated that the gaps behind the handrails in all four of the bathrooms created ligature anchor points. Record review of the assignment sheet for Unit 1-E, dated 2.10.2026, showed 12 patients (Patients #11 - #22) on Suicide Precautions. Patient #11. Record review of the History & Physical by Staff D (MD) dated 2.5.2026 at 4:11pm showed an 8-year-old male with escalating behavioral dysregulation characterize by impulsivity, aggression, and recurrent self-harming behaviors. He had tried to choke himself at school. He explained that he chokes himself when he becomes angry. He had also engaged in severe self-injurious behaviors such as “punching the left side of his face” and choking himself, leaving bruises and black eyes, indicating significant safety concerns. Suicide precautions. Review of Physician Orders by Staff E (MD) dated 2.5.2026 at 7:27pm showed Suicide Precautions. Patient#12. Record review of the History & Physical by Staff D (MD) dated 2.6.2026 at 1:23pm showed an 11-year-old male in CPS care due to child abuse. He presented with suicidal ideation, self-injurious behavior - head banging and biting self, and significant aggression toward others. Suicide precautions based on patient protective factors. Record review of Physician Orders by Staff F (APRN) dated 2.5.2026 at 3:54pm showed Suicide Precautions. Patient #13. Record review of the History & Physical by Staff H (MD) dated 1.31.2026 at 1:12am showed a 6-year-old male with threats to kill others, assaultive towards others, impulsivity, and explosive outbursts. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff G (MD) dated 1.31.2026 at 1:12am showed Suicide Precautions. Patient #14. Record review of the History & Physical by Staff G (MD) dated 1.28.2026 at 2:25am showed an 8-year-old male with auditory hallucinations telling him to hurt himself and his mother. His mother reported the voices were often commanding, involving about five distinct male and female voices. Suicidal ideation had worsened over a 1-2-week period. He recently attempted to stab himself with scissors and choke himself. He had once tried to jump from a moving vehicle. There were concerns raised for medical child abuse by the mother (Munchausen syndrome by proxy). Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff G (MD) dated 1.28.2026 at 4:45am showed Suicide Precautions. Patient #15. Record review of the History & Physical by Staff I (MD) dated 2.3.2026 at 1:01am showed an 11-year-old female admitted with acute suicidal ideation and worsening thoughts of self-harm. Patient’s mother reported patient made a statement “why can I not hurt myself like [her cousin] does.” Patient uncooperative. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff I (MD) dated 2.3.2026 at 3:02am showed Suicide Precautions. Patient #16. Record review of the History & Physical by Staff J (MD) dated 2.3.2026 at 10:24pm showed a 9-year-old female admitted with a 3-week history of suicidal ideation. The patient stated she had suicidal ideation whenever she became upset. She had been in two different psychiatric facilities back-to-back for similar presentation. She also had a history of head banging and biting herself. She outlined a plan to “run away and get hit by a car, or to wake up in the middle of the night, get a knife, and stab myself in the heart when no one is watching me.” She stated she “sees a shadow and it has a knife and a baby.” Record review of Physician Orders by Staff J (MD) dated 2.3.2026 at 10:33pm showed Suicide Precautions. Patient #17. Record review of the History & Physical by Staff K (MD) dated 1.13.2026 at 8:17pm showed a 16-year-old female with suicidal ideation. She stated, “I tried to kill myself on December 28.” She reported scratching herself and cutting herself for relief from anxiety. She displayed multiple superficial lacerations on her arms. Struggles with impulse control. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff G (MD) dated 1.13.2026 at 10:26pm showed Suicide Precautions. The assignment sheet for Unit 1-E, dated 2.10.2026, showed Patient #17 to be on Close Observation 1:1 - arm’s length. Patient #18. Record review of the History & Physical by Staff L (MD) dated 2.7.2026 at 3:37pm showed a 16-year-old female with suicidal ideation. She described thoughts of jumping off a building or strangling herself. Record review of Physician Orders by Staff L (MD) dated 2.6.2026 at 8:16pm showed Suicide Precautions. Patient #19. Record review of the History & Physical by Staff M (MD) dated 2.4.2026 at 10:36am showed a 13-year-old female admitted with suicidal ideation and self-harm behaviors since 2022 - cutting her thighs with a box cutter or a razor blade. