Behavioral Hospital of Bellaire

“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 . A. Patient #1 Based on observations, interviews, and record review, 1) The facility failed to ensure that 1 of 1 patients (Patient #1) was safe from an assault by two patients (Patients #2 and #3), both of which were on Aggression/Homicide Precautions and Unit Restriction Precautions. 2) The facility failed to ensure that 1 of 1 Registered Nurses remained on her assigned unit to provide nursing oversight of Patients #2 and #3. 3) The facility failed to ensure that 1 of 1 Mental Health Technicians remained on her assigned unit to provide nursing oversight of Patients #2 and #3. This failure resulted in Patients #2 and #3 eloping from their unit to an adjacent unit and violently attacking Patient #1 with Patient #1 sustaining a head injury. B. Patient #2 and #5. Based on record review, video review and interview, the facility failed to ensure a safe setting, as evidenced by not recognizing patients at risk for sexual victimization and then placing them on appropriate safety precautions (Patient #2 & #5). Both of these patients were later involved in inappropriate sexual incidents. Findings included: A. Patient #1. Policies. Review of “Elopement Prevention” [not dated or timed] showed: “Risk factors or warning behaviors, which may influence and/or predict elopement, can include ... Patients watching doors closely ... Patients exhibiting noncompliance to the treatment program or facility rules ... “HOW THINGS CAN GO WRONG ... Patients can suddenly make a run for an exit ... “WHAT CAN YOU DO? ... When exiting units, turn around and put your hand on the door until it closes. Look for patients loitering around doors when entering and exiting units.” Review of policy, “Medical Risk Acute Change of Condition,” last reviewed 3/15/26, showed: “When clinical nursing staff identify symptoms in a patient that constitute a medical condition they will proceed with the following steps: a. Assess whether the patient’s condition requires emergent action (transfer to medical facility emergency room) or whether the condition can wait until the nurse can consult with the medical staff.” Review of policy, “Patient Abuse and Neglect In-House Patients,” reviewed 4/2026, showed: “Behavioral Hospital of Bellaire promotes respect, dignity, and safety to all its patients and their rights ... If it is determined that patient has been abused by another patient: ... The physicians of both patients will be advised so as to insure effective intervention and assessment of patients.” Tour of the Adolescent Girl’s Unit. Staff A (CNO) provided a tour of the Adolescent Girl’s Unit (Unit 7) on 4/15/2026 at 10:30am. Observation of the unit showed a hallway lined with patient bedrooms. A set of wooden double doors with a magnetic locking mechanism divided the hallway into two separate units: the front unit and the back unit. There were 6 rooms on one side of the double doors and 5 rooms on the other. Each bedroom had two beds. Staff A stated that the unit had a capacity of 22 patients. She further explained that the double doors divided the girls into two age groups - older and younger. She also stated that patients sometimes have conflicts; the two areas afford a means by which patients can be separated. She also stated that on 3/19/2026, the adolescent units were adequately staffed. Patient Care Assignment Sheet. Review of the Patient Care Assignment Sheet dated 3/19/2026 for the 6:45AM-7:15PM shift showed the RN and MHT assignments for the two Adolescent Girls’ Units: Front Unit - Staff I (RN) and Staff R (MHT) Back Unit - Staff K (RN) and Staff S (MHT) Video Surveillance Footage of the Assault on Patient #1. On 4/15/2026 at 11:00am, Staff B (RM) provided video surveillance footage along with commentary of an incident in which Patient #1 was assaulted by Patient #2 and Patient #3 on Unit 7. The video footage was dated and timed 3/19/2026, 5:49pm. The double doors that separated the two Adolescent Girls’ Units were propped open by two staff members. The two staff members were standing in the doorway talking. Staff B (RM) identified them as Staff R and Staff S, both Mental Health Technicians (MHT). In the foreground a staff member was observed in the doorway of the first bedroom. Staff B (RM) identified this staff member as Staff K (RN), adding that Patient #1 was in the bedroom. He stated the two MHTs were engaged in conversation and not attending to their units, adding that they should not have been positioned in such a way as to keep the doors open. Further review of the video surveillance footage showed Patient #2 and Patient #3 bolting through the doorway being held open by Staff R and Staff S (MHTs). The two patients pushed the MHTs to the side and immediately ran into the first bedroom, identified by Staff B (RM) as Patient #1’s bedroom. At the bedroom door, they pushed Staff K (RN) to the side. It only took about 2 seconds for the two patients to go through the double doors into Patient #1’s bedroom. The details of the assault of Patient #1 inside the bedroom was not captured by the camera. Interviews of the Assault on Patient #1. In an interview with Staff K (RN) on 4/15/2026 at 1:32pm and 4/16/2026 at 11:51am, she stated that an MHT had asked her to speak with Patient #1. While she was talking with Patient #1, Patient #2 and Patient #3 “rushed through the door.” She stated that Patient #1 was sitting on her bed when Patient #2 and Patient #3 began hitting her on her head with their fists. Staff K stated her wrist was injured while “pulling” Patient #2 off Patient #1. When asked to describe any injuries sustained by Patient #1, she described a “large knot - the size of a golf ball that was open a little bit. It was bloody.” She also stated, “I knew she needed to be seen [by a physician].” She also stated that she told Staff I (RN - on the front unit) to “call 911 or let her parents know.” She went on to explain that the father of Patient #1 was in the lobby awaiting his daughter’s discharge. When questioned as to why Patient #1 was targeted by Patient #2 and Patient #3, she stated that they thought Patient #1 was “talking about them.” In an interview with Staff I (RN) on 4/15/2026 at 11:28am, she stated she was the nurse on the front unit on 3/19/2026 and remembered the assault of Patient #1 by Patient #2 and Patient #3. She also stated that “another nurse told her about the bump” on Patient #1’s head and “to get her off the unit.” She stated she did not make an incident report. She also stated that she did not phone the attending physician. In conclusion, Staff I (RN) stated that since Patient #1 had been discharged, the patient was no longer the hospital’s patient and that the EMS would evaluate her. In an interview with Staff L, attending physician for Patient #1, on 4/16/2026 at 12:16pm, he stated Staff I (RN) should have notified him of the assault, adding, “She needed medical clearance.” He also stated that he had not been informed of this assault. In an interview with Staff J (Patient Coordinator) on 4/15/2026 at 12:32pm, she stated she saw Patient #1 following the assault. She and Staff I (RN) walked Patient #1 to the lobby for discharge. She also stated the father was informed of the assault, adding that the father wanted to press charges and have his daughter “checked.” She said she saw Patient #1 holding her head and heard her complaining of her head hurting. She stated she thought the father called for an ambulance. She never heard Staff I (RN) talk about the need for Patient #1 to have her head checked. In an interview on 4/15/2026 at 1:53pm with Staff M (RN), she stated she was the house supervisor on 3/19/2026. She stated that following the assault, the discharge could have been “temporarily stopped,” adding that Staff I (RN) should have notified the attending physician. She also stated that Staff I (RN) should have filled out the medical part of the nursing note following the assault. Medical Record of Patient #1. Review of the “History & Physical” by Staff P (MD) dated 3/14/2026 at 5:43pm showed no injury to the head. Review of “Final Ancillary Orders” showed that Staff L (Attending Physician) wrote a discharge order on 3/19/2026 at 3:19pm. Review of the Daily Nurse Progress Note by Staff I (RN) dated 3/19/2026 at 3:11pm showed: “Patient ... tearful and anxious due to being in the hospital on her birthday.” The medical portion of the nursing note was blank. Though the assault happened on 3/19/2026 at 5:49pm, there is no documentation of the incident by Staff I (RN) in the chart. In an interview with Staff I (RN) on 4/16/2026 at 2:07pm, she stated, “Should I make a late entry?” when asked about her lack of documentation about the incident in which Patient #1 was violently attacked by Patient #2 and #3. She had no explanation as to why she failed to document the incident. She did state that once Patient #1’s father arrived to pick her up, Patient #1 was no longer a patient of the hospital. Medical Records of Patient #2 (assaulted Patient #1). Review of Final Ancillary Orders by Staff L (MD) dated 2/22/2026 at 5:08pm showed: Aggression/Homicide Precautions, Elopement Risk, Unit Restrictions Precautions. Review of Final Ancillary Orders by Staff Q dated 3/12/2026 at 1:03pm showed: Sexual Aggression Risk. Review of Final Ancillary Orders by Staff Z dated 3/12/2026 at 7:23pm showed: Medical consult - patient got into a fight with a patient - complained of shoulder and wrist pain. Review of the Daily Nurse Progress Note by Staff K (RN) dated 3/19/2026 at 10:10pm showed: “Sometime after 6pm, patient and a peer together jumped another patient on the unit causing an injury. Not long after that, patient fought with other peers on the unit ... police were contacted, charges were pressed, and patient was arrested and discharged to police custody.” Medical Records of Patient #3 (assaulted Patient #1). Review of Final Ancillary Orders by Staff Y dated 3/19/2026 at 1:00pm showed: Aggression/Homicide Precautions, Elopement Risk, Self-Harm Risk, Suicide Precautions, Unit Restrictions Precautions. Review of the Daily Nurse Progress Note by Staff K (RN) dated 3/19/2026 at 9:35pm showed: “Patient is hyperactive, impulsive, intrusive, provoking, irritable, agitated, and labile. Attacked peer unprovoked causing head injury to peer. Fought with other peers ... Patient was arrested for assault and discharged.” . 38015 B. Patient #2 and #5. Review of facility policy #20307588 titled “Sexual Aggression and Victimization Prevention and Precautions”, last revised 4/26, showed the following: The policy’s purpose was to ensure the facility provided a safe environment of care. This included planning for the prevention of sexual behaviors by identifying early warning signs of potential sexual aggression/victimization, and implementing steps to minimize risk of sexual behavior. Action steps included early identification for potential of sexual victimization and aggression by assessing the patient’s history gathered from previous hospitalizations, placements and social history. If a patient had a history of sexual victimization or aggression, they were to be placed on SAO (sexual acting-out) Precautions. This would alert staff to be more vigilant in monitoring these patients and preventing sexual behaviors. In an interview on 4/15/26 at 11:30 am, RN Staff #I stated that there was an incident a few weeks ago on Unit 7, the female adolescent unit, involving four girls who were inappropriately sexually acting out with each other. RN Staff #I could not provide further details. Review of facility incident reports showed the following: On 3/11/26, Patient #2 made inappropriate sexual remarks and was redirected by staff, then reeducated about sexual boundaries. On 3/12/26, Patient Coordinator Staff #J noticed a “suction” mark on the neck of Patient #4, who was sitting in the adolescent girl’s unit dayroom. When questioned, Patient #4 stated that Patient #2 gave her the “passion mark” and performed oral sex on her the previous night on 3/11/26. When Patient #2 was subsequently questioned, she also acknowledged that oral sex had occurred the night of 3/11/26 inside her bedroom. Record review of Patient #2’s clinical chart showed the following: 14-year-old female admitted to facility on 2/2/26 due to homicidal ideation and running away. She was placed on Assault and Elopement Precautions, but not on Sexually Acting out Precautions. -Pre-admission Evaluation & Medical Clearance on 2/22/26 by Dr. Staff #W showed “History of Sexual Victimization” with pre-admit orders for patient to be placed on Sexual Acting Out-Victim precautions; -There was a “High Risk” notification for Sexual Victimization present in the chart; -The Comprehensive Standardized Assessment showed “Potential for Sexual Victimization ....at age 13”, and; -Multidisciplinary Notes on 2/25/26 by Therapist Staff #X showed “mother states that she believes the patient’s anger and behavior stems from being molested by a man when she was younger. Mother states charges were pressed against this individual”. However, further review of Patient #2’s chart showed inconsistencies: - The initial Nursing Admit assessment on 2/22/26 showed “History of Sexual Victimization=No”. -The initial Psychosocial Assessment did not include anything about sexual victimization history and only showed “Sexual Orientation=Homosexual”. -The Initial Psychiatric Assessment dated 2/23/26 by NP Staff #Q failed to show anything related to sexual victimization and there were no further orders in the chart for the patient to be on SAO Precautions until the patient engaged in oral sex (“intercourse” per facility) on 3/11/26. Record review of Patient #4’s clinical records showed: 17-year-old female with history of sexual abuse; victim of sex trafficking, High Risk Alert for Sexual Victimization. Further review of facility incident reports showed there was another event with patients sexually acting act on the same date, 3/11/26. This one involved Patient #5 and #6; Patient Coordinator Staff #J had also noticed a “suction” mark on Patient # 5’s neck on 3/12/26 (similar to Patient #4). Patient #5 reported she had engaged in kissing a peer, Patient #6, on 3/11/26. Record review of Patient #5’s clinical chart showed the following: 12-year-old female first admitted to facility on 2/24/26. She had just been to Texas Children’s Hospital on 2/21/26 for a SANE exam (Sexual Assault Nurse Exam) for sex assault occurring 2/19/26. There was a High Risk Notification document in the chart for Sexual Victimization and an internal ‘SBAR’ communication sheet indicating the patient was a “SAO victim”. In addition, the Psychosocial Assessment labeled the patient as a Sexual Assault Victim. However, review of all physician orders failed to show the patient was placed on SAO Precautions of any type. Video review of adolescent girls Unit 7 for 3/11/26 starting 9:00 pm showed Patient #2 and #4 going into Patient #2’s bedroom unnoticed by RN Staff #U and MHT Staff # V. These two staff monitoring the patients failed to notice Patient #4 sneaking into Patient #2’s room. In addition, Patient #5 and #6 were subsequently seen also seen sneaking into the bedroom around this same time period just after Patient #2 & #4, which the two staff also failed to notice. During interviews on 4/16/26 at the time of findings of record and video review, both CNO Staff #A and RM Staff #B acknowledged that Patient #2 and Patient #5 should have been placed on SAO Precautions because both met criteria. .”

“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: 35028 . Based on observations, interviews, and record review, the facility failed to ensure that a registered nurse evaluated the head injury 1 of 1 patients (Patient #1) following a brutal assault by two patients (Patients #2 and #3), both of which were on Aggression/Homicide Precautions and Unit Restriction Precautions. Additionally, Staff I discharged the patient instead of contacting the attending physician (Staff L). Findings included: Review of the Patient Care Assignment Sheet dated 3/19/2026 for the 6:45AM-7:15PM shift showed the RN and MHT assignments for the two Adolescent Girls’ Units: Front Unit - Staff I (RN) and Staff R (MHT) Back Unit - Staff K (RN) and Staff S (MHT) In an interview with Staff I (RN) on 4/15/2026 at 11:28am, she stated she was the nurse on the front unit on 3/19/2026 and remembered the assault of Patient #1 by Patient #2 and Patient #3. She also stated that “another nurse told her about the bump” on Patient #1’s head and “to get her off the unit.” She stated she did not make an incident report. She also stated that she did not phone the attending physician. In conclusion, Staff I (RN) stated that since Patient #1 had been discharged, the patient was no longer the hospital’s patient and that the EMS would evaluate her. Review of the Daily Nurse Progress Note by Staff I (RN) dated 3/19/2026 at 3:11pm showed: “Patient ... tearful and anxious due to being in the hospital on her birthday.” The medical portion of the nursing note was blank. Though the assault happened on 3/19/2026 at 5:49pm, there is no documentation of the incident by Staff I (RN) in the chart. In an interview on 4/15/2026 at 1:53pm with Staff M (RN), she stated she was the house supervisor on 3/19/2026. She stated that following the assault, the discharge could have been “temporarily stopped,” adding that Staff I (RN) should have notified the attending physician. She also stated that Staff I (RN) should have filled out the medical part of the nursing note following the assault. In an interview with Staff L, attending physician for Patient #1, on 4/16/2026 at 12:16pm, he stated Staff I (RN) should have notified him of the assault, adding, “She needed medical clearance.” He also stated that he had not been informed of this assault. .”

“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: 37322 Based on facility document, and staff interview, the registered nurse failed to supervise and evaluate the nursing care for an involuntary patient (ID#A) when he was in distress as reported by the Licensed Vocational Nurse (ID#14), and ultimately died. Findings Include: Facility policy “Medical Risk Acute Change of Condition” that was last reviewed on 12/14/20 stated “to ensure staff is trained to recognize warning signs of clinical deterioration in a patient’s medical condition and know what action is to be taken. Record review the incident report revealed the licensed vocational nurse (LVN) (ID #14), and mental health technician (ID#13) notified the registered nurse (RN) (ID#15) of the change in condition at 4:30 p.m. The RN did not go into the patient’s (ID#A) room until 5:52 when the code began. Interview with staff (ID #12) who stated, “we did a root cause analysis, and as a result we no longer employee LVN’s at this facility, and the nurse was written up.” She (ID#12) went on to say, the nurse (ID#15) refused to sign the counseling form because she did not believe she did anything wrong. No other disciplinary action was done. The facility did provide nursing competency testing on the subject on 05/5.6.8.9/2025 facility wide.”

“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 policy, patient records, and confirmed in interview, the facility failed to ensure patients received care in a safe setting for one of six records (Patient #A) reviewed. Facility failed to monitor Patient #A with appropriate precautions for two days after his admission. Findings included: Review of the facility policy Patient Precaution Level’s Procedure (issues 07/25/2014) it stated “all patient precautions and restrictions must be ordered by a physician and must be reviewed by a physician every twenty-four hours to assess the patient’s clinical symptoms and renew or discontinue precautions and/or restrictions. They physician must document in their physician’s progress notes the clinical justification for continuing all precautions and/or restrictions... SAO V- Victim Document on the High Risk Notification Form All staff made aware in shift report daily Place close to nursing station if available Sleep same sex hall monitor daily for sexually provocative hypersexual behaviors” Review of Patient #A chart revealed he is a 14 year old male who admitted to the facility on 07/19/2025 for SI with a plan and history of sexual victimization. Review of Patient #A initial assessment under Potential for Sexual Victimization a selection of ‘yes’ with notes of ‘at 2018 and 2024’ Risk summary from the initial assessment also included “per mother, patient was sexually assault[ed] at school in Nov 2024 and at church in 2018. Per mother, investigation is still on.” Review of Patient #A initial nursing assessment under potential for sexual victimization, nurse staff selected ‘yes’ for history of sexual victimization and indicated ‘victim of sexual abuse’ Review of Patient #A physician orders revealed no documentation that SAO-V was ordered until 07/22/2025, three days after admission. In an interview with Staff #4 on 07/25/25 at 1:30 PM in the conference room, she confirmed that “any history of sexual trauma would indicate SAO precautions.” She acknowledged that Patient #A should have had SAO precautions at admission.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to have an active process for prompt resolution of patient grievances, as shown by the lack of an active mechanism for handling complaints and grievances. The facility failed to: a) Keep complaint/grievance data for the first three months of 2025 and produce any evidence that data was collected for patient and family grievances for January, February and March of 2025. There was also no Grievance log available for this time period; b) Produce any evidence that patient complaints were addressed for the first three months of 2025, and; c) Effectively monitor the Patient Advocate’s activities-the person responsible for managing the facility’s complaints and grievances-to ensure that complaints and grievances were being addressed. Findings included: Review of facility policy (no ID#) titled “Patient & Family Complaints & Grievances”, last revised 3/1/19 showed the following: The facility will provide an effective mechanism for handling patient & family complaints. In addition, the facility’s Patient Advocate: acts as the liaison between patient and facility to facilitate problem-solving actions; facilitates the investigation of complaints and grievances to help resolve them in a timely manner; informs the complainant once the issue is resolved; presents a report to the Performance Improvement committee for review and to decide if further action is necessary. The policy also states that data from complaints and grievances are aggregated and used as part of the organization’s performance improvement activities. In an interview in the facility’s conference room on the afternoon of 4/1/25 after requesting the facility’s Complaint & Grievance logs, DRM Staff #B, CCO Staff #C and other staff stated there was no longer a facility Patient Advocate. In an interview on 4/2/25 at 9:30 am, DRM Staff #B stated there was no available complaint data or other information available since part of December of 2024 through all of March, 2025 inclusive. Staff #B added that the facility’s Patient Advocate, Staff #M, was responsible for handling complaints and grievances and was no longer employed starting in February, 2025. Record review of Patient Advocate Staff #M’s HR files showed he was terminated from employment 3/3/25 and was not eligible for re-hire. There were no exact reasons listed as to why he was terminated. In an interview on 4/2/25 at 3:30 pm, DRM Staff #M stated the reason for the termination of the patient advocate was due to him not performing his job duties adequately.”

“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 ensure the rights of a patient (Patient #1) to make an informed decision regarding his care, as evidenced by staff not obtaining consent for 4 out of 6 psychoactive drugs prescribed for him. Findings included: Review of facility policy titled “Informed Consent for Medication Administration”, last reviewed 3/1/24, showed that informed consent for psychoactive medication is required for all patients, must be written, and is part of the medical record. In addition (except in an emergency), psychoactive medications may not be administered to a patient without informed consent. Record review of Patient #1’s clinical records showed there were six psychoactive medication consent forms present for the following drugs: Seroquel, Celexa, Trazadone, Zyprexa, Lithium and Depakote. The consents were done by nurses who filled out the consent forms on 9/1/24. For four of these medications- Seroquel, Celexa, Trazadone and Zyprexa, the consent forms showed that the patient did not sign them or give verbal consent. Instead, telephone verbal consent was obtained from the patient’s mother by nurses, and the forms indicated that she was the legal guardian. Further record review failed to reveal evidence the patient had a legal guardian. In an interview on 10/8/24 at 3:30 pm, RM-Staff #A stated the patient did not have a legal guardian. In an interview on 10/9/24 at 10:15 am, PI-Staff #D also stated the patient did not have a legal guardian, and if the patient did have one, it would be in his chart. Also, the legal paperwork related to court commitment present in the chart would show if there was a legal guardian. During an interview on 10/9/24 at 10:30 am, Intake-Staff #H stated that legal guardianship is usually initially determined during the intake process, and also confirmed that Patient #1 did not have a legal guardian. In a group interview during exit conference on 10/9/24 at 3:34 pm, Staff #A, B, C, D and #H acknowledged that the consent processes for four of Patient #1’s psychoactive medications were not properly executed.”

“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: 37490 Based on record review and interviews the facility failed to ensure the effective implementation of policies and procedures that promoted care in a safe setting for two (2) patients on the adolescent unit (ID#s 1 and 3). The facility failed to ensure staff were accurately documenting patient observations every 15 min. The findings include: Record review of facility policy titled “Observation Levels” dated 12/14/20 showed the following information: Policy: Observation levels are defined as levels of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. Reasons for these levels of awareness may include but are not limited to: suicide risk, homicide risk, fall risk, potential for aggressive behavior, potential for sexually acting out behavior and/or elopement risk. It is the policy of behavioral hospital of Bellaire to provide a safe and secure environment for patients during their hospitalization. Special observation for precaution procedures can be initiated by physician or nursing staff when a patient may be considered to be an increased risk of harm to self, others or property, for those patients who are identified as an elopement risk or for those who need an increased level of observation and precaution for other reasons, such as fall prevention. Clinical staff should assess the patient’s risk factors and initiate the following procedures to help protect the patient and others. Procedure: 6. Medical record entries should consistently reflect behavioral observations and patient mental status indicating the necessity for the level of special observations or precautions ordered. B. Routine Patient Observation every 15 minute Guidelines for implementation of this level of observation include, but are not limited to, the following: (1.) The patient should only be allowed off the secure unit under direct staff supervision. (3.) patients may not leave the facility unless in an emergency at which time a staff member must be assigned to accompany. (4.) A patient rounds sheet, which reflects the patient’s location and observed behaviors every 15 minutes, is maintained. (5.) a nurse on the unit is required to conduct oversight of patient observation rounds and provide documentation by signature on the patient observation rounds sheets a minimum of every two hours. Review of video recording on the unit 1/2/2024 showed patient(s) (ID#s 1 and 3) (along with others) elope from the unit/facility at 6:07 PM, returning to the unit at 6:50 PM. Record review of medical record for patient (ID# 1) showed rounding sheets for 1/2/2024 that documented the patient “in the hallway, talking” at 6:15PM, when the patient had eloped from the unit/facility. AWOL/Elopement precautions were documented on the rounding sheet. Record review of medical record for patient (ID# 3) showed rounding sheets for 1/2/2024 that documented the patient “in the hallway, talking” at 6:15PM, when the patient had eloped from the unit/facility. Interview with facility staff (ID# 51) on 1/11/24 at 11:45 AM confirmed the above findings, stating that the observation rounding sheets should be documented and by staff and accurate.”