Cypress Creek Hospital

“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 observation, records review and interview, the facility failed to ensure a patient (Patient #1) was re-evaluated appropriately after sustaining injuries, as shown by the inaccuracy of nursing assessment and documentation. Findings included: Review of facility policy titled “CYPRESS CREEK HOSPITAL ADMINISTRATIVE POLICY ON DOCUMENTATION”, last revised 10/2025 showed that a registered nurse shall perform an assessment each shift using the nursing process. During interview/observation with Patient #1 on 5/18/26 at 2:45 pm, it was revealed that the patient had bruises under and around both of her eyes, a quarter-sized lump/bruise on her forehead above her right eye, an inch-long scratch on the bridge of her nose, multiple bruises on both of her arms, and bruises on both of her kneecaps. The patient stated she received the injuries after she got upset when she was told she could not go home after requesting to do so. Patient #1 stated she was upset and threw herself on to the floor and also hit the walls and door, then was physically held and given an injection to calm her down. She then said, “nobody examined or even looked at me after I was hurt and nobody checked on me afterwards”. Record review of Patient #1’s clinical chart showed the following: 27-year-old female, wheelchair-bound due to several physical comorbidities, admitted to facility under MD Staff #E for suicidal ideation on 5/10/26 with the primary diagnosis of Major Depressive disorder without psychotic features. On 5/13/26 at 6:05 pm, the patient requested to be discharged, signing a ‘four-hour letter’. MD Staff #E instructed nursing to hold the patient until morning when a psychiatric assessment could made to determine if the patient needed to be court-committed to facility. The patient soon became irate, threw herself to the floor, and hit herself on the walls and door. She was physically restrained on 5/14/26 at 12:12 am and given the emergency medication injection of Zyprexa 10 mg IM. The mandatory face-to-face assessment was performed by nursing directly following the restraint. It showed the patient was not injured, skin was intact, and there was no bruising. Physician progress notes on 5/14/26 from MD Staff #E showed that during the evening (5/13/26), patient attempted to break down doors and had “severe bruising over upper and lower extremities and reports significant pain”. More physician progress notes on 5/15/26 showed patient had “severe ecchymosis around her orbits” (bleeding under the skin due to bruising). Review of facility incident report showed on 5/14/26 at 2:15 pm, patient was sent to the ER due to injuries and bruises to rule out basilar skull fracture (from bruising around eyes) and broken bones in extremities. However, nursing assessments on 5/14/26 for both morning and evening shifts showed normal skin assessments with no bruising, redness, or superficial scratches, and, skin was “WNL” (within normal limits). There were no other nursing notes addressing the injuries sustained earlier in the morning and no notes about treatment or follow up for the injuries. Then, nursing notes on 5/15/26 showed “ ...RN reminded patient that she received IM medication on 5/14 due to self harm behavior that resulted in severe bruising”. In an interview on 5/18/26 at 4:00 pm, QAPI Staff #A acknowledged the discrepancies with the assessments and stated that there should have been more complete and accurate nursing assessment and documentation for Patient #1.”

“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: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure that the parents of 1 of 1 patients (Patient #2) were always provided adequate telephonic access to the Patient Advocate. Findings were: In a telephonic interview with Staff D (Patient Advocate / Court Liaison) on 1.29.2026, at 2:53pm, she stated she spoke with Patient #2’s mother 2-3 times. “The mom was concerned about medications.” The mother also complained about her lack of communication with Staff E (Attending MD), adding that she forwarded the information to the physician. On 1.20.2026 at 3:36pm, Staff D (Patient Advocate) was phoned by the surveyor. There was no personalized greeting, only Staff D’s name. The surveyor left a recorded message in which a return phone call was requested. The surveyor’s name, title, and phone number were provided. As of 1/22/2025 at 1:00pm, the surveyor had not received a call back from the Patient Advocate. In an interview with Staff A (Quality Director) on 1.20.2026 at 1:00pm, she stated that Staff D (Patient Advocate) was on vacation, adding that Staff D’s coverage should have retrieved the phone call from voice mail and phoned the surveyor. Staff A also identified a problem with the absence of a personalized greeting, adding that the greeting should let callers know that the office of the Advocate and Court Liaison has been reached. .”