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff N (MD) dated 2.4.2026 at 9:45am showed Suicide Precautions. Patient #20. Record review of the History & Physical by Staff O (MD) dated 2.8.2026 at 10:29am showed a 13-year-old female admitted with acute decompensation and suicidal ideation to overdose on medication she had gotten from a previous psychiatric hospitalization. She reported an increase in hearing voices and intrusive thoughts. She saw shadows. Father “scared and concerned about the patient’s safety.” Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff O (MD) dated 2.8.2026 at 11:20am showed Suicide Precautions. Patient #21. Record review of the History & Physical by Staff P (MD) dated 2.4.2026 at 3:06pm showed a 13-year-old female admitted after she was found at the window of her group home threatening to end her life. She reported a history of suicidal thoughts beginning around the time she was told of her father’s suicide attempt while in prison. She tried to cut an artery. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff N (MD) dated 2.4.2026 at 3:00pm showed Suicide Precautions. Patient #22. Record review of the History & Physical by Staff I (MD) dated 2.8.2026 at 11:41pm showed a 16-year-old male with worsening depression, suicidal ideation - wanting to end his life, and cannabis/synthetic cannabis use. Uncooperative. Debilitating depression with inability to safely care for self. Suicide precautions are based on patient protective factors. Record review of Physician Orders by Staff I (MD) dated 2.9.2026 at 1:27am showed Suicide Precautions. B) Fitted sheets with elastic bands. During a tour of Unit 1-E, a child and adolescent unit, on 2.10.2026 at 10:30am, it was observed that the beds in 11 bedrooms all had fitted sheets with a 1.5cm elastic band that ran the entire border of the sheet. The elastic band was removed from the fitted sheet by picking at the stitching. Record review of the assignment sheet for Unit 1-E, dated 2.10.2026, showed 12 patients (Patients #11 - #22) on Suicide Precautions. In an interview with Staff A (PI Director) on 2.10.2026 at 2:00pm, she observed the elastic band that had been removed from the fitted sheet and stated the fitted sheets created a ligature risk. Staff Q (Nursing Manager) also stated the fitted sheets created a ligature risk. In an interview with Staff U (Facilities Director) on 2.10.2026 at 1:14pm, he stated the elastic band on the fitted sheets had never been brought up as an issue. He also stated, “All fitted sheets [in the hospital] have the elastic band” and that these fitted sheets “are used all over the hospital.” In a tour of Central Supply at 1:25pm with Staff U, it was noted that all the sheets for the facility were fitted sheets with a 1.5cm elastic band that ran the entire border of the sheet. He concluded the interview by saying he would get in touch with the laundry service to have flat sheets delivered. An environmental risk assessment that features identified risks, risk reduction features, and current mitigation strategies was provided by Staff T (facilities personnel). The assessment did not address fitted sheets. C) Ligature anchor point between a bed and a shelving unit. An environmental risk assessment that features identified risks, risk reduction features, and current mitigation strategies was provided by Staff T (facilities personnel). The assessment stated: “Ligature points do not exist between patient bed and wall ... If [a] ligature issue exists between wall and bed, pick proof caulk or additional remediation efforts must [be] installed.” During the tour of Unit 1-E on 2.10.2026 at 10:30am, it was observed in bedroom E-71 that the positioning of the stationary bed adjacent to a built-in shelving unit created a 1-2-inch gap. A knot was tied in one corner of the bedspread and wedged into the gap. The bedding was then draped over the bed to the opposite side. The bedding remained wedged in the gap when it was pulled forcefully. Record review of the Unit 1-E list of patients on 2.10.2026 showed that Patient #12 was in bedroom E-71. Record review of the History & Physical by Staff D (MD) dated 2.6.2026 at 1:23pm showed Patient #12 was an 11-year-old male in CPS care due to child abuse. He presented with suicidal ideation, self-injurious behavior - head banging and biting self, and significant aggression toward others. Suicide precautions based on patient protective factors. Record review of Physician Orders by Staff F (APRN) dated 2.5.2026 at 3:54pm showed Patient #12 was on Suicide Precautions. In an interview with Staff Q (Nursing Manager) at the time of this finding, he stated that the gap between the bed and the built-in shelving created a ligature anchor point that could be used to hang oneself. D) The cleaning cart, commercial trash can, plastic bags, and aluminum cans. A policy identifying restricted items on the psychiatric units was requested by the surveyor from Staff A (PI Director). A document that listed permitted and restricted items was