Dallas Behavioral Healthcare Hospital LLC

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47892 Based on document review, observation, interview, policy review, and review of video surveillance footage, the hospital failed to ensure that medications were administered in accordance with accepted standards of practice and facility policy by failing to ensure nursing staff remained with patients until oral medications were swallowed and confirmed as ingested for 1 (patient #1) of 3 patients observed. Findings: A review of patient #1’s medical record was conducted on 07/13/2026 after 12:00 p.m., and it revealed that patient #1 was a 13-year-old female admitted with anxiety, depression, and suicidal ideation. She was at risk for danger to herself, danger to others, and elopement precautions. Patient #1’s medical record revealed that on 06/29/2026, she was involved in an incident of kissing a peer in a patient room. Patient #1 was placed on 5-minute observations and placed in a blocked room. Patient #1 was discharged on 07/06/2026 after 5:00 p.m., and she was picked up from the hospital by her case worker. Patient #1 reported to her case worker that, while she was still a patient at Dallas Behavioral Healthcare Hospital, she had been hoarding her medication and ingested about 20 pills at approximately 12:00 p.m. on 07/06/2026. Patient #1 was discharged from Dallas Behavioral Hospital (DBHH) on 07/06/2025 around 5:30 p.m., when she told her caseworker she had ingested approximately 20 pills. Patient #1’s caseworker took her to Hospital #2 on 07/06/2025. A review of patient #1’s Emergency Department (ED) medical record from Hospital #2 was conducted on 07/13/2026 after 10:00 a.m. Patient #1 was admitted to Hospital #2’s ED on 07/06/2026 at 8:41 p.m. The record indicated that patient #1 presented with a complaint of “overdose.” Patient #1’s vital signs were: Temperature 97.8 °F, pulse 83, respiration rate 20, blood pressure 101/70, and oxygen saturation 98% on room air. The record noted that patient #1 stated she felt “kinda sleepy” but had no loss of consciousness. The record indicated that patient #1 was alert and oriented to person, place, and time. The record also stated that patient #1 reported the ingestion was a combination of Lexapro, Seroquel, and Trileptal. A drug screen was performed, and it was negative. The drugs that she allegedly ingested would not show up on a drug screen. An EKG was performed twice on Patient #1, and both EKG tests were normal. Patient #1 was considered stable and was discharged on 07/07/2026 after 3:00 a.m. to Hospital #3. An interview was conducted with patient #1 on 7/13/2026 at 9:40 AM at Hospital #3. She was an inpatient at the time of the interview. Patient #1 alleged that she attempted suicide by ingesting 20 pills while she was still an inpatient at DBHH. Patient #1 was asked about her allegations, and she stated, “When the nurse would give the medications, I wouldn’t take them, and I would just take them and put them in my room. The bed was broken, and I hid them under the mattress.” Patient #1 was asked whether the nurse looked into their mouths after they were given the medication. Patient #1 replied that the nurses would give her the meds and then turn their backs, and that was when she would stick them in her pocket and take them to her room. Patient #1 stated that on the day that she was leaving, she took about “20-something pills” around 12:00 PM. When the caseworker picked her up around 5:00 to take her to her new placement, she told her that she felt suicidal and overdosed on all the pills she had been hiding in her room at the hospital. She stated she told the caseworker that she did not feel good but confirmed she never vomited or passed out. Patient #1 was asked if she “cheeked” her medications every time they were given to her, and she confirmed that she did this most of the time, except when RN #9 was working, because RN #9 always checked. “Cheeking” is the act of concealing a pill or liquid in the mouth (such as between the cheek and gums or under the tongue) instead of swallowing it, so the medication can later be spit out, hoarded, or misused. . A tour of inpatient unit 7 of DBHH was conducted on 07/13/2026 after 11:30 a.m. with Director of Risk staff #1 and Quality Assurance and Risk RN staff #2. During the tour, the team entered the room patient #1 had been assigned on the day of her discharge, room #220. When the room was inspected, the mattress was uncovered from bed B in room #220. There were 2 tears in the mattress cover on the top side of the mattress that ran along the seam, and a tear on the flat surface of the mattress cover exposed the foam of the mattress. When the mattress was lifted out of the wooden frame, the presence of a partially empty medication capsule concealed beneath the patient’s mattress demonstrated that medication was not consistently verified as swallowed. Staff #1 and #2 were asked if they knew what type of medication capsule this was. It was determined that the portion of the capsule was from a Vistaril medication capsule. An interview was conducted with DBHH Staff RN #5 on 7/13/2026 after 12:00 PM. Staff RN #5 was asked how she ensured that the children were taking their medications. Staff RN #5 stated, “After the medications were put into a small medication cup and handed to the children, she made sure that they swallowed them by having them open their mouths and lift their tongue.” An interview was conducted with patient #3, a current patient at DBHH on 7/13/2026 after 12:30 PM. Patient #3 was asked to explain the process for medication administration on Unit 7. Patient #3 stated that “the nurses pass out the medications from the nurses’ station.” Patient #3 was asked if the nurses made sure that the patients swallowed their medications before they walked away from the nurses’ desk. The patient stated, “We have to open our mouth, stick out our tongue, and then lift it up before we walk away.” A review of the video surveillance footage was performed on 07/13/2026 at 1:15 p.m. with Director of Risk staff #1, Quality Assurance and Risk RN staff #2, and PI manager Staff #11. The video surveillance footage reviewed was patient #1 on 6/22/2026 at 8:22 a.m. This footage was unclear as to whether Staff RN #7 checked her to ensure that she swallowed her medication due to the quality of the footage and the nurse being out of the camera view, but it did appear that Patient #1 did take her medication. It did not reveal that she placed anything in her pocket. The video surveillance footage reviewed was of patients #1 and #3 on 6/24/2026 after 7:30 a.m. This footage was with Staff RN #9. Staff RN #9 was out of camera range while patient #1 took her medication, and it appeared that patients #1 and #3 took their medication. The video surveillance footage reviewed was of patient #1 and #4 on 6/24/2026 at 7:50 p.m. This footage was with Staff RN #8. Staff RN #8 never turned away from patient #1 and #4 while they took their medication. The video surveillance footage reviewed was of patient #1 on 6/29/2026 after 8:00 p.m. This footage was with Staff RN #6. Staff RN #6 was seen placing cups on the counter for patient #1 to take her medication. Patient #1 picked up her medication and walked away from the counter. It was unclear, due to video footage skipping and having a grainy appearance, whether she took her medication or not. She walked into her room after the medication pass. The video surveillance footage reviewed was of patient #1, #3, and #4 on 6/30/2026 after 8:00 p.m. This footage was with Staff RN #6. Staff RN #6 was observed placing cups on the counter for the medication of patients #1, #3, and #4. Patients #1, #3, and #4 picked up their medication and took it. Due to broken and grainy video surveillance footage, it was hard to determine if patient #1 opened her mouth or stuck her tongue out to show that the medication had been swallowed. Director of Risk staff #1, Quality Assurance and Risk RN staff #2, and PI manager Staff #11 were asked if they agreed with what was observed on the video surveillance footage. Director of Risk staff #1, Quality Assurance and Risk RN staff #2, and PI manager Staff #11 confirmed that it was hard to determine if Patient #1 swallowed her medication or if she “cheeked “ the medication on video surveillance. Staff #1 was asked if she had received an email from Patient #1’s caseworker about the allegation of Patient #1 “cheeking” her medication. Staff #1 stated that she had not received an email regarding this allegation. A review of Staff RN #5 and #6’s training on medication administration was conducted on 07/13/2026 after 3:00 p.m. with Director of Risk, Staff #1. The training revealed that Staff #5 and #6 were current on their training in medication administration. The Medication Administration training stated that the Staff RNs were to “Observe the resident taking medication and ensure all medication had been swallowed. Checked the patient’s mouth after swallowing medication to prevent cheeking the medication.” A review of the hospital’s policy titled “Medication Administration” effective 1/10/2014 and last reviewed on 2/26/2026 was conducted with Director of Risk staff #1 on 07/13/2026 after 3:00 p.m. The policy stated: “POLICY: ... The following policies will govern the administration of medication in this institution ... The nurse administering the medication will stay with the patient until the medication is taken ...” Director of Risk staff #1 was asked if the hospital followed its policy, and Director of Risk staff #1 confirmed that the hospital did not follow its policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on video surveillance review, document review, and interview, the hospital failed to: 1. Ensure chemical restraints were administered only in response to an immediate threat to the patient or others in 2 (Patient #1 and Patient #2) of 2 patients reviewed. Refer to Tag A0154 2. Ensure physician orders for chemical restraints clearly specified the route of administration and time for 1 (Patient #1) of 1 patient reviewed. The physician’s order for Patient #1 was written as oral or intramuscular (PO or IM), allowing nursing staff to determine whether the medication would be administered orally or as a forced intramuscular injection to control the patient’s agitation. This practice allowed nursing staff to determine the route of administration and when to administer, rather than the physician, which created the potential for the inappropriate use of forced medication as a chemical restraint. Refer to Tag A0160 3. Ensure appropriate monitoring occurred after the administration of an emergency behavioral medication/chemical restraint in 1 (Patient #1) of 2 (Patient #1 and #2) patients reviewed. Refer to Tag A0175 The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 40989 Based on video surveillance review, document review, and interview, the hospital failed to ensure emergency behavioral medications/chemical restraints were administered only in response to an immediate threat to the safety of the patient or others in 2 (Patient #1 and Patient #2) of 2 patients reviewed. Findings: Patient #1 Patient #1 was a 17-year-old male who was admitted to the hospital on 2/23/2026 with a diagnosis of Bipolar Disorder, Severe Depression, Cannabis Use Disorder, Cocaine Use Disorder, and Suicidal and Homicidal Ideation. He was admitted to Unit 8 and placed on a 1:1 observation. A review of the medical record revealed that on 2/27/2026 at 6:30 PM, Patient #1 reported to Registered Nurse (RN) Staff #11 that he was verbally threatened by Mental Health Tech (MHT) Staff #4, after he made remarks about the staff member’s daughter and alleged that the staff member stated that he would physically harm him. MHT Staff #4 was suspended pending investigation outcome, and Patient #1 was transferred to Unit #6 for safety. Unit 6 was a unit for 11-14 year olds. A review of the nurse’s note dated 2/27/2026 at 7:45 PM (signature illegible) revealed that Patient #1 requested to speak to the nursing supervisor because he did not feel safe on Unit 