“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: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure that informed consent for the administration of psychoactive medications was obtained prior to the administration of the medication for 2 of 4 patients (Patient #1 and Patient #2). This was evidenced by the facility’s failure to ensure; 1) Patient #1 signed a consent for the administration of Zyprexa (olanzapine), an atypical antipsychotic medication used to treat bipolar I disorder; 2) Patient #2 signed a consent for the administration of Zyprexa (olanzapine); and 3) Patient #2 signed a consent for the administration of Depakote (divalproex sodium), a mood stabilizer used to treat manic episodes of bipolar disorder, prior to the administration of two (2) doses. Findings were: Review of the “Medication Consent for Antipsychotics - Atypical” form lists Zyprexa (Olanzapine) as a medication needing a signed consent prior to its administration. Review of the “Medication Consent for Mood Stabilizers” form lists Depakote as a medication needing a signed consent prior to its administration. Review of Medical Record for Patient #1. “Medication Administration Record” showed Zyprexa Zydis 10mg by mouth was administered on 11.26.2025 at 8:31am by Staff K (LVN). Consent forms in the medical record of Patient #1 were reviewed. There was no consent form signed by Patient #1 for Zyprexa in the medical record. Review of Medical Record for Patient #2. “Medication Administration Record” showed Zyprexa Zydis 5mg by mouth was administered on 11.24.2025 at 8:37am by Staff G (RN). Additionally, Depakote 750mg by mouth was administered on 11.25.2025 at 2:21pm and 9:10pm by Staff W (RN). “Medication Consent for Depakote” showed a verbal consent by signed by Patient #2 on 11.26.2025 at 9:27am. Two RNs witnessed the verbal consent on 11.26.2025 at 9:27am. Staff E (Attending MD) signed the consent on 11.27.2026 at 8:00am. The consent for Depakote was signed AFTER two doses of the medication had been administered. Consent forms in the patient’s medical record were reviewed. There was no consent form signed by Patient #2 for Zyprexa. Interview with Staff A (Quality Director) On 1.23.2025 at 10:30am, Staff A (Quality Director) stated she could not find a consent for Zyprexa in the medical records of Patient #1 and Patient #2. She stated the Depakote should not have been given to Patient #2 prior to signing a consent form to it. Finally, she stated that all routine and one-time doses of psychotropic medications needed a consent form signed except for emergency medications. .”

“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: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure that 1 of 1 patients (Patient #2) received mental health services that were free from neglect. This was evidenced by the facility’s failure to ensure that an Absolute Neutrophil Count (ANC) was conducted within a seven (7) day period prior to the initiation of clozapine (Clozaril), an antipsychotic medication. Clozapine, an atypical antipsychotic primarily used to treat severe, treatment resistant schizophrenia, can cause neutropenia (a low level of neutrophils). Agranulocytosis, a severe, acute form of neutropenia marked by extremely low levels of granulocytes, can develop, severely weakening the immune system and leaving the body highly vulnerable to severe infections. Findings were: Policy Review. Review of facility policy, “Patient Rights,” showed: “You have the right to be free from mistreatment, abuse, neglect, and exploitation.” Review of facility policy, “Policy 65 - Clozapine,” showed: “This hospital shall consider clozapine a high-risk medication ... Prior to dispensing clozapine, ANC is evaluated within 7 days of the last blood draw date for patients monitored weekly.” Review of Literature. Review of the August 27, 2025, U.S. Food & Drug Administration (FDA) Drug Safety Communication, showed: “The ... FDA removed the risk evaluation and mitigation strategy (REMS) for clozapine ... effective June 13, 2025. Clozapine, an antipsychotic medicine, can cause severe neutropenia (a low level of certain white blood cells), which can lead to serious and fatal infections. The removed REMS required enrollment of prescribers, pharmacies, and patients in a restricted distribution program and reporting of the level of ... the absolute neutrophil count (ANC) to mitigate the risk of severe neutropenia ... ANC monitoring can help identify neutropenia early to allow for timely intervention. Therefore, prescribers should continue to monitor patients’ ANC according to the monitoring