provided by Staff A. Restricted items included: “soda in aluminum cans ... plastic bags ... any type of sharp object.” Record review of the admission criteria of numerous hospitals across the United States show that aluminum cans and plastic bags are not allowed on inpatient psychiatric units due to safety risks. Aluminum cans are classified as potential sharp objects or contraband because they can be torn or broken to create sharp edges, which pose a risk of self-harm or injury to others. [Penn Psychiatry, The Jason Foundation, San Jose Behavioral Health] During a tour of Unit 1-E, a child and adolescent unit, on 2.10.2026 at 10:30am, it was observed that a cleaning cart and trash can were outside of bedroom #70 while Staff R (housekeeper) was inside the room cleaning. Staff R had her back to the equipment. The trash can was lined with a large plastic bag. There was a large roll of the same plastic bags in one of the pockets of the trash can apron attached to the trash can. Inside the trash receptacle were two aluminum soft drink cans - a Monster Energy drink and a Celsius drink. The cleaning cart housed a broom with a 4-foot wooden handle. In an interview with Staff A (PI Director), Staff U (Facilities Director), Staff S (Housekeeping Supervisor), and Staff V (Infection Control Practitioner), they stated that the trash receptacle and the cleaning cart should have been in a secure location with Staff R (housekeeper). Staff U stated the cleaning cart, and the trash receptacle should have always been in the sight of the housekeeper. There was much discussion about how the aluminum cans ended up on Unit 1-E. Staff S (Housekeeping Supervisor) speculated that Staff R (housekeeper) emptied the trash from the offices adjacent to the unit into the large trash receptacle when she was cleaning the offices. Staff V (Infection Control Practitioner) stated there was no policy on having aluminum cans on the unit. Staff A, U, S, and V stated there should not have been any plastic bags on the unit. Staff V stated there has been an issue with plastic on the units in the past and at one time having plastic on the units had been stopped. Staff S stated that there was no policy on plastic bags on the unit. E) Staff R (housekeeper). During a tour of Unit 1-E, a child and adolescent unit, on 2.10.2026 at 10:30am, it was observed that a cleaning cart and trash can were outside of bedroom #70 while Staff R (housekeeper) was inside the room cleaning. Staff R had her back to the equipment. The surveyor attempted to speak with Staff R (housekeeper) about these safety and security issues. She did not understand the surveyor. She smiled, turned, and continued with her cleaning. In an interview with Staff S (Housekeeping Supervisor) on 2.11.2026 at 10:20am, he stated that Staff S spoke Swahili and does not understand English, adding, “She needs to be trained.” He also stated that Staff S was one of three staff members that speak Swahili and that he would have one of the other two Swahili-speaking staff members retrain Staff S. He stated he understood the safety and security issues of having an improperly trained, non-English speaking staff member working on an inpatient psychiatric unit. F) Hard plastic markers with conical tips. During a tour of Unit 1-E, a child and adolescent unit, on 2.10.2026 at 10:30am, it was observed that five hard plastic markers with conical tips were on the unit: four in patient bedrooms and one in a commons area. The markers were not monitored by staff. Record review of the assignment sheet for Unit 1-E, dated 2.10.2026, showed 8 of 19 patients (Patient #11, 13, 17, 21, 23, 24, 25, and Patient #26) were on Combative & Destructive Precautions. In an interview with Staff Q (Nursing Manager) during the tour, he stated the hard plastic markers with conical tips could potentially be used as a weapon to harm someone. G) Metal access door in ceiling of a patient bathroom. During a tour of Unit 1-D, an adult unit, on 2.10.2026 at 11:30am, a metal access door in the ceiling of room 34, a patient bathroom was observed. The door had a gap that could be forced open. In an interview with Staff Q (Nursing Manager) during the tour, he stated the door was an access door to plumbing and possible electrical wiring, both ligature anchor points. In an interview with Staff W (Facility Supervisor) on 2.11.2026 at 10:55am, he stated there was plumbing and “maybe electrical” above the access door in the bathroom (room 34) on Unit 1-D. He also stated the door needed to be secured so that it could not be forced open. H) Shower ledges. During a tour of unis 1-D and 1-C on 2.10.2026 at 12:00pm, it was observed that two showers on Unit 1-D and four showers on Unit 1-C had a tiled ledge/half-wall/pony wall separating the shower from the rest of the bathroom area. The walls, about 5 feet high, acted as a long, continuous shelf. At the end of the ledge/shelf (at the doorway) the edges were not rounded, thus creating two sharp points. The bathrooms involved were 1-D 34 and 1-D 25, and four male bathrooms on Unit 1-C. During the tour of Unit 1-D, the surveyor was approached by Patient #27 who identified the sharp edges of these shelves as a safety hazard. He stated he had worked in the tile business. He went on to say that an individual could slip in the shower and hit their head on the pointed edge of the shelf causing a serious accident. In an interview with Staff Q (Nursing Manager) during the tour, he stated that the sharp points on the shelving created a safety hazard. In an interview with Staff W (Facility Supervisor) on 2.11.2026, he stated the shelves created a potential safety hazard. .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 . Based on observation, interview, and record review, the facility failed to ensure that patients passing through the elevator lobby of the second floor of the HCPC building were provided a safe setting. More specifically, the facility failed to ensure that staff members in Dietary Services accounted for their aprons while in patient care areas. Findings included: During a tour of the psychiatric units on 12.17.2025 at 1:30 PM with Staff B (Nurse Manager), a black apron was found on top of the metal cabinet that housed the emergency evacuation device. The metal cabinet was in the elevator lobby on the second floor. A hospital staff member (Staff J) was observed walking through the lobby area. She walked over to retrieve the apron. Further observation of apron showed it to be a black poly-cotton blend apron with a neck strap and two waist ties. In an interview with Staff J, she identified herself as a “cook” in the Dietary Services Department, adding that she was not responsible for the apron being on the top of the metal cabinet. She stated the apron should not be on the cabinet because it was “unsanitary.” She removed the apron and exited the lobby. In an interview with Staff B (Nurse Manager) on 12.17.2025 at 1:30 PM, he stated that not only was the apron “unsanitary” and an “infection control issue,” it was also a potential “ligature risk.” He also stated that by placing “a heavy item in the apron, it could be used as a weapon.” Staff B demonstrated how a heavy object could be placed in the apron to create an improvised impact weapon. He concluded by saying that patients passing through the lobby area on their way to the dining hall could potentially have access to the apron. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure patients’ right to be free from abuse, as shown by: a) Staff (RN Staff #Z) cursing at a patient, inciting aggression, then physically fighting with a patient (Patient #1); b) Failing to protect other patients by allowing the staff member (RN Staff #Z) to return to work with patients after abuse allegations were not fully investigated, and; c) Not having a clear policy for their abuse investigation process that protected patients from staff who were alleged perpetrators of abuse, such as removing the staff from direct patient care. Findings included: Review of facility policy #PR-0002 titled “Patient Rights, Responsibilities, and Limitations on Patient Rights” dated 3/5/24 showed that patients had the right to be free from mistreatment and abuse. Review of facility policy #PR-0004 titled “Staff Responsibilities and Actions Associated with Suspected Abuse, Neglect, or Exploitation” dated 3/4/24 showed the following: Class II abuse was described as striking or pushing a patient, regardless of it resulting in injury; Class III abuse was described as staff cursing at a patient. A) RN Staff #Z incitement and abuse of Patient #1: Review of facility incident report showed that on 12/5/25 at 1:56 pm while in an outside courtyard of the Dunn building (DCB) during a fresh air break, Patient #1 “eloped” by crossing a gate and went into a different courtyard (HCPC) which was off limits, despite her having a 1:1 close sitter, who failed to prevent this. RN Staff #Z, a nurse from HCPC became involved, used derogatory language which escalated the patient, and the patient attempted to strike the nurse and grab her hair. However, facility began an investigation, and it was revealed that Patient #1 and RN-Staff #Z had a verbal and subsequent physical fight, after RN Staff #Z incited the patient to become aggressive by cursing at her and not removing herself from area. RN Staff #Z hit the patient back during the fight and had to be pulled off the patient and restrained by other staff. Although video review of the event with DON Staff #A on 12/17/25 at 12:20 pm failed to capture the entire incident due to blind spots, numerous statements from onsite witnesses to the event showed that RN Staff #Z verbally and physically abused the patient: Portions of written statements via emails from Psychiatric Technicians (PTs) dated 12/5/25, who were witnesses to the incident showed the following: PT Staff #U wrote that things were under control with Patient #1 and they were walking back to the DCB courtyard after techs calmed her down. The patient stated she did not want the nurse near her (RN Staff #Z) and the nurse “out loud in front of everyone” called her a bitch. PT Staff #W wrote that the nurse told the techs to put their hands on the patient but the techs were able to verbally deescalate the patient who became cooperative and was walking back to the DCB courtyard on her own. The patient said several times she did not want the nurse near her. The nurse then called her a bitch twice. The patient and nurse started fighting physically and the nurse punched the patient back. They were separated after the patient pulled the nurse’s hair, but then the nurse “charged” back at the patient. Staff #W tried to hold the nurse back, who said to her “get the f*** off” of her, and she was going “to “f*** her up” (hurt the patient), and also said “I told y’all to put your hands on the patient”. PT Staff #X wrote that the techs were able to get the patient to walk back to the DCB courtyard “peacefully” but when they crossed the gate, the nurse was there which agitated the patient. The nurse called the patient a bitch and it started a fight between the two of them. PT Staff #Y wrote that the nurse and patient were cursing at each other. While the patient was walking back to the DCB courtyard, the nurse kept instructing the techs to put their hands on the patient but there was no need to because the patient “wasn’t attacking anyone”. The nurse kept “antagonizing” the patient and the patient said she did not want that nurse near her. The techs asked the nurse to move away but she refused. The patient threatened to hit the nurse if she didn’t move, then the nurse called her a bitch. A fight broke out and the nurse “fought the patient back”. The techs “screamed” at the nurse to stop but “she (the nurse) didn’t care” and had to be pulled off the patient. Portions of verbal statements from PTs made to Patient Advocate Staff #S on 12/10/25 showed the following: PT Staff #R said the situation became under control and the patent began following staff directions, but the nurse refused to remove herself from the area and insisted on restraining the patient. The nurse was “calling the patient out” and refusing to move away from a gate that led back to the DCB courtyard, which was the pathway for the patient coming back. A fight between the nurse and patient ensued and the entire group of PTs who were there had to physically restrain the nurse. PT Staff #R also stated that the fight was preventable. PT-Staff #T said that he heard the nurse and patient cursing at each other. As staff were taking the patient back through the gateway, with the patient cooperating, the nurse stood in the direct path of the patient which was the primary cause of the patient’s aggression escalating, sparking the fight. He also stated that all the other PTs present asked the nurse to stand elsewhere but she would not listen to them. PT Staff #V said that the patient told the nurse to go away, and the nurse said, “I’m not moving, I’ll stand right here”. The patient became mad and pulled the nurse’s hair. A physical fight followed and several techs had to hold the nurse back, telling her it wasn’t worth her license. PT Staff #V also said that the nurse made the patient mad and the patient could have been fully deescalated without a restraint. In an interview on 12/17/25 at 3:50 pm, Patient Advocate Staff #S stated that allegations of verbal abuse against RN Staff #Z were substantiated. However, allegations of physical abuse were inconclusive due to the video of the altercation not being completely visualized due to a blind spot. Although there was no audio sound in the video tapes, the facility confirmed verbal abuse based on numerous verbal and written statements from direct witnesses. However, these same witness statements also described physical abuse as well. B) Facility failing to protect other patients: In an interview on 12/17/25 at 3:55 pm, HR Director Staff #AA and DON Staff #A stated the investigation was still ongoing and administrative staff were going to discuss investigation findings today, adding that the full investigation was not yet complete. When asked if RN Staff #Z was allowed back on the unit to work, they stated that she had just returned to work today. Staff #AA then stated that this should not have happened and RN Staff #Z should have been out on administrative leave, adding that she should not have been allowed to return to work today. C) Policy to protect patients from staff accused of abuse: Further review of facility abuse policy #PR-0004 titled “Staff Responsibilities and Actions Associated with Suspected Abuse, Neglect, or Exploitation” dated 3/4/24 failed to show that staff were either temporarily suspended or removed from direct contact with patients during an investigation if they allegedly abused a patient. The policy described the various definitions of abuse and the abuse investigation process. However, it did not describe the action of suspending or removing a staff member from being with patients during the investigation process. In two separate interviews on 12/17/25 at 4:40 pm and 4:50 pm, PI Director Staff #D stated there was no policy addressing what to do with staff members who were accused of abusing patients during the facility investigation. When asked specifically if there was any formal policy or procedure that suspended or removed the accused staff member from contact with patients during abuse investigations if the staff was the alleged perpetrator, Staff #D stated there was nothing the facility had that addressed this and she stated this was confirmed with HR Director Staff #AA.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38387 Based on observation of facility video surveillance, review of facility policy, record reviews, and interviews, the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital’s restraint policy, training program and in accordance with State law during the implementation of a physical restraint for one of eight patients reviewed (Patient #A). Findings included: Review of the facility policy Restraint Process (Policy Number 2.26, effective 04/01/2022), under Initiation of Personal/Physical Hold Restraint, it stated “staff member will utilize approved SAMA technique to restrict the patient’s movement for safety.” Video review of 06/28/2025 incident involving Patient #A who was having an emergency behavioral incident 06:23 PM Staff #6 places Patient #A’s arms behind her back and forces her towards seclusion room 06:25 PM Patient #A placed in seclusion 06:50 PM Patient #A released from seclusion Video review of 06/30/2025 incident involving Patient #A who was having an emergency behavioral incident that required seclusion 11:04 PM Staff # 8 who stands over Patient #A face to face (dialogue inaudible) 11:05 PM Staff # 8 pushes against Patient #A onto Staff #7 11:05 PM Staff # 7 pulls Patient #A by the arm towards the seclusion room 11:05 PM Patient #A hits Staff #7 11:06 PM Patient #A is on the floor behind the seclusion room with indistinguishable staff above her trying to force her into seclusion room 11:09 PM seclusion doors closed and locked 11:15 PM Patient #A attempts to push the seclusion door open 07/01/2025 01:24 AM seclusion doors unlocked, but staff is blocking the exit 02:10 AM patient is released from seclusion Review of Patient #A’s chart revealed a restraint hold were ordered for the above incidents. Review of the facility training for techniques for effective aggression management (SAMA) did NOT include physical holds like the ones observed in the video for both incidents. An interview with Staff #1 on 07/08/25 at 11:20 AM in the conference room confirmed the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 38387 Based on review of facility policy, review of medical records and confirmed in interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 2 hour time limit for adolescents in one of five patients with restraints reviewed (Patient #A). Findings included: Review of the facility policy Seclusion Process (Policy Number 2.28, effective 11-2024), it stated “Each and every Seclusion episode requires a separate physician’s order in an emergency situation, the RN may authorize the use of seclusion. In those circumstances, however, a physician’s order (written/verbal) for seclusion must be obtained immediately following or no later than one hour following the initiation of seclusion/restraint. As part of obtaining that order, the RN consults with the physician regarding the patient’s physical/ psychological condition and release criteria. Seclusion orders are time-limited as follows: Ages (18 and up) - 4 hours Ages 9 to 17 - 2 hours Ages under 9 - 1 hour Orders include: Reason for seclusion/restraint Type of Restraint Release criteria If the original order is about to expire, and a clinically competent RN has evaluated the individual face-to-face and determined the continuing existence of an emergency, he/she must contact the physician to obtain a new order to continue the process. The physician must sign all telephone orders for seclusion, to include the time of the order, within 48 hours of the time that the order was originally issued” Review of Patient #A’s medical chart revealed she is a 16 year old female with a history of ADHD, DMDD, and GAD who was admitted to the facility for their program. Further review of her chart revealed personal and seclusion