8 with his peers, and he felt like his peers may harm him. At 10:00 PM on 2/27/2026, Patient #1 was transferred to Unit 6 for safety and remained on a 1:1 for safety. A review of Physician #13’s order dated 3/03/2026 at 8:30 AM read, “ Move Patient #1 back to Unit 8 (age-appropriate unit)”. A review of the RN Staff #9’s nurse’s note dated 3/03/2026 at 11:00 AM was as follows: “Patient arrived on unit at 9:15. Calm and cooperative w/neutral effect. Alert and oriented (A&O) x4. Pt. refused to participate in group. Pt asked to use restroom and laid down in bed. Pt. redirected out of room and instructed that he needs to go to group. Pt. continued to refuse. At 10:25 pt went to nursing station and stated he needed to use phone. MHT Staff #10 instructed patient that he can make phone call after group time. Patient reached over nursing station and threw computer and keyboard off desk. MHT Staff #10 attempted to redirect patient and pt held up fists to MHT stating he was going to fight MHT. MHT held patient at 10:26 and escorted to seclusion. Seclusion started at 10:27. Order from Physician #13 received for seclusion, restraint, and emergency medications. Order for Zyprexa (antipsychotic) 5 milligrams (mg) intramuscular (IM) Now and Benadryl (antihistamine that causes drowsiness) 25mg IM Now for aggression. Administered to left (L) glute at 10:40. MHT’s held patient at 10:40 for med administration and released at 10:41. Pt tolerated injection well. Seclusion discharged (dc) at 11:17 ...” A review of the video surveillance camera footage was conducted on 3/09/2026 with Risk Manager (RM) Staff #3 after 12:25 PM. The review revealed that from 10:27 AM-10:41 AM, Patient #1 was observed walking around in the seclusion room and sitting in the corner. At 10:41 AM, MHT Staff #10 and MHT Staff #12 entered the seclusion room and pulled Patient #1 to his feet from the corner of the room. MHT Staff #10 and #12 struggled with Patient #1 and ended back on the floor, where Patient #1 was placed in a restraint hold. At 10:42 AM, RN Staff #9, RN Staff #7, and RN Staff #14 entered the seclusion room, and RN Staff #14 administered the emergency behavior medications/chemical restraint. The administration of the emergency behavioral medication/chemical restraint was administered 14 minutes after Physician #13 ordered the medication. An interview was conducted with the Chief Nursing Officer (CNO), Staff #2, on 3/09/2026 at 2:30 PM. CNO Staff #2 was asked if Patient #1 was an immediate threat to himself and/or others at the time he received the emergency medications/chemical restraint. CNO Staff #2 confirmed Patient #1 did not exhibit any signs of an immediate threat to himself or others at the time of the medication administration. CNO Staff #2 was asked why the staff would give the emergency medication to Patient #1 when he did not exhibit any signs of being an immediate threat to himself or others. CNO Staff #2 stated, “I guess because they had an order to administer the medication, but they should have assessed the patient before the administration of the medication”. CNO Staff #2 confirmed the emergency behavior medication was administered 14 minutes after Physician #13 gave the telephone order when Patient #1 no longer presented an immediate threat to himself or others. An interview was conducted with Risk Manager (RM) Staff #3 on 3/09/2026 after 11:30 AM. Staff #3 confirmed that Patient #1 was not an immediate threat to himself or others at the time of the administration of the emergency behavioral medication/chemical restraint. Patient #2 Patient #2 was an 8-year-old male who was admitted to the hospital on 3/02/2026 with a diagnosis of Disruptive Mood Dysregulation Disorder. A review of the medical record was completed with RM Staff #3 on 3/09/2026. The review revealed Patient #2 was seen by the telehealth provider, Physician #16, on 3/02/2026 at 6:22 PM. Further review revealed Physician #16 gave an order for Ativan (anti-anxiety medication) 0.5 mg Oral (PO) or IM x 1 for agitation. A review of the restraint and seclusion document revealed that a Telephone Order Read Back (TORB) from Physician #16 was given to RN Staff #20 on 3/02/2026 at 8:20 PM. Further review revealed the emergency medication/chemical restraint ordered for agitation was administered IM at 8:15 PM. This was before the TORB on 3/02/2026 at 8:20 was given. Further review revealed the medication administration record revealed the medication was administered on 3/02/2026 at 8:10 PM by RN Staff #20. This was also before Physician #16 gave the telephone order for the emergency behavior medication/chemical restraint. In the afternoon of 3/09/2026, the video surveillance footage of Patient #2 was reviewed with RM Staff #3. The review of the video surveillance footage dated 3/02/2026 showed that Patient #2 was placed in the seclusion room at 7:46 PM on 3/02/2026. At 7:46:44 PM, the camera jumps to 8:13:28 PM. RM Staff #3 confirmed there was no available footage for 27 minutes of Patient #2 in the seclusion room. At 8:13:28 PM, MHT Staff #15 was seen entering the seclusion room. Patient #2 was seen walking away from the MHT backwards and crying. Two nurses entered the room at 8:13:35. At 8:13:40, MHT Staff #15 picked Patient #2 up from the floor in the corner of the seclusion room by both arms and raised him up to eye level, and placed the child against the wall while the nurse administered the emergency medication/chemical restraint IM. At 8:14:27, the child was released, and the staff exited the room at 8:14:32 PM. A telephone interview was conducted with MHT Staff #15 on 3/09/2026 at 4:24 PM. MHT Staff #15 was asked to describe Patient #2’s behavior while he was in the seclusion room before he received the emergency behavior medication/chemical restraint. MHT Staff #15 stated, “He was crying, and I think he kicked the wall”. MHT Staff #15 was asked if Patient #2 calmed down after being placed in seclusion. He replied that he was still crying and upset, but he was no longer banging his head on the wall. An interview was conducted with CNO Staff #2 on 3/09/2026 at 3:30 PM. Staff #2 was asked if the nursing staff got a new order from Physician #16 at 8:20 PM for the Ativan. Staff #2 stated the order was given on admission because Patient #2 was a rapid admit to the unit because he was crying and agitated, and they took him to the unit and placed him straight in seclusion to try and calm him down. CNO Staff #2 confirmed the telephone order from Physician #16 was timed at 8:20 PM. CNO Staff #2 confirmed RN Staff #20 documented the administration time on the restraint and seclusion document was at 8:15 PM, and the administration time on the medication administration record was at 8:10 PM. CNO Staff confirmed that both administration times documented by RN Staff #20 were before the telephone order was given for the emergency behavioral medication/chemical restraint. A review of the video surveillance footage was conducted with CNO Staff #2 and RM Staff #3 in the afternoon on 3/09/2026. CNO Staff #2 confirmed there did not appear to be a reason for Patient #2 to receive the emergency behavior medication/chemical restraint. RM Staff #3 confirmed there was no video surveillance footage of Patient #2 in the seclusion room for greater than 25 minutes. CNO Staff #2 was asked if MHT Staff #15 had completed an appropriate hold on Patient #2 while the nurse administered the medication. CNO Staff #2 confirmed it was an incorrect hold and that Patient #2 should not have been pressed against the wall at any time for the medication administration during the hold. A review of the facility policy titled, Restraint and Seclusion, Policy # PC.4.04, with a review date of 7/09/2025, was as follows: “POLICY STATEMENT Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified. Restraint or seclusion may not be used solely based on the patient’s diagnosis or history of dangerous behavior. It is not used as a means of coercion, discipline, convenience, or staff retaliation. Restraint and seclusion are used only with appropriate and adequate clinical justification, when less restrictive interventions are ineffective, or it is determined that the use of seclusion or restraint is a safer option than to use a less restrictive intervention in that moment. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm ... The types of restrictive measures used at Dallas Behavioral Healthcare Hospital include: o Physical holds o Seclusion Emergency medications may be ordered to relieve the patient’s acute symptoms such as psychosis, severe anxiety, or agitation. Medications are not administered as chemical restraints with the intent of restricting the patient’s freedom of movement or administered in a manner that is not a standard treatment for the patient’s condition ...” An interview was conducted with CNO Staff #2 and RM Staff #3 on 3/09/2026 after 4:00 PM. CNO Staff #2 confirmed that the medication administered to Patient #1 and Patient #2 was administered to control the patients’ behavior and should have only been administered if the patient was an immediate threat to themselves or others. Also, CNO Staff #3 and RM Staff #2 confirmed that Patient #1 and Patient #2 were not an immediate threat to themselves or others at the time the emergency behavioral medication/chemical restraint was administered.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 40989 Based on video surveillance review, document review, and interview, the hospital failed to ensure that physician orders for emergency behavioral medications/chemical restraints clearly specified the time and route of administration for 1 (Patient #2) of 2 (Patient #1 and #2) patients reviewed. The physician’s order for Patient #2 was written as oral or intramuscular (PO or IM), allowing nursing staff to determine whether the medication would be administered orally or as a forced intramuscular injection to control the patient’s agitation. This practice allowed nursing staff to determine the route of administration and when to administer, rather than the physician, which created the potential for the inappropriate use of forced medication as a chemical restraint. The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings: Patient #2 Patient #2 was an 8-year-old male who was admitted to the hospital on 3/02/2026 with a diagnosis of Disruptive Mood Dysregulation Disorder. A review of the medical record was completed with Risk Manager (RM) Staff #3 on 3/09/2026. The review revealed Patient #2 was seen by the telehealth provider, Physician #16, on 3/02/2026 at 6:22 PM. Further review revealed Physician #16 gave an order for Ativan (anti-anxiety medication) 0.5 mg Oral (PO) or intramuscular (IM) x 1 for agitation. RM Staff #2 confirmed that Physician #16 failed to give a time for the medication to be administered or clear orders on how the medication was to be administered for the patient’s agitation. Further review of the medical record revealed Patient #2 received the medication on 3/03/2026 at 8:15 PM at the same time he was released from seclusion. An interview was conducted with Chief Nursing Officer (CNO) Staff #2 on 3/09/2026 at 3:30 PM. CNO Staff #2 confirmed the order for the emergency behavior medication/chemical restraint was given for the patient’s agitation and allowed the nurse to determine when and how to administer the medication. CNO Staff #2 also confirmed there was no documentation in the medical record that revealed the oral route was attempted before forcing the IM injection on the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 40989 Based on video surveillance review, document review, and interview, the hospital failed to ensure appropriate monitoring occurred after the administration of an emergency behavioral medication/chemical restraint in 1 (Patient #1) of 2 (Patient #1 and #2) of 2 patients reviewed. Also, the hospital failed to follow its own policy titled, Restraint and Seclusion with a review date of 7/09/2025. The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Findings: Patient #1 Patient #1 was a 17-year-old male who was admitted to the hospital on 