frequencies ... pharmacies no longer need to VERIFY patients’ enrollment in the rems and patients’ absolute neutrophil count before dispensing clozapine.” [CAPS are the emphasis of the writer.] Review of accessdata.fda.gov, showed: “Severe neutropenia ... occurs in a small percentage of patients taking Clozaril and is associated with an increase in the risk of serious and potentially fatal infections. Risk of neutropenia appears greatest during the first 18 weeks of treatment ... [If] ANC level [is within the] normal range, ... initiate treatment.” Review of “Clozapine National Protocol Guidance - Monitoring March 2025,” showed: “ANC Monitoring Recommendations. Obtain baseline ANC before treatment initiation. Maintenance treatment - weekly from initiation to 6 months.” Review of the article, “Neutrophil Kinetics in Health and Disease,” found in Trends in Immunology, August 2010, showed: ANC can drop within hours during severe bacterial or viral infections. Review of Medical Record for Patient #2. “Physician Medication Orders” showed that Clozapine 25mg tablet was ordered on 12.13.2025 at 9:50am by Staff E (Attending MD). The Clozapine start date was 12.13.2025 at 9:00pm. The “Medication Consent for Clozaril” showed that Patient #2 gave verbal consent (witnessed by two RNs) on 12.13.2025 at 9:30pm. “Medication Administration Record” showed Patient #2 was administered Clozapine 25mg on: 12.13.2025 at 9:30pm by Staff FF (RN) and 12.14.2025 at 8:07pm by Staff GG (RN). “Medication Administration Record” dated 12.14.2025 at 4:45pm, showed Patient #2 refused to have blood drawn for a CBC with differential by Staff W (RN). On 12.15.2025 at 6:39pm, Staff L (RN) documented the CBC with differential was successfully drawn. This was two (2) days after the Clozapine was first administered. Laboratory Observations dated 12.15.2025 at 11:45pm, showed: WBC - 8.1 (3.4-10.8) Neutrophils (Absolute) 6.0 (1.4-7.0). Staff E (Attending MD) reviewed the laboratory results on 12.16.2025 at 10:14am. “Medication Administration Record” dated 12.19.2025 at 12:37pm showed CBC with differential / platelet - Clozaril EVERY FRIDAY. Staff DD (RN) performed a successful blood draw. Interviews. In an interview with Staff E (Attending MD) on 1.27.2025 at 10:58am, he stated he was okay starting the medication several days prior to the CBC being completed, adding, “A nurse called me about the lab not being done.” However, review of the Psychiatric Progress Note by Staff E (Attending MD), dated 12.15.2025 at 11:11am, showed: “The patient refused labs over the weekend, so Clozaril was held.” As has been noted above in the Medication Administration Record, Patient #2 received Clozaril 25mg on the nights of 12.13.2025 and 12.14.2025, two days PRIOR TO blood being drawn for the CBC. On 1.30.2026 at 10:15am, Staff A (Quality Director), Staff B (CNO), and Staff C (CEO) were provided the following excerpt from “Policy 65 - Clozapine” - “Prior to dispensing clozapine, ANC is evaluated within 7 days of the last blood draw date for patients monitored weekly.” There were no questions regarding the policy. .”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 35028 . Based on staff interviews and record review, the facility failed to ensure that the discharge plan given to Patient #2 at the time of discharge included all medications the patient needed after discharge. This was evidenced by the facility’s failure to ensure that Depakote 500mg BID was included on the Discharge Medication Reconciliation as a medication to be continued for 1 of 1 patient (Patient #2). Findings were: Record review of the “Discharge Summary” by Staff E (Attending MD) dated 12.24.2025 at 12:04pm showed three discharge medications for Patient #2. Clozaril 175mg at bedtime for psychosis. Lithium 1200mg at bedtime for mood stabilization. Depakote 500mg BID for mood stabilization. Record review of the “Discharge Medication Summary” for Patient #2 showed: Clozapine 175mg oral every night at bedtime. Lithium 1200mg oral every night at bedtime. The form was signed Patient #2 and an RN on 12.24.2025 at 2:00pm. Record review of the “Discharge Medication Reconciliation” form for Patient #2 showed: Continue these medications - Clozapine 175mg oral every night at bedtime. Lithium 1200mg oral every night at bedtime. Do not continue these medications - Depakote 500mg twice a day. In an interview with Staff E (MD) on 1.27.2025 at 10:58am, he stated he had noticed that the Depakote had been left off the “Discharge Medication Summary” adding that he had included in the discharge medications listed in the Discharge Summary. .”

“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 observation and interview, the facility failed to provide a safe setting by not identifying and removing safety hazards, as shown by the presence of: a. Rusty bolts protruding from the bases of toilets in 8 of 16 patient bathrooms (Rooms 104, 105, 107, 108, 200, 201, 205, 206), potentially affecting 16 patients; b. ‘Golf pencils’ in 3 of 16 patient bedrooms (Rooms 108, 206, 207), potentially affecting 3 of 6 patients (Patient #4, #5, and Patient #6) that were on High-Risk Aggression/Homicidal Precautions, and; c. A “Bic” pen left unattended on a table in Unit 200’s common area dayroom, accessible to all 16 patients on the unit. Findings included: Review of facility policy initiated 1/26/12 titled “Patient Observation Rounds”, last revised 11/2017, showed that either MHTs (Mental Health Technicians) or other staff member, such as nurses and therapists, will perform safety rounds at least every 15 minutes. In addition, Environment of Care (EOC) rounds are to be conducted every shift to identify and report any safety hazards, physical plant damage and contraband present. A. Rusty bolts in bathrooms Observation on 12/3/24 starting at 11:45 am of facility’s Unit 100 showed the following; there were eight patient bedrooms, each with two beds and a shared bathroom. The bathrooms in rooms 104, 105, 107 and 108 had exposed rusty toilet bolts protruding upwards from the floor, all approximately one inch or slightly greater in length. These uncovered bolts helped secure the toilets to the floors. These bolts posed safety risks for patients who might accidentally step on them while bare-footed, causing puncture to the feet and potential infection. In addition, these bolts had the potential for patients to self-harm, as some of them had sharp edges. Further observation on 12/3/24 at 12:15 pm of facility’s Unit 200 showed similar findings: there were eight patient bedrooms, similar in layout to Unit 100. Each of these room had two beds with a shared bathroom. The bathrooms in rooms 200, 201, 205 and 206 also had the same type of exposed protruding rusty toilet bolts present. In an interview on 12/3/24 with DCS-Staff #C at the time these findings, who was also present during observation of the toilet bolts, acknowledged they were safety hazards and should not have been present. In addition, after reporting the findings to Dir QAPI-Staff #A and CEO-Staff #B, both agreed the bolts were safety hazards and began facilitating efforts to remove the problematic risks. B. Gold pencils and C. Bic pen A tour on 11/3/2024, 11:45am-12:30pm, of Units 100 and 200 was conducted by Staff C, Director of Clinical Services. Observation of the commons area dayroom on Unit 200 at 11:55am, showed a BIC pen unattended on one of the large round tables. Patient #4: Observations of bedroom #108 on Unit 100 were conducted at 11:35am. Observations showed a placard to the right of the bedroom door with Patient #4 assigned to that room. Further observation of bedroom #108 showed a golf pencil unattended on the patient’s bedside table. Review of Psychiatric Evaluation by Staff H (MD) dictated on 11/30/2024, 1:47pm, and signed 12/1/2024, 3:59pm, showed Patient #4 was a 50-year-old female brought into the hospital by the police involuntarily. Review of the Columbia-V4 Direct Admission Assessment Tool completed on Patient #4 by Staff G (RN) dated 11/28/2024, 10:34am, showed: “ History of assault/‘threats toward police. “ Paranoid ideation, command hallucinations, and visual hallucinations. “ Aggression toward hospital staff. Review of Nursing Admission Assessment by Staff J (RN) dated 11/30/2024, 7:30pm, showed Patient #4 to be loud and rambling. She was hostile, demanding, impulsive, threatening, and uncooperative with much of the assessment, refusing to answer or allow vital signs to be taken. The Risk Assessment showed her to be assaultive and homicidal. Review of the Physician Orders by Staff I (MD) dated 11/30/2024, 11:04am, showed Patient #4 was placed on High-Risk Aggression/Homicidal Precautions. Patient #5: Observations of bedroom #206 on Unit 200 were conducted at 11:45am. Observations showed a placard to the right of the bedroom door with Patient #5 assigned to that room. Patient #5 was observed pulling a golf pencil out of his pocket, sitting on his bed, then replacing the pencil to his pocket. Review of Psychiatric Evaluation by Staff K (MD) dictated 11/25/2024, 12:24pm, and signed 11/25/2024, 2:03pm, showed Patient #5 was a 26-year-old male with acute psychosis and aggression. He attacked his father. Police brought him to the hospital involuntarily. Review of the Physician Orders by Staff L (DO) dated 11/25/2024, 1:02am, showed Patient #5 was placed on High-Risk Aggression/Homicidal Precautions. Patient #6: Observations of bedroom #207 on Unit 200 were conducted at 11:50am. Observations showed a placard to the right of the bedroom door with Patient #6 assigned to that room. Further observation of room 207 showed a golf pencil unattended on Patient #6’s bedside table. Review of Psychiatric Evaluation by Staff F (MD) dictated 11/22/2024, 3:12pm, and signed 11/23/2024, 6:32am, showed a 41-year-old male admitted under a mental health warrant. He was very paranoid, highly agitated, and aggressive requiring an injection of Haldol to calm down. He had a diagnosis of Schizophrenia, disorganized type. Review of the Physician Orders by Staff F (MD) dated 11/22/2024, 6:00am, showed High-Risk Aggression/Homicidal Precautions. In an interview with Staff M (Unit 200) on 12/3/2024, 12:04pm, she stated she was the charge nurse. She also stated patients on precautions “cannot have pencils in their room,” adding, “Sometimes patients will put it [golf pencil] in their pockets and hide it.” She ascertained through medical records review that Patient #5 and Patient #6 were on High-Risk Aggression/Homicidal Precautions. When informed that these two patients had golf pencils in their rooms, she was unable to verbalize the next step in securing the unit. Staff C spoke up, stating the unit needed to be “swept” for additional golf pencils. Both Staff M and Staff C stated the BIC pen should not be on the unit unattended. Staff M also stated she did not know how the pen got there. In an interview with Staff A (Director of Quality) on 12/3/2024, 2:30pm, she stated a golf pencil should not be in a patient’s room unattended. She stated she would explore options for a quick, efficient way to inventory golf pencils in the patient care areas. She also stated the BIC pen should not have been in a patient care area unattended.”

“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: 33326 Based on record review, observation, and interview, the facility failed to protect a patient’s right to privacy when Patient #1 was allowed to sleep on a mattress, in the facility’s dayroom; the patient was not afforded the privacy of a bedroom. Findings: Review of the facility provided policy Patient’s Rights, (undated) reflected, “PURPOSE: ...shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times ... BASIC RIGHTS FOR ALL PATIENTS ...B. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs and are treated with respect and dignity.” Incident report dated 11/14/24 at 7:45 pm reflected, Patient #1 reported a sexual incident between himself and his roommate, the incident took place on 11/13/24 between 9:00 pm and 10:00 pm. Nurse’s note dated 11/14/24 at 8:30 pm reflected,” ...was struck multiple times before boys could be separated ...visually upset after altercation ...” During an interview, on the morning of 11/18/24, Patient #1 stated in part, “After I got jumped, they (facility staff) said I had to get off of this unit. I told them I didn’t feel safe being in the same room with patient #2. They put me to the other side of the unit, I slept on a mattress on the floor in the dayroom. I don’t know why I had to move, why was I being punished?” Observation made during a review of the facility provided video tape dated 11/14/24 at 8:35 pm, revealed Patient #1 being struck by patients #2 and #3. The boys are separated by staff. Staff are observed placing a mattress and bedding in a corner of the adjoining dayroom’s floor. There is a locked door between the rooms, preventing patient #2 & #3 from going into this dayroom. Patient #1 is observed lying down with a blanket over his head; other patients are seen standing and walking around the dayroom. Patient #1 remains sleeping in the dayroom until the next day. Other patients are seen walking in the dayroom. During an interview, on the morning of 11/18/24, when asked why Patient #1 was sleeping in the dayroom, Staff # stated in part, the unit was full. It happened in the evening; we would have had to wake other patients up to make a room change. We placed him in the dayroom at his request.”

“Treatment Plan - Adequate Documentation CFR(s): [The written plan must include] Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This Standard is not met as evidenced by: 33326 Based on record review, and interview the facility failed to ensure each patient had an individualized master treatment plan, developed and made available to the staff providing therapeutic care for (8) eight out of (8) eight patient’s medical records reviewed. This failure places patients at risk of delayed, or inappropriate psychiatric treatment. (Patients #2,3,4,5,6, 11, 12, and 13) Findings include: Review of the facility provided Administrative Policy on “Treatment Plans”, (reviewed on 1/02/2020) reflected, “Purpose: 1. To provide guidelines for the documentation of the Master Treatment Plan (MTP) and treatment plan revisions. 2. The MTP is completed by the Unit therapist. The plan includes psychological problems and diagnosis as identified by the admitting psychiatrist’s psychiatric evaluation, history and physical, intake assessment, psychosocial assessment, nursing assessment or other collaborative information. 3. The multidisciplinary treatment team consists of the unit therapist, psychiatrist, charge nurse. Other ancillary members may be included such as activity therapy utilization review but are not required. Treatment Planning: The multidisciplinary treatment team will meet and formulate a comprehensive Master Treatment Plan (MTP) within three (3) day, after the patient’s admission. 4. The therapist is responsible for documenting the decisions of the team in regards[sic] to: a. Problem b. Manifestations c. Patient strengths and barriers to treatment d. Long-term and short-term goals. e. Therapeutic interventions to be used ... 12. The multidisciplinary treatment team will meet three times a week to review, update and/or revise the treatment plan for those patients that are due for an update according to their length of stay, or who have received a revision due to change in their status.” - Review of Patient #2’s Master treatment plan cover sheet dated 11/13/24 reflected a problem list of Aggression with homicidal Ideation and Suicidal Ideation. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. Patient #2’s Restraint Debriefing dated 11/14/24 at 9:00 pm reflected a restraint hold to prevent Patient #2 from continuing to hit Patient #1. Patient #2 stated, “I will do it again.” The incident occurred after patient #1 reported a previously unreported sexual encounter, that had reportedly taken place on 11/13/24 with Patient #2. The master treatment plan did not reflect an update for Patient #2’s sexually acting out encounter and new risk. - Review of Patient #3’s Master treatment plan cover sheet, dated 11/15/24, reflected a problem list of Aggression, mood, and depression. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #4’s Master treatment plan cover sheet, dated 10/25/24, reflected a problem list of depression with suicidal ideation, psychosis, and homicidal ideations. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #5’s Master treatment plan cover sheet, dated 10/25/24, reflected a problem list of depression with suicidal ideation, and psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #6’s Master treatment plan cover sheet, dated 10/2/24, reflected a problem list of depression with suicidal ideation. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #11’s Master treatment plan cover sheet, dated 11/13/24, reflected a problem list of Aggression, mood with suicidal ideation, and Psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #12’s Master treatment plan cover sheet, dated 11/10/24, reflected the nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. - Review of Patient #13’s Master treatment plan cover sheet, dated 10/20/24, reflected a problem list of depression and psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient’s psychological needs, interventions, and goals. During an interview on the morning of 11/18/24 in an administrative office, when asked about the missing master treatment plans (the therapist’s portion of the master treatment plan), Staff #5, Clinical Director pointed to the Master treatment plan coversheet and stated, “That is the Master Treatment Plan”. When informed the sheet was titled Master Treatment Plan Coversheet, Staff #5 stated, “It hasn’t been filed yet. We try to get them in the chart before the patient is discharged. Our treatment plans have to be created individually, it takes longer than the nursing treatment plan, we try to do our best, we do what we can.” Staff #5 provided Patients 2’s and 3’s completed master treatment plans several hours later. During an interview on the morning of 11/18/24 in an administrative office, Staff #3, Quality Director stated in part, “The initial Treatment plan, which included the multidisciplinary team, is completed within 8 hours of the admission. The Master treatment plan is completed and placed in the chart within 3 days of the admission. The master treatment plan should be in the chart at all times. There is no explanation, they should all have a master treatment plan, absolutely no reason.””

“A life safety code (LSC) complaint] was conducted on site on 08/27/2024. An entrance conference was held for the hospital’s Director of QA/Compliance and medical staff services, Director of maintenance to discuss the purpose of the LSC survey complaint and the survey process were explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 08/27/2024 in the hospital. In attendance were the Director of QA/Compliance and medical staff services, Director of maintenance. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36250 Based on observation the facility failed to provide a properly sealed through the wall penetration for the electrical connection required from the rental generator to the existing transfer swicth located in the existing electrical room. “Floor, wall and ceiling penetrations by pipes, ducts, and conduits or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents and insects. Joints of structural elements shall be similarly sealed.” - HLR, 133.162 (d)(2)(B)(v).”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 36250 Based on observation the facility failed to provide adequate clear path to the electrical room exterior door. Wires from the temporary rental generator that connected to the existing transfer switch located inside the electrical room, inpeded a clear path to the entry of the electrical room. Wires were located on the ground and penetrated the exterior wall of the eletrical room by the hinge side of the electrical room door.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility’s policy for “Room Assignments” did not accurately describe the actual process being used. This inconsistency could lead to an inadvertent unsafe room assignment by staff. Findings included: Review of facility policy tithed “Patient Rights,” undated, showed: ‘Basic Rights for All Patients’ included: the right to a clean and humane environment; protection from harm, and privacy.... During an interview on 6/27/2024 at 2:15 PM with Staff-C, Quality Director, she provided an overview of the patient room assignment process. She said many factors are considered in appropriate patient room placement including choice of roommate. These elements include age; gender, history of sexually acting out ( victim; perpetrator); current diagnosis and condition & other factors. Staff-C said, for example: for adolescent roommates, practice is not to have a greater age gap than 3 years The Quality Director said there was an electronic bed board located in intake and also in the nursing supervisor’s office. Both bed boards are continually updated in real time. When a bed was needed for a new admission , intake sends an SBAR (situation, background , assessment, communication ) document to the nursing unit with information about the patient. Intake also calls the Nursing Supervisor; they may suggest an open room on a unit. Intake asks the nursing supervisor if this room choice is appropriate ? It is the ultimately the nursing supervisor’s decision and responsibility to approve room assignments. This is done in collaboration with the charge nurse on the unit. Staff C verified the SBAR communication was retained . Record review of facility policy titled “Room Assignment “ dated 5/2023, showed the policy to be incomplete and not consistent with facility’s current practice. This was verified by Staff-C during the discussion and policy review.”