restraints were used on 06/30/2025. Staff #8’s nursing notes included: “Patient was observed filling cups with hand sanitizer and pouring it onto the floor, then proceeded to throw milk cartons into the nurses’ station and at staff. When staff attempted to retrieve the items, patient became physically aggressive, striking staff in the face. Due to continued combative behavior-including punching, kicking, hair-pulling staff, and refusing to release grip-staff initiated personal restraints from 23:05 to 23:08. Special Teams was called, and patient was placed in seclusion at 23:09. While in seclusion, patient was noted to be yelling, crying, and cursing at staff. Patient removed her clothing and attempted to strangle herself. Staff immediately intervened to remove the clothing for patient safety; however, patient remained combative toward staff. The House Officer was notified of the patient’s status. An order was received for Thorazine 25 mg IM STAT, which was administered to the right ventrogluteal site. Medication was tolerated well, with no adverse reactions noted. Patient was released from seclusion at 01:09 after demonstrating decreased agitation and aggressive behaviors. No injuries were observed. An attempt was made to notify the patient’s caseworker; however, there was no answer. Patient was able to return to her room without further behavioral concerns” Review of Patient #A’s medical chart revealed the following orders for restraints: 11:13 PM Personal Restraints, Restraints adolescent seclusion with reason as “To prevent imminent physical or emotional harm to others because of threats, attempts or other acts the patient overtly or continually makes or commits” Video review of 06/30/2025 incident involving Patient #A who was having an emergency behavioral incident that required seclusion 11:04 PM Staff # 8 who stands over Patient #A face to face (dialogue inaudible) 11:05 PM Staff # 8 pushes against Patient #A onto Staff #7 11:05 PM Staff # 7 pulls Patient #A by the arm towards the seclusion room 11:05 PM Patient #A hits Staff #7 11:06 PM Patient #A is on the floor behind the seclusion room with indistinguishable staff above her trying to force her into seclusion room 11:09 PM seclusion doors closed and locked 11:15 PM Patient #A attempts to push the seclusion door open 07/01/2025 01:24 AM seclusion doors unlocked, but staff is blocking the exit 02:10 AM patient is released from seclusion Restraints were kept on for over 2 hours (2 hours 15 minutes) with no documentation of a new order to continue. In an email received 07/23/2025 with Staff #2, she acknowledged that the restraints were kept on longer than the 2 hour limit for patient’s age.”

“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: 43549 Based on review of records, observations, and interviews, the facility failed to ensure safe care for 1 of 1 patient (# G) on one-to-one observation for falls and agitation. Findings include: POLICY Number 2.4: One-to-One or Two-to-One Supervision of Patients (Arm’s length and Direct Observation) One-to-One or Two-to-One Supervision of Patient is close observation of patients that have been identified as an imminent danger to themselves or others. PROCEDURE: Staff Responsibilities included: 1. Document the patient’s behavior/ activity every 15 minutes on S/R Event Monitoring, 2. While on duty the assigned staff may not leave the patient unattended under any circumstances. 3. Keep within arm’s length of patient at all times unless distance supervision is ordered. 4. Stay Alert. 5. Avoid distractions at all times 6. To provide safety and care for the patient, you are expected to observe, and care for the patient at all times. During a tour 02/21/24 at 10:55 am the dayroom was entered by one surveyor and employee (#1), Director of Clinical Performance. Unlicensed Mental Health Technician (MHT) (staff #20) was seated by a window in the dayroom approximately 10 feet past the nursing station counter watching the dayroom television where she remained until interviewed. When interviewed at 11:35 she was asked was asked what she was doing. She responded she was doing 1:1 observation on a patient in bed. She then pointed to a room several yards behind her. The room interior and patient therein were not visible where staff # 20 was seated. Patient #G was assessed as moderate/high fall risk and had a medical order dated 11/29/23 for fall precautions. On 12/01/23 for 1:1 monitoring as ordered. Both orders remained in place on 02/21/24. Staff #20’s every 15-minute documentation was checked at 11:30 am. It indicated she had checked the patient in the patient room while still sitting in the dayroom at 11:00, 11:15 and 11:30 am. When interviewed 12/21/24 at 11:45 employee (#1), Director of Clinical Performance confirmed patient # 20 was not visible to the staff assigned to monitor her 1:1.”