2/23/2026 with a diagnosis of Bipolar Disorder, Severe Depression, Cannabis Use Disorder, Cocaine Use Disorder, and Suicidal and Homicidal Ideation. He was admitted to Unit 8 and placed on a 1:1 observation. A review of the medical record was conducted on the morning of 3/09/2026 with Risk Manager (RM) Staff #2. The review revealed that Patient #1 was placed in seclusion on 3/03/2026 at 10:27 AM. A restraint was initiated at 10:40 AM, and at 10:42 AM, an emergency behavioral medication/chemical restraint of Zyprexa (antipsychotic) 5 milligrams (mg) and Benadryl (antihistamine that causes drowsiness) 25mg was forced on the patient for aggression and administered intramuscularly. A review of the Post Emergency Medication Administration Assessment revealed Registered Nurse (RN) Staff #9 documented that the vital signs were refused by the patient at 11:05 AM, 11:20 AM, 11:35 AM, and 11:40 AM. Only respiration counts were documented for the times listed. During a review of the video surveillance footage with RM Staff #2 and Chief Nursing Officer (CNO) Staff #3 on 3/09/2026, it was confirmed that RN Staff #9 failed to assess the patient’s vital signs after the administration of the emergency behavioral medication/chemical restraint. The review of the video surveillance footage dated 3/03/2026 from 10:42 AM to 11:18 AM confirmed the seclusion room door remained closed and no one entered the seclusion room to assess or attempt to assess Patient #1 after the administration of the emergency behavioral medications/chemical restraint. Patient #1 was released from seclusion by RN Staff #9 at 11:19:33 AM and transferred to Unit 6. An interview was conducted with Mental Health Tech (MHT) Staff #10 on 3/09/2026 at 2:00 PM. MHT Staff #10 was asked who was responsible for assessing and monitoring the patient after the administration of emergency behavioral medications/chemical restraints. MHT Staff #10 confirmed that the nurse on the unit gets the vital signs and assesses the patient. A review of the facility policy titled, Restraint and Seclusion, Policy # PC.4.04, with a review date of 7/09/2025, was as follows: “POLICY STATEMENT Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified. Restraint or seclusion may not be used solely based on the patient’s diagnosis or history of dangerous behavior. It is not used as a means of coercion, discipline, convenience, or staff retaliation. Restraint and seclusion are used only with appropriate and adequate clinical justification, when less restrictive interventions are ineffective, or it is determined that the use of seclusion or restraint is a safer option than to use a less restrictive intervention in that moment. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm ... The types of restrictive measures used at Dallas Behavioral Healthcare Hospital include: o Physical holds o Seclusion Emergency medications may be ordered to relieve the patient’s acute symptoms such as psychosis, severe anxiety, or agitation. Medications are not administered as chemical restraints with the intent of restricting the patient’s freedom of movement or administered in a manner that is not a standard treatment for the patient’s condition ... ...Monitoring Qualified staff members do the following: 1 . Remain in proximity to that patient that allows continuous visual observation of and communication with the patient at all times. 2. Evaluate the patient for safety and comfort at the initiation of restraint or seclusion and minimally every 1 5 minutes unless otherwise noted (below). The evaluation includes any of the following, as appropriate to the patient and the type of restraint or seclusion: o Signs of any injury associated with the application of restraint o Nutrition and hydration - offer fluids at least hourly; offer meals and snacks per hospital schedule. o Circulation and range of motion in the extremities o Vital signs - if the patient is too agitated to tolerate vital signs initially, obtain and record vital signs as soon as possible ...” During an interview with CNO Staff #2 on 3/09/2026 after 5:00 PM, it was confirmed that the nursing staff failed to monitor Patient #1 according to hospital policy after the administration of an emergency behavioral medication/chemical restraint.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on observation, medical record review, and interview, the facility failed to: 1. ensure a physician’s order was obtained for a physical restraint due to an emergent situation to protect the safety and well-being of 1 (Patient #1) of 3 (Patient #1, #2, and #3) of 3 medical records reviewed. The facility also failed to follow the hospital policy titled Restraint and Seclusion, Policy #PC.4.04. Refer to Tag A0168 2. ensure a face-to-face was completed within 1 hour following the initiation of a restraint in 1 (Patient #3) of 3 (Patient #1, #2, and #3) patient medical records reviewed. The facility also failed to follow the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025. Refer to Tag A0178 3. ensure a Registered Nurse (RN) consulted with the treating physician as soon as possible after the completion of the one-hour face-to-face evaluation in 1 (Patient #3) of 3 (Patient #1, #2, and #3) patient medical records reviewed. The facility also failed to follow the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025. Refer to Tag A0182”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 40989 Based on observation, medical record review, and interview, the facility failed to ensure a physician’s order was obtained for a physical restraint due to an emergent situation to protect the safety and well-being of 1 (Patient #1) of 3 (Patient #1, #2, and #3) of 3 medical records reviewed. The facility also failed to follow the hospital policy titled Restraint and Seclusion, Policy #PC.4.04. Findings: Patient #1 Patient #1 was an 11-year-old male admitted to the facility on 12/30/2025 with a diagnosis of Disruptive Mood Dysregulation Disorder. A review of the Restraint Log for January 2026 did not reveal that Patient #1 had a restraint on January 15, 2026. A review of the incident log for January 2026 revealed Patient #1 was documented on the log twice on January 15, 2026. The first documented incident was for an “Out of Control Behavior (Seclusion and Restraint Packet)”, and the second documented incident was on January 15, 2026, and read “Process Failure”. An observation of the recorded video surveillance dated 1/15/2026 was reviewed with the Quality Director/Risk Manager (RM), Staff #5, on 2/03/2026 at 10:00 AM in the administrative conference room. The video footage review revealed Patient #1 was placed in a physical restraint on 1/15/2026 from 4:30 PM until he was released at 4:34 PM in the dining area by Mental Health Tech (MHT) Staff #4. A review of the medical record was completed on 2/03/2026 with RM Staff #5 and Assistant Director of Nursing (ADON) Staff #2 in the administrative conference room. During an interview on 2/03/2026 at 10:45 AM, RM Staff #5 confirmed there was no physician order obtained for the physical restraint on Patient #1 on 1/15/2026. RM Staff #5 also confirmed that the restraint and seclusion packet included the physician order, type of restraint, the 1-hour face-to-face evaluation, the patient and staff debriefing, and the name of the family or legally authorized representative notified. An interview was conducted with the Director of Nurses (DON), Staff #3, on 2/12/2026 at 1:43 PM. DON Staff #3 confirmed there was no physician order obtained for the physical restraint applied to Patient #1 on 1/15/2026. A review of the facility policy titled Restraint and Seclusion, Policy # PC.4.04, with a reviewed date of 6/2025 was as follows: “POLICY STATEMENT Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified. Restraint or seclusion may not be used solely based on the patient’s diagnosis or history of dangerous behavior. It is not used as a means of coercion, discipline, convenience, or staff retaliation ... RESPONSIBILITIES The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner (LIP) authorized to order restraint or seclusion by Dallas Behavioral Healthcare Hospital Medical Staff rules and regulations, and in accordance with Texas state law. The attending physician must be consulted as soon as possible if they did not order the use of restraint or seclusion. PROCEDURES Authorizing/Ordering Restraint or Seclusion The psychiatrist or other licensed independent practitioner (LIP) will: 1 ... In an emergent situation in which the psychiatrist or other LIP is not immediately available, a registered nurse (RN) who is competent in restraint or seclusion usage will: 1. Direct that the patient be restrained or secluded. 2. Notify the attending or on-call psychiatrist/ provider as soon as possible to obtain an order ... In an interview on 2/03/2026 after 10:30 AM, RM Staff #5 confirmed the facility failed to follow their own policy and obtain an order for an emergency behavior physical restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure a face-to-face was completed within 1 hour following the initiation of a restraint in 2 (Patient #1 and #3) of 3 (Patient #1, #2, and #3) patient medical records reviewed. The facility also failed to follow the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025. Findings: Patient #1 Patient #1 was an 11-year-old male admitted to the facility on 12/30/2025 with a diagnosis of Disruptive Mood Dysregulation Disorder. An observation of the recorded video surveillance dated 1/15/2026 was reviewed with the Quality Director/Risk Manager (RM), Staff #5, on 2/03/2026 at 10:00 AM in the administrative conference room. The surveillance video footage reviewed revealed that Patient #1 was placed in a physical restraint on 1/15/2026 from 4:30 PM until he was released at 4:34 PM in the dining area by Mental Health Tech (MHT) Staff #4. A review of the medical record was completed on 2/03/2026 with RM Staff #5 and Assistant Director of Nursing (ADON) Staff #2 in the administrative conference room. During an interview on 2/03/2026 at 10:45 AM, RM Staff #5 confirmed there was no 1-hour face-to-face evaluation. Patient #3 Patient #3 was a 17-year-old female admitted to the facility on 1/17/2026 with a diagnosis of Bipolar Disorder Manic with Severe Psychosis. A review of the Restraint and Seclusion Packet was completed on 2/03/2026 after 1:00 PM with Risk Manager/Quality Director Staff #5 and Assistant Director of Nursing (ADON) Staff #2 on 2/03/2026. The review revealed a telephone order from Physician #16 dated 1/17/2026 at 1429 (2:29 PM). The order was as follows: “Zyprexa (antipsychotic medication) 10 milligrams (mg) intramuscular (IM) for aggression and Benadryl (antihistamine) 50mg IM”. The medication was administered on 1/17/2026 at 2:40 PM by Registered Nurse (RN) Staff #17. A review of the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025, was as follows: “ POLICY STATEMENT Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified. Restraint or seclusion may not be used solely based on the patient’s diagnosis or history of dangerous behavior. It is not used as a means of coercion, discipline, convenience, or staff retaliation .... Monitoring Qualified staff members do the following: 1 ... 2 ... *Physical and psychological status and comfort - a full (face to face) assessment of the patient’s physical and psychological status must be completed within 1 hour of the initiation of the restrictive measure by a physician/provider or a trained RN with demonstrated competence in conducting the assessment. The assessment must be completed even if the restrictive measure has been discontinued within the hour. If the assessment is completed by an RN, he/she must also communicate findings of the assessment with the attending/on-call psychiatrist or provider as soon as possible. The assessment as well as notification of the provider (and any subsequent orders/interventions) must be documented. The RN who initiated the seclusion or restraint may not conduct the one-hour face to face assessment ...” An interview was conducted with Assistant Director of Nursing (ADON) Staff #2 on 2/03/20026 and Chief Executive Officer (CEO) Staff #1 after 1:30 PM. ADON Staff #2 confirmed that a face-to-face was not completed for the chemical restraint on 1/17/2026. CEO Staff #1 confirmed that the emergency medication administered to Patient #3 on 1/17/2026 was administered to control Patient #3’s behavior and should have been treated and monitored as a chemical restraint and required a face-to-face evaluation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 40989 Based on document review and interview the Registered Nurse (RN) failed to consult with the treating physician as soon as possible after the completion of the one-hour face-to-face evaluation in 1 (Patient #3) of 3 (Patient #1, #2, and #3) patient medical records reviewed. The facility also failed to follow the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025. Findings: Patient #1 Patient #1 was an 11-year-old male admitted to the facility on 12/30/2025 with a diagnosis of Disruptive Mood Dysregulation Disorder. An observation of the recorded video surveillance dated 1/15/2026 was reviewed with the Quality Director/Risk Manager (RM), Staff #5, on 2/03/2026 at 10:00 AM in the administrative conference room. The surveillance video footage reviewed revealed that Patient #1 was placed in a physical restraint on 1/15/2026 from 4:30 PM until he was released at 4:34 PM in the dining area by Mental Health Tech (MHT) Staff #4. A review of the medical record was completed on 2/03/2026 with RM Staff #5 and Assistant Director of Nursing (ADON) Staff #2 in the administrative conference room. During an interview on 2/03/2026 at 10:45 AM, RM Staff #5 confirmed there was no 1-hour face-to-face evaluation. Patient #3 Patient #3 was a 17-year-old female admitted to the facility on 1/17/2026 with a diagnosis of Bipolar Disorder Manic with Severe Psychosis. A review of Patient #3’s medical record was completed in the administrative conference room with Risk Manager/Quality Director Staff #5. A review of the restraint packet dated 1/18/2026 at 8:30 AM, completed by RN Staff #18, revealed the one-hour face-to-face evaluation was completed by (signature illegible) at 8:30 AM. This was the same time the chemical restraint was administered by RN Staff #18. A review of the 1 hour face to face revealed staff (signature illegible) documented that Physician #16 was consulted regarding the evaluation of the face-to-face on 1/18/2026 at 8:16 AM. This was 14 minutes before the chemical restraint was administered. A review of the facility policy titled Restraint and Seclusion, Policy #PC.4.04, with a review date of 6/2025, was as follows: “ POLICY STATEMENT Use of restraint and seclusion is limited to situations in which it is necessary to ensure the immediate physical safety of the patient, staff members, or others as imminent risk has been identified. Restraint or seclusion may not be used solely based on the patient’s diagnosis or history of dangerous behavior. It is not used as a means of coercion, discipline, convenience, or staff retaliation .... Monitoring Qualified staff members do the following: 1 ... 2 ... *Physical and psychological status and comfort - a full (face to face) assessment of the patient’s physical and psychological status must be completed within 1 hour of the initiation of the restrictive measure by a physician/provider or a trained RN with demonstrated competence in conducting the assessment. The assessment must be completed even if the restrictive measure has been discontinued within the hour. If the assessment is completed by an RN, he/she must also communicate findings of the assessment with the attending/on-call psychiatrist or provider as soon as possible. The assessment as well as notification of the provider (and any subsequent orders/interventions) must be documented. The RN who initiated the seclusion or restraint may not conduct the one-hour face-to-face assessment ...” In an interview on 2/03/2026 with Risk Manager/Quality Director, Staff #5 confirmed the above finding. Chief Executive Officer Staff #1 confirmed that the administration of the emergency behavioral medications to Patient #3 was considered a restraint, and the facility failed to follow the hospital policy and notify the treating physician after the face-to-face evaluation was completed.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 40989 Based on document review and interview, the facility failed to ensure 2 (Physician #12 and #16) of 2 Physicians authenticated telephone orders given for chemical restraints within 48 hours in 3 (Patient #2,#3, and #10) of 4 (Patient #1, #2,#3, and #10) patient medical records reviewed as required by 26 Texas Administrative Code (TAC) 320.119(b)(2). Additionally, the facility failed to follow the facility policy titled ‘Telephone, Verbal, and Written Orders for Medication.’ Findings: Patient #2 Patient #2 was a 28-year-old female admitted involuntarily to the facility on 1/11/2026 for Suicidal Ideation. She had a past psychiatric history of Bipolar Disorder, Depression, and Schizophrenia. A review of the medical record revealed that Physician #16 gave a telephone order to the Registered Nurse (RN-signature illegible) on 1/15/2025 at 1745 (5:45 PM). The order was as follows: “Physical Hold, Seclusion, and Emergency Medication; Zyprexa (antipsychotic) 10 milligrams (mg) Intramuscular (IM) stat x1 Now and Benadryl (antihistamine) 50mg IM stat x1 Now. Physician #16 failed to sign the telephone order within 48 hours. Patient #3 Patient #3 was a 17-year-old female admitted to the facility on 1/17/2026 with a diagnosis of Bipolar Disorder mixed severe with psychosis. A review of the medical record revealed that Physician #16 gave a telephone order to RN Staff #17 on 1/17/2025 at 1429 (2:29 PM). The telephone order was as follows: “Zyprexa Zydis 10mg IM for aggression and Benadryl 50mg IM for Extrapyramidal symptoms (EPS-involuntary movements caused by antipsychotic medication)”. Physician #16 failed to sign the telephone order within 48 hours. Patient #10 Patient #10 was a 25-year-old female admitted to the facility on 1/13/2026 with a diagnosis of Schizophrenia, Cannabis Use Disorder, mild, and Sedative-Hypnotic use disorder, moderate. A review of the restraint and seclusion packet dated 1/17/2026 revealed that Physician #16 gave a telephone order to RN #18 on 1/17/2026 at 10:10 AM The telephone order was as follows: “Seclusion and Emergency Medication Thorazine (antipsychotic) 50mg IM for psychosis, Ativan (antianxiety medication) 1mg IM for anxiety and Benadryl 50mg IM for EPS. Physician #16 failed to sign the restraint order within 48 hours. A review of the restraint and seclusion packet dated 1/24/2026 revealed that Physician #12 gave a telephone order for RN Staff #19 on 1/24/2026 at 1300 (1:00 PM). The telephone order was as follows: “Seclusion and Emergency Medication. Ativan (antianxiety medication) 2mg IM x1 for agitation, Haldol (antipsychotic medication) 10mg IM x1 for agitation, and Benadryl 50mg IM for EPS”. Physician #12 failed to sign the telephone order within 48 hours. A review of the facility policy titled, Telephone, Verbal, and Written orders for medication, Policy # MM.2.02, with a reviewed date of 5/30/2025, was as follows: “I. POLICY: A. Verbal and telephone orders are allowed; however, in an effort to reduce medication errors, the use of these types of orders is discouraged. The medical staff is educated on a continual basis to make all attempts to minimize the use of verbal and telephone orders. The hospital shall never allow verbal or telephone orders for the purposes of medical staff practitioners’ convenience only. Whenever possible and practicable, all members of the medical staff with privileges and approval to prescribe medication will do so by physically entering an order in the patient’s medical record or on a Pharmacy prescription pad. II. Procedure: ...B. The prescribing practitioner must date, time and authenticate the verbal order within the time designated by state law...” An interview was conducted with the Assistant Director of Nurses (ADON), Staff #2, and Risk Manager (RM), Staff #5, in the afternoon of 2/03/2026. RM Staff #5 confirmed that Physician #12 and #16 failed to authenticate telephone orders within 48 hours for the chemical restraints in 3 (Patient #2,#3, and #10) of 4 (Patient #1, #2, #3 and #10) patient medical records reviewed as required by 26 TAC 320.119(b)(2). As of the survey exit date, 2/03/2026, the telephone orders given by Physician #12 and Physician #16 for restraints had not been signed.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47578 51905 Based on interviews and record review, Facility A failed to comply with 42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on record reviews and interviews, Facility A failed to provide appropriate transfers for eight of eleven patients (Patients #F1, #F2, #F6, #F7, #F8, #F9, #F10, and #F11) whose records were reviewed. Facility A failed to provide an appropriate transfer when: 1. Facility A failed to ensure that the receiving hospital and physician were appropriate to the medical needs of Patients #F1, #F2, #F6, #F7, #F8, #F9, #F10, and #F11, and had accepted responsibility for the patients’ medical treatment and hospital care. 2. Facility A failed to ensure that the transfer was effected through qualified personnel and transportation equipment for patients #F1, #F2, #F6, #F7, #F8, #F9, #F10, and #F11. 3. Facility A failed to ensure that a receiving hospital, had received the appropriate records to determine that the appropriate standard of care could be met for Patients #F1, #F2, #F8, #F9, #F10, and #F11, who were transferred from Facility A, when t here was no documentation of records being sent to the receiving hospital. 4. Facility A failed to ensure that the date, time, and signature of the physician certification (patients #F1, #F2, #F6, #F7, #F8, #F9, #F10, and #F11) and risks and benefits (patients #F1, #F2, #F6, #F7, #F8, #F9, #F10, and #F11) were documented in the medical record. Cross reference to Tag 2409”

“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: 40989 Based on documentation review and interview, the hospital failed to ensure that an informed consent for all Psychoactive Medications was signed by the patient, the legally authorized representative, or had a court order signed by the County Judge to administer Psychoactive medications as in 1 (Patient #1) of 3 (Patient #1, #2, and #3) patient medical records reviewed. Findings: Patient #1 A review of Patient #1’s medical record was conducted on 12/01/2025 after 11:30 AM. Patient #1 was voluntarily admitted to the hospital on August 13, 2025, with an admitting diagnosis of Major Depressive Disorder, recurrent, without psychotic features, Cannabis Use Disorder, and Alcohol Use Disorder. A medication order was written by Physician #5 on 8/14/2025 for Latuda (antipsychotic medication) for mood. A review of the medication administration record (MAR) confirmed Patient #1 was administered Latuda on 8/14/2025 at 5:00 PM by the nurse. Patient #1 refused the medication on 8/15/2025 and 8/16/2025. Further review of the medical record revealed Patient #1 had not signed an informed consent for the administration of Latuda until 8/17/2025 at 5:00 PM. An interview was conducted with Registered Nurse (RN) Staff #1 and Assistant Chief Nursing Officer (ACNO) Staff #3 on 12/15/2025 at 1:00 PM. Both RN’s confirmed Patient #1 was administered the medication before an informed consent was signed. A review of the hospital policy titled “Psychoactive Medication Consent”, Policy # MM.3.09, with a reviewed date of 5/30/2025, was as follows: “PURPOSE To assure all patient rights are respected regarding their treatment with psychoactive medications. POLICY Except in an emergency, all patients at Dallas Behavioral Health Hospital will be informed of their rights and give informed consent PRIOR to administration of psychoactive medication ...” RN Staff #1 and ACNO Staff #2 confirmed Patient #1 was administered Latuda 40 milligrams by mouth before she signed an informed consent.”

“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: 32143 Based on reviews, observations, and interviews, the facility failed to ensure that nursing was following the policy and procedure for Code Blue, and the Registered Nurses failed to ensure that completed patient medical assessments and reassessments were performed for 4 of 4(patient #7, # 9, 15, and #16) patients. FINDINGS: A review of the patient #7’s chart revealed she was a 47-year-old female on a voluntary admission. She was given a diagnosis of psychosis but was oriented x 3 and could understand her rights upon admission. A review of her Intake form dated 10/16/25 at 15:39 stated, “Pt is a 47-year-old female. Pt is a voluntary walk-in accompanied by her case worker. Pt is highly psychotic and aggressive. Pt made threats to staff to physically assault them. Pt goes on tangents and speech is ineligible (sic) and rapid. Pt’s case worker reports that pt wanders off out of residence, impulsively buys junk food, has not slept in 5 days, and cries uncontrollably, stating that she is being repeatedly raped by a Dallas police officer every time she goes to sleep. Pt is observed to be responding to internal stimuli. Pt denies current SI. Pt’s CSRSS is moderate suicide risk due to history. Pt’s DASA score is 7 due to verbal threats, unwilling to follow directions, sensitive to perceived provocation, and negative attitudes. Requesting inpatient services due to the patient being a danger to others.” A review of the physician’s history and physical dated 10/17/25 revealed, Patient #7 was seen for her Physical and History on 10/17/25 at 1615. Patient was oriented to person and place. All systems were marked as normal except for musculoskeletal, stating that the patient had 2+ edema in both lower legs. Recommendation for a low-sodium diet and elevate extremities. “The patient had stopped taking her medications 7 days ago.” The physician wrote an order to elevate the bilateral legs on a pillow when in bed on 10/17/25. A review of the nurses’ notes on 10/17/25 for the 7am to 7pm shift and the 7pm to 7am shift revealed there was no documentation on the patients’ systems ( neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and integumentary) or edema. There was no documentation concerning leg elevation or pain. A physician order was written on 10/18/25 to start HCTZ (blood pressure and diuretic) 12.5 mg po daily. A review of the nurse’s notes dated 10/18/25 and 10/19/25 revealed there was no documentation on the patient’s edema, new medication and effectiveness, or of the TED hose. A review of the physician orders revealed to move the patient to a blocked room for Sexual Acting Out (SAO) precautions. The nurse had written on 10/19/25 that the patient continued to take her clothes off, was found masturbating in the seclusion room, and needed redirection. Patient was also placed on a q 5-minute observation. A review of the nurse’s note dated 10/20/25 revealed there was no documentation concerning the edema in the patient’s legs, whether she had elevated legs with TED hose, or if medication was effective. There was no documentation of a systems review. A review of the nurse’s notes dated 10/20/25 revealed that there was no documentation concerning the patient’s edema and at 0630, the patient had refused to put on her TED hose, but was signed by the nurse taking them off at 2100. There was no documentation when the hose was applied. A review of the nurse’s notes dated 10/21/25-10/22/25 revealed there was no documentation on the patient’s edema, systems, or medication effectiveness. A review of the Master Treatment Plan revealed there was no written plan on the patient’s new medication regimen for HCTZ, edema, or the TED hose. A review of the nurse’s note on 10/24/25 at 250am revealed the “patient was found with mucous coming out of her nose and on the pillow. The nurse went into the patient’s room and changed her position. Mucous was cleared, and the vital signs were 100/68, HR 66, Resp 16, and O2 sat 95%. No further change in condition. At 220am the nurse stated that there was a change in condition, and MHT (Mental Health Technician) informed the nurse. “Patient gasping for air. Pulse faint at this time. B/P 60/40, Hr 45, resp 6, O2 sat at 68%. 222am responding cart available, no pulse and no B/P noted. 223 Code blue initiated. Patient pulseless. CPR started at 110 bpm, O2 was initiated, and suction performed. Skin warm, more mucous coming out. Patient jumped up and relapses. 226- 911 called 240- EMS arrived and took over the resuscitation. 310- Paramedics stopped CPR. Dr. Kern Brotell pronounced the patient dead ...” (patient was pronounced by phone.)” A review of the Code Blue policy and procedure stated, “ PROCEDURE 1. Establish the nature of the emergency and initiate “Code Blue” using the overhead paging system. At least one staff member, the one with the most clinical experience, should remain with the patient at all times until assistance arrives. 2. Initiate First Aid, as appropriate or begin basic cardiac life support. 3. Admit RN, supervisor and/or designee brings Emergency Cart to the scene. The most senior RN or medical staff member will assume responsibility for the code and will determine if 911 should be activated. If the code leader is not a physician and a physician arrives on the scene, the lead position should be assumed by the physician. One staff member will be designated by the code leader to record the events on the Cardiopulmonary Resuscitation Flow Sheet. One staff member remains at the desk to notify the provider to place, receive and record all incoming and outgoing calls regarding the emergency. MHT will clear all other patients and staff from the area. BCLS (Basic Cardiac Life Support) is continued until: a. Directed to stop by a medical provider or; b. The paramedics arrive and take over the care of the patient. When the situation has been resolved, the code leader will announce over the paging system “Code Blue all clear”. The code leader or designated unit RN should document in the medical record the events of the code. The RN will also complete the Code Blue Event Debriefing/Critique form. The patient’s provider should be notified as soon as appropriate. The RN will notify the patient’s family/guardian if the adolescent or if adult patient with Release of Information as soon as appropriate. If patient is in Assessment and Referral area, admit RN will notify ER and give report to ER nurse. If patient is on the unit, unit RN will notify ER and give report to ER nurse. Patient will be transferred via ambulance to closest ER.” A review of patient #7’s chart revealed that there was no Cardiopulmonary Resuscitation Flow Sheet or Code Blue Event Debriefing/Critique form found on the chart. A review of the house supervisor’s note dated 10/24/25 stated that EMS had told the nursing staff that they were not allowed to take the patient to the ER unless they had obtained a pulse on the patient. An interview was conducted with Staff #1 and #2 concerning the death and events of the death on 11/3/24 at 2:00pm. Staff #2 stated she had contacted the EMS station multiple times and had requested a run sheet with no results. Staff # 1 made a complaint to the EMS company and to the State of Texas. Staff #1 revealed an email that was sent to the DE Soto police department that the medical examiner (ME) had notified De Soto Police to initiate an investigation for failure to notify ME and transport. Staff #1 had also requested an autopsy report and revealed a form from the Southwestern Institute of Forensic Sciences at Dallas. The form stated the results of the autopsy were still pending. “Pending issues: Toxicology results.” Staff #1 and Staff #2 had started a Root Cause Analysis RCA) but were still in the investigation of the death. Staff #1 stated that she is aware that the staff need further training on Code Blue, and plans were in place to start training and perform drills. The facility had no code blue drills to provide for the surveyor. UNIT 6 A tour of the facility was conducted on the morning of 11/4/25 with Staff #4. Staff #5 RN on Unit 6 was performing her nursing shift assessment with patient # 9. Staff #5 RN was sitting behind the nurse’s desk, and the patient was standing on the other side. Staff #5 RN administered patient #9 her medications, asked about her sleep, if she had eaten breakfast, and if she was having any mental health issues. Staff # 5 RN thanked the patient, and she walked away from the desk. Staff #5 RN called patient #15 to the desk and performed the same assessment as patient # 9. An interview was conducted with staff #5, RN, on 11/4/25 at 9:20 am. Staff #5 was asked if this was the procedure for nursing assessments for her patients. Staff #5 RN stated, “Yes. I have them come to the desk for their medications and ask them some questions, and chart on them.” Staff #5 was asked when she would listen to their lung, heart, or gastrointestinal sounds. Staff #5 RN stated that if the patient was having any issues, like coughing. A review of the Nursing assessment sheet revealed the patient should be assessed for pain, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and integumentary. The nurse had checked “systems were within normal limits,” but never assessed or touched the patients concerning these systems. A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope). UNIT 8 A tour of the facility was conducted on the morning of 11/4/25 with Staff #4. Staff #7 RN performed a nursing assessment on patient # 16. The RN asked the patient questions concerning his mental health, but did not ask any questions about his pain, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, or integumentary. The nurse had checked “systems were within normal limits,” but never assessed or touched the patients concerning these systems. An interview was conducted with Staff #7 on 11/4/25 at 9:35 am concerning nursing assessment and how they are performed. Staff #7 stated that he assesses each patient the same and has them come to the desk to answer questions and administer medications. A review of the policy and procedure, “ASSESSMENT AND RE-ASSESSMENT OF PATIENTS” stated, “o Reassessments are completed by the Registered Nurse on day and night shifts and documented on the Daily Nursing Assessment form (minimum of 2 times per calendar day). Registered Nurses will also complete at least one progress note per day, with a focus on problems identified in the Interdisciplinary Treatment plan. In addition, each patient is reassessed as necessary based on the patient’s plan for care or change in their condition, including change in the patient’s level of pain. Reassessments for pain are conducted as part of the routine nursing reassessments, minimum two times per day. Pain assessments are also conducted prior to and following the administration of pain medications o Reassessments are also based on the patient’s diagnosis; desire for care, treatment and services and response to previous care, treatment and services. In addition, the assessment and reassessment information include the patient’s perception of the effectiveness of, and any side effects related to their medication.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 26151 Based on record reviews and interviews, Facility A failed to provide an appropriate transfer for one of 20 patients (Patient #13) whose records were reviewed. Facility A failed to provide an appropriate transfer when: 1. Patient #13 was transferred to Facility B without a completed Memorandum of Transfer (MOT). 2. Facility A failed to ensure that the receiving physician from Facility B was secured by the transferring physician at Facility A. 3. Facility A failed to ensure that a receiving hospital and physician that were appropriate to the medical needs of Patient #13 had accepted responsibility for the patient’s medical treatment and hospital care. 4. Facility A failed to ensure that a receiving hospital, Facility B, had received the appropriate records to determine that the appropriate standard of care could be met for Patient #13 who was transferred from Facility A when there was no documentation of records being sent to Facility B. 5. Facility A failed to document in the medical record for Patient #13, if any, parts of the medical record were sent to the receiving facility. 6. Facility A failed to ensure that a call was placed to the receiving facility for Patient #13 and document it in the medical record. The findings included: . 1-Record Review Patient #13 Facility A: On 5/10/2025 at 5:58 PM, Patient #13 presented to Facility A, as a walk-in accompanied by her spouse for a behavioral health evaluation and admission. A review of patient #13’s medical record included a 14-page registration document. Further review of the document was a section titled, “Intake Assessment” completed by the registered nurse (RN) and revealed the following vital signs: Heart rate- 122, Respirations - 24, Temperature -100.1 Fahrenheit, Blood pressure - 150/85 and Oxygen saturation - 100%. Further review of the medical record included a form titled, “Memorandum of Transfer” (MOT). A review of the MOT, revealed that the following numbered sections (#1 - #14) to be completed by the registered nurse (RN) that were left blank: Number 5 - Initial contact with the receiving hospital administration, date, time, and name of contact person at the receiving hospital. Number 6 - The receiving Physician secured by the transferring physician, date, time and name of the receiving physician. Number 7 - The transferring physician’s signature or the signature of hospital staff acting under the physicians’ orders. Number 8 - The name of the transferring physician. Number 9 - The accepting hospital secured by the transferring hospital with the date and time. Number 10 - The name of the receiving hospital Administrator, and transferring Hospital administration who contacted the receiving hospital, signature, title and time. Number 11 - The type of vehicle and company used, equipment needed, personnel needed. Number 12 - The facility transported to, address, diagnosis. Number 14 - Attachments: x-rays, lab reports, history & physical, physician progress notes, nurses progress notes, medication record, and physician orders. Further review of the MOT under the section titled, “Summary of Risks and Benefits” RN documented Medical Clearance, and documented “yes” that Patient #13 acknowledged that the benefits and risks were explained. Continued review of the document did not include the signature of the physician, Facility A’s House Supervisor or the signature of the RN. Record Review Patient #13 Facility B: On 05/10/2025 at 9:25 PM, Patient #13 presented to Facility B’s ED via ambulance as a transfer from Facility A for medical clearance . Per patient’s spouse, patient went to Facility A to be checked in for in-patient admission but during the intake patient had an elevated temperature (above 100.0) and was transferred to Facility B for medical clearance. Chief complaint was anxiety, and fever. At 9:38 PM - Patient #13 was triaged by RN ED staff. Vital Signs: Pulse-110, Blood Pressure-129/84, Temperature-99.5’ F, Respirations-16, Oxygen Saturation-98%. A review of the medical record under “History of Present Illness” (HPI) revealed that ED provider documented that Patient #13 stated since she received the COVID-19 vaccine in 2021 she has felt “unwell. Feels something is wrong with her body, and stated “I just can’t explain it.” The ED provider documented that Patient #13 also has concerns that she has Mercury poisoning and was seen my a neurologist for headaches. Further review of the ED provider notes revealed that Patient #13’s spouse stated that in the past two years, had seen a decline in the patient’s behavior. That Patient #13 is anxious, talks to herself like there is someone in the room. He stated that two weeks ago, Patient #13 ran into a closet and tried to lock herself in; that he went in the closet to try and remove the loaded shotgun, and found Patient #13 with the shotgun in her hand with the finger on the trigger. Continued review of the ED provider’s notes revealed that Patient #13 denied suicidal ideation, but admits to feeling fearful that she may hurt herself. Further review revealed that patient’s spouse tried to check Patient #13 into Facility A this evening, but during the intake, patient was noted to have an elevated temperature and was sent to Facility B’s ED for evaluation. A review of the medical record under “Medical Decision Making” revealed that ED provider documented that Patient #13 presented to Facility B’s ED for erratic behavior at home, speaking to herself, hallucination, and was unable to be checked into Facility A because of an elevated temperature. Further review revealed that Patient #13 is not febrile and has no localizing symptoms of infection. Will check screening labs and urinalysis, if Patient #13 remains afebrile will medically clear for Psychiatric evaluation. Labs ordered: urinalysis with reflex to culture, COVID-19, Influenza, RSV/PCR, comprehensive metabolic panel, complete blood count with differential, urine screen for drugs, blood screen for alcohol, and chest x-ray, and consult for psychiatric evaluation once patient is medically cleared. Patient #13 refused chest-X-ray. Lab interpretation revealed, no leukocytes, renal functions and electrolytes were within normal limits. 5/11/2025 at 1:35 AM psychiatric evaluation was conducted by a licensed clinical social worker. Review of the psychiatric evaluation revealed that Patient #13 had zero risk for suicidal ideation, (S/I). That Patient #13 stated she needed a check up because “of a lot of stress and anxiety is off the charts,” and is getting worse. Further review of the psychiatric evaluation, revealed Patient #13 was diagnosed with: anxiety. and was admitted. 2 - Facility A - Staff Interview: During a telephonic interview conducted on 7/1/2025 at approximately 3:30 PM, RN, Staff F stated that she had been working at Facility A since October of 2023, and that her responsibilities included, patient intake assessments and performing the medical screening examinations. RN, Staff F further stated that during the intake assessment, Patient #13 had elevated temperature of 101.1 and needed to be sent out for medical clearance. RN Staff F, stated that Patient #13 and her spouse wanted to be taken to Facility B, by the local ambulance and was transported to Facility B. RN, Staff F stated that She used her nursing judgement based on the findings of the intake assessment to send patient out for medical clearance, with the expectation that the receiving hospital would send the patient [13] back to the facility [A] once medically cleared. RN, Staff F stated that a physician’s order is not required in all cases for transfers for medical clearance. RN Staff F, stated that they are supposed to do a nurse-to-nurse consult when doing and transfer and responded, “no” when asked if she spoke with the nurse at the receiving hospital (Facility B). RN, Staff F stated that they are supposed to have a physicians’ order for transfers and responded, “no” when asked if there was a physicians’ order for the transfer. During the same interview, RN, Staff F further stated that she would have to review the document [MOT] to see what was not completed. During an interview conducted on 7/1/2025 at 6:00 PM, the Intake Director, Staff G, stated, “that RN, Staff F did not follow the proper protocol for patient transfer.” Staff G, stated, “that RN, Staff F did not notify the receiving hospital, did not contact the physician, and did not complete the MOT form.” Staff G, further stated, “that a physician’s order is required when sending a patient out for medical clearance, that the MOT did not include the physician notification, was not signed by the physician or anyone, and that this should be documented in the medical record.” 3 - Policy Review A review of Facility A’s policy titled, “Transfer of Patient to Another Facility” (effective 1/10/2014) read in part, “ A. The hospital will provide a Memorandum of Transfer, as prescribed by the Texas Department of State Health Services, to be completed for every patient who is transferred. B. The Memorandum of Transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician’s order if a delay in transferring has been determined to be detrimental to the patient. C. The Memorandum of Transfer must also be signed by hospital administration.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 47061 Based on record review and interview, the facility failed to ensure the provision of a response to a grievance, in that 1 of 1 patients (Patient #1) did not receive a response to a grievance within the specific time frames. Findings Include: Daily Nursing Assessment completed on 01/26/2025 at 7:25 PM by Personnel #8, reflected the following, “During shift change, while RN was getting report, this pt [patient]/[Patient #1] reported that his roommate touched him inappropriately on his buttocks. He said ‘he was slappy my butt and I told him to stop.’ He decided to report because the roommate would not stop. Roommate did not offer any explanation, he just shrugged his shoulders when he was asked...House Sup [supervisor] aware and his mother notified...” Progress Note completed on 01/27/2025 at 3:19 PM by Personnel #7, reflected the following, “T [therapist] contacted pt [patient] foster mother...for flash update. Foster mother was upset ...felt nothing was being done about pt being touched inappropriately. T stated that the situation is being looked at.” During an interview with the complainant/patient’s mother, via telephone on 03/05/2025 at 9:44 AM stated the following, “the incident occurred the end of January. We don’t know any of the specifics because [Patient #1] refuses to talk about it. The only thing we know is that it was his roommate and they removed him from the room. I told the facility that I would be reporting the incident to the state. I also contacted the police department. The police told us they couldn’t do anything because [Patient #1] wouldn’t talk about what happened. I spoke with the nurse advocate and she said she would investigate it and get back to me and she never did. I even went up to the facility to speak with the house supervisor and she told me she would get to the bottom of it, and I never heard anything from her either. I never received any follow up from the facility after multiple requests...” During an interview with Personnel #1 on 03/05/2025 at 10:30 AM stated the following, “our current Patient Advocate is new and wasn’t here when [Patient #1] was here the end of January. [Patient #1] does not show up on our Complaint/Grievance Log for January. We do not have record that [Patient]’s mom filed a grievance with us or that an outcome letter was sent to her. I never spoke with [Patient]’s mom. I will send out an outcome letter to [Patient]’s mom as soon as possible regarding the incident.” During an interview with Personnel #7 via telephone on 03/06/2025 at 3:00 PM stated the following, “I remember [Patient #1] and speaking with his mom regarding an incident with his roommate. I had called the mother to touch base with her and she started asking me questions about what had happened the previous night. I told her I was not aware, but that I would get someone to follow up with her...I apologized to her and told her I would speak with [Patient #1]’s nurse. I updated [Patient #1]’s nurse on what happened, but I did not report the incident to the Patient Advocate. I don’t know what happened after that. I had no further contact with the patient’s mother.” The Complaint and Grievance Log for January 2025 did not evidence a grievance filed by Patient #1’s mother. The facility policy on “Patient Complaint and Grievance Process” last revised on 04/22/2021 reflected the following, “ ...Procedure ...All grievances are to be submitted verbally or in writing to the Patient Advocate, either by the patient, the patient’s representative or a staff member to whom the grievance was reported ...The Patient Advocate will conduct an investigation of the grievance, reviewing the patient’s medical record, to obtain information regarding the patient’s clinical condition ...All grievances receive immediate priority and must be investigated with efforts made toward resolution. This organization will make every attempt to provide a response within seven (7) days of receiving a grievance ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33326 Based on record reviews and interviews, the facility failed protect and promote each patient’s rights when, - 4 out of 4 patients, (Patients #2, 3, 4, and 5) were placed in seclusion for over 2 hours and their hygiene, hydration, nutrition, elimination needs were not provided for, placing these patients at risk for pain, dehydration, and at risk for urinatry tract infections. - patients placed in seclusion were not reassessed by licensed professionals to determine the need for continuation in seclusion, placing these patients at risk of emotional and physical harm. (Patients # 2,3,4,5) Cross refer: A0154”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 33326 Based on record reviews, and interviews, the facility failed to provide an organized nursing services when - the facility failed to restrict or define ‘today’ orders resulting in 2 out of 2 patients, with an order for an EKG (electrocardiogram, measures the hearts rhythm and rate) today order, having to wait 24-48 hours for diagnostic testing, the delay in treatment placed the patients at risk of a negative cardiac event. (Patients #6 and #11) - the facility failed to implement a policy and procedure for the assessing and monitoring of patient wounds to ensure proper healing resulting in Patient #1’s knee and left antecubital wound worsening without the physician’s notification or interventions. Cross refer: A0386”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 33326 Based on record reviews, and interviews, the facility’s nursing staff failed to ensure the immediate physical safety of patient placed in seclusion were released at the earliest possible time when (4) out of (4) patients placed in seclusionpatients placed in seclusion comply with the requirements set forth by State law and hospital policy when the use of restraint or seclusion is necessary; - were not reassessed by licensed professionals to determine the need for continuation in seclusion, placing these patients at risk of emotional and physical harm. (Patients # 2,3,4,5) and - were placed in seclusion for over 2 hours and their hygiene, hydration, nutrition, elimination needs were not provided every two hours as the Texas Administrative Code Title 25 Chapter 415.266 (c)(1) and (2) requires. Findings include: Review of the facility provided policy “RESTRAINT AND SECLUSION” (last reviewed 8/17/23) reflected, “Definitions: 2. Seclusion is the involuntary confinement of a person alone in a room or an area from which the patient is physically prevented from leaving. 1. Indications: a. Restraint or seclusion may be used when less restrictive means are not sufficient to protect the physical safety of patients, staff members or others. b. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member, or others ... 7. Assessment and Monitoring of Restraint Seclusion: Assessment: Assessments by a registered nurse or physician assistant or evaluations completed by a responsible Licensed Independent Practitioner shall occur as often as indicated by the patient’s condition, behavior, and environmental considerations and at least once every 60 minutes. 8. Documentation of Monitoring: Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms. The annotation of actual real time continuous monitoring is not required to be documented concurrently but is encouraged. Discontinuation: Restraint or seclusion shall be discontinued: a. Once the behaviors or situations that prompted the use of restraint are no longer evident; or b. When it is determined that less restrictive means will be effective in protecting the patient / others. Review of the facility provided medical records of patients Patients # 2,3,4,5, reflected the patients were placed in seclusion for over 2 hours and did not receive the required reassessments every 60 minutes. During an interview on the morning of 9/10/24, in the administrative office, Staff #1, Risk Manager confirmed the medical records did not have the required hourly reassessments documented, either in the nursing notes or on the reassessment form; the patient’s on-going need for seclusion was not indicated. The following seclusion records were reviewed for start and stop times, bathroom and fluids were requested or offered to the patients and reassessments: Patient #2 - 8/31/24 in seclusion for 3.57 hours, start time 12:20 pm released at 4:05 pm, reassessed by a nurse at 1:07pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. - 9/1/24 in seclusion for 3.17 hours, start time 5:55 pm released at 9:12 pm, reassessed by a nurse at 6:32 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. - 9/1/24 in seclusion for 3.40 hours, start time 9:59 pm released at 1:45 am. There were no further assessments available. There was no recorded bathroom or fluids request or provisions. - 9/2/24 in seclusion for 3.45 hours, start time 7:17 pm released at 11:15 pm, reassessed by a nurse at 7:51 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. Patient #3 - 7/28/24 in seclusion for 2.47 hours start time 8:28 am released at 11:15 am, reassessed by a nurse 9:00 am. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. Patient #4 - 8/23/24 in seclusion for 3.07 hours start time 9:40 am released at 12:47 pm, reassessed by a nurse 10:11 pm. There were no further assessments available. There was no recorded bathroom or fluids request or provisions. - 8/24/24 in seclusion for 4.0 hours start time 12:00 pm released at 4:00 pm, reassessed by a nurse 12:31 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. Patient #5 - 8/25/24 in seclusion for 3.50 hours start time 3:10 am released at 7:00 am, reassessed by a nurse 4:10 am. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions. - 8/36/24 in seclusion for 3.50 hours start time 12:43 am released at 3:50 am, reassessed by a nurse 1:20 am. There were no further assessments available. There was no recorded bathroom or fluids request or provisions. During an interview on the morning of 9/10/24, in the administrative office, when asked how the monitoring staffs document if the patients are provided bathroom breaks or something to drink, Staff #3, CEO stated in part that the facility could not open the doors of the seclusion room, it would require them to start new orders for seclusion. The facility was unable to provide evidence that the patients were being offered or the patients had asked for bathroom breaks and fluids.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 33326 Based on record review and interview, the facility failed provide a well-organized nursing services when it failed to develop and enforce policies to ensure patient care, the facility 1. failed to restrict or define ‘today’ orders resulting in 2 out of 2 patients, with an order for an EKG (electrocardiogram, measures the hearts rhythm and rate) today order, having to wait 24-48 hours for diagnostic testing, the delay in treatment placed the patients at risk of a negative cardiac event. (Patients #6 and #11) 2. failed to implement a policy and procedure for the assessing and monitoring of patient wounds to ensure proper healing resulting in Patient #1’s knee and left antecubital wound worsening without the physician’s notification or interventions. Findings: Review of Patient #6’s physician’s order dated 8/31/24 at 11:00 am reflected, “EKG today - chest pain.” Review of Patient #6’s physician’s order, dated 9/2/24 at 11:45 am reflected, “Please follow up on EKG orders 8/31/24. Pt reported nobody did the EKG.” Review of Patient #6’s EKG dated 9/2/24 reflected abnormal EKG and was initialed by the physician as having been read. Review of Patient #11’s physician’s orders dated 8/23/24 at 1:00 pm reflected, “EKG today - bradycardia (slow heart rate)” Review of Patient #11’s EKG dated 8/24/24 at 10:35 am reflected A-fib (atrial fibrillation, an abnormal heart rhythm with an increased risk of stroke) and initialed by the physician as having been read and interpreted. During an interview on the morning of 9/10/24, when asked about the orders for EKGs, Staff #5, NP (Nurse Practitioner) stated, “Patient #6 came from the hospital, he had gotten an EKG while he was there. He was reporting a lot of pain, all over. He had an EKG before he came here, I wanted to see if there were any changes; I ordered the EKG to be done that day. When I came back in, (two days later) patient #6 reported no one had done the EKG, so I wrote the second order. After we got Patient #11’s EKG we placed her on anticoagulants. (Blood thinners)” During an interview on the afternoon of 9/9/24, Staff #2, CNO (Chief Nursing Officer), stated, “We contract our Radiology services. We have 24 hours to get an EKG, if it is on the weekends, we have till Monday.” During an interview on the afternoon of 9/9/24, Staff #3, CEO (Chief Executive Officer) when asked what the time for completion for a today order stated in part, the today order is not a term used at the facility. We have STAT orders, done immediately and routine orders, can be done the next day. Staff #3 confirmed the facility did not have a policy for the use of today orders and the nursing staff had not clarified the order with the physician. 2.)1. Review of the facility provided policy “Record of Care, Treatment and Services”, (last reviewed 8/10/2022) reflected, “It is the policy of Dallas Behavioral Healthcare Hospital to assure that the maximum possible information about a patient is available to the professional staff providing care, subsequent caregivers, regulatory/accrediting bodies and utilization review ...Progress Notes 3. Notes should include a brief and concise description of the patient’s condition ...” Review of the facility provided policy, “Wound Care” (last review date 8/1/23) reflected, “Purpose: To provide clear guidelines for the treatment and management of wounds, including those acquire by patients during their stay, ensuring medical intervention and adherence to discharge care plans ...Any wounds or bruises that develop will be promptly assessed by a Registered Nurse (RN), who will consult with our medical team. Necessary treatment will be provided based on the assessment, and the patient’s condition will be closely monitored to ensure proper healing.” Review of the facility provided policy, “Assessment and Re-Assessment of Patients” (last reviewed 8/17/23) reflected, “ ...each patient is reassessed as necessary based on the patients plan for care or change in their condition ...” Review of the facility provided policy “Record of Care, Treatment and Services”, (last reviewed 8/10/2022) reflected, “It is the policy of Dallas Behavioral Healthcare Hospital to assure that the maximum possible information about a patient is available to the professional staff providing care, subsequent caregivers, regulatory/accrediting bodies and utilization review ...Progress Notes 3. Notes should include a brief and concise description of the patient’s condition ...” Review of Patient #1’s Nursing Admission Assessment dated 8/27/24 reflected bruises, to the back of patients #1’s arms and a spider bite to the abdomen; there were no other indications of injuries or wounds. Review of Patient #1’s Skin Assessment Sheet dated 8/28/24 at 6:10 pm reflected, bruises to both knees and a laceration to the nose. A note reflected, “pt started to run and trip over her foot an [sic]felled [sic]and hit her face to the floor. RN came and met pt on the floor crying with a laceration on the top of her nose bleeding, and bruises bil (bilateral, both) knee ...Pt sent out via 911 to ER.” Review of Patient #1’s Acute Care Hospital’s emergency room discharge instructions dated 8/28/24 reflected, “Diagnosis: Open fracture of nasal bone.” Review of Patient #1’s pictures, taken 9/3/24 by the ISS (Individual Socialization Skills) facility staff and sent to this surveyor reflected the following: - Picture #1 had an approximately 5cm x 2 cm opened wound to the AC (left antecubital, inside elbow) with a dark pink inside and reddened edges; the wound was open to air. - Picture #2 reflected an approximately 10 cm x 6 cm open wound to the left knee, the edges had healing scabs with the inside showing reddened/dark pink inside the wound. - Picture#3 showed an approximately 4 cm x .5 cm healing laceration across the bridge of the nose; the wound was already healing leaving a thick scab. The edges were slightly reddened. During an interview, on the afternoon of 9/9/24, when asked for the policy for wound care documentation and patient #1’s skin assessment sheets, showing the measurements and description of the wounds upon her return from the ER, Saff #2, Chief Nursing Officer stated, “We don’t do that here, we aren’t going to be doing measurements in this environment ...They (nurses) should be documenting the wounds in their notes, there isn’t a specific form.” Staff #2, CNO confirmed there were no documented measurements of patient #1’s wounds. During an interview on the morning of 9/10/24, when asked about patient #1’s wounds Staff #5, Nurse Practioner stated, “I saw her (patient #1) when she returned from the hospital, there was a cut on her nose. I don’t see her every day. I expect the nurse to clean and observe the wound and call me if needed. I know she had a nasal fracture and a very superficial cut to the left AC.” Staff #5, NP was shown the pictures (taken after discharge) of patient #1 and stated, “When she left here it was a small linear line (the nose laceration). I wasn’t aware of the wound to the knee; it was a bruise when she came back from the ER. I ordered treatments for the left AC wound, it didn’t look like that, it was still superficial.” Staff #5 reported, she had not reassessed patient #1’s left arm prior to discharge. During an interview, on the afternoon of 9/9/24, Staff #1, Risk Manager, confirmed there was no available documentation of the left knee opening or of the worsening wound to the left AC.””

“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: 32143 Based on record review and interview, nursing failed to ensure the Registered Nurse (RN) was completing a comprehensive nursing assessment, obtaining vital signs, and assessing the patient for adverse reactions or effectiveness of the administration of psychotropic medication administration administered as a chemical restraint/ emergency behavioral medication (EBM) on 2 (#6 and #7) of 2 patient charts reviewed. A review of patient #6’s medical chart revealed the following verbal physician orders for the administration of psychoactive medications as a chemical restraint. 8/14/24 @1910- Haldol (psychotropic) 5 mg IM, Benadryl (Antihistamine) 25mg IM, Ativan (sedative) 2 mg IM for agitation and EPS. 8/15/24 @1310- Thorazine (psychotropic) 50 mg IM and Benadryl IM, and physical hold for aggression and EPS. 8/15/24 @ 2218- Thorazine 25 mg IM, Benadryl 50mg IM, and Ativan 1 mg IM for severe aggression. 8/16/24 @ 1430- Thorazine 50 mg IM and Benadryl IM, physical hold and seclusion for aggression and EPS. A review of patient #6’s chart revealed there was no documentation on how the patient was monitored, assessed for adverse reactions, vital signs, or effectiveness of the psychotropic medication administered as a chemical restraint/ emergency behavioral medication (EBM) According to www.accessdata.fda.gov There is no specific antidote for Haldol or Thorizine. The possibility of respiratory depression and multiple drug involvement should be considered. Close medical supervision and monitoring should continue until the patient recovers. A review of the restraint packet revealed a section “Activity/Behavior During Seclusion and Activity and Behavior Post Seclusion.” The area allowed the writer to document the patient’s behaviors and activities for seclusion only. There was no specific place to put a nursing assessment of the patients in physical restraints, holds, or chemical restraint administration. There was no documentation of when the nurse returned to monitor the patient, how often, or for how long after patient #6’s chemical restraint administration. An interview was conducted with staff # 2 on 8/27/24. Staff #2 confirmed that there was no policy or process developed to determine how the patient would be monitored or assessed after the administration of a chemical restraint. Staff #2 stated that the patients are being monitored by the nursing staff however, there needed to be a place and process on how and where to document in the restraint record. 40989 Findings: Patient #7 was an 11-year-old female admitted to the facility on 8/09/2024 with a diagnosis of Disruptive Mood Dysregulation. A review of the document titled, “Restraint/Seclusion/Emergency Medication Order and Documentation” dated 8/10/2024 at 1945 (7:45 PM) by RN Staff #8 was as follows: “8/10/2024 ... Type of Intervention: Physical hold, Emergency Medication, and Seclusion. Medications: Zyprexa (antipsychotic) 5 milligrams (mg) Intramuscular (IM) for severe agitation and Benadryl (an antihistamine drug that has a sedating effect) 25 mg IM ...” A review of the medication administration record confirmed RN Staff #8 administered the emergency behavioral medication/chemical restraint on 8/10/2024 at 8:35 PM. A review of the restraint packet revealed there was no documentation of an assessment by the RN after the administration of the emergency behavioral medications/chemical restraint. An interview was conducted with Staff #2 on 8/27/2024 at 10:45 AM. Staff #2 confirmed the facility policy titled, “Restraint and Seclusion” did not instruct the RN when or how often to monitor a patient after the administration of a chemical restraint/emergency behavioral medication.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37325 Based on record review and interview the facility failed failed to protect the rights to receive care in a safe setting for 3 of 8 (Patient #1, #2,#3) patients. Patient #1 was on one-to-one staff observation for his sexually aggressive behavior. Patient #1 was assigned to be a roommate to Patient #2, a 5-year old who had also been ordered one-to one staff observational status due to his age and for his safety. Both patients were left by staff unsupervised for close to an hour on 02/11/24 when the younger patient was sexually assaulted by the older patient. 2. Patient #1 was administered Hydroxyzine 25mg PO as needed (PRN) medication on 02/05/24 at 06:38 PM. Patient #1 was administered Tylenol 325mg PO PRN on 02/06/24 at 02:13 PM. The medical record did not reflect the reason for the medication administration nor a response to the medication. Patient #3. On 02/05/24 the MAR reflected Patient #3 received Ibuprofen 400mg PO at 01:00 PM and 06:40 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented. Cross Refer Tag A0144.”

“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: 37325 Based or record review and interview the facility failed to provide care in a safe setting. 1. The Mental Health Techs (MHT) failed to provide one-to-one (1:1) observation for 2 of 2 (Patient #1 and #2) preadolescent patients that were ordered 1:1 staff observation as a precautionar measure for the patient’s safety. The patients were left unattended for 58 minutes, and an 8-year-old male performed oral sex on a 5-year-old male. 2. After administering as needed (PRN) medication to 2 of 8 patients (Patient #1 and Patient #3) nursing staff failed to document the reason for the medication administration or a patient response. Findings included: 1. The Preliminary Summary of the investigation reflected on 02/11/24 at 01:30 PM Patient #2 made an outcry to Personnel #7 that Patient #1 had placed his mouth on Patient #2’s penis while sitting on the bed in room 220. The Preliminary Summary of the investigation reflected...”pt (Patient #1) stated ‘I did, but I don’t know why?’...” Patient #1, an 8-year-old male was admitted to the facility on 02/04/24 according to the patient information face sheet. The Physician Orders dated 02/07/24 at 03:29 PM reflected...”1:1 (observation). SAO (sexually acting out)...”. The Physician Orders for 02/08/24, 02/09/24, 02/10/24 and 02/11/24 reflected the orders for 1:1 observation were renewed. Patient #2, a 5-year-old male, was admitted to the facility on 02/07/24. The Physician Orders dated 02/07/24 at 05:25 PM reflected...”1:1 for safety/age...” The Physician Orders dated 02/09/24, 02/10/24 and 02/11/24 reflected the order for 1:1 observation was renewed. A review of camera footage for the pediatric unit reflected on 02/11/24 at 11:56 AM Patient #1 and Patient #2 entered room 220 for a nap. The video did not reflect any adults entered the room to provide 1:1 observation. Personnel #7, assigned to provide 1:1 observation to Patient #2, and Personnel #8, assigned 1:1 observation of Patient #1, sat at a table in the day area in front of the nursing station. There was not a direct line of sight into room 220 from the table where Personnel #7 and Personnel #8 sat. At 12:04 PM a MHT briefly entered room 220 and then walked back out. Personnel #8 handed Personnel #7 their observation sheet at 12:48 PM and Personnel #8 exited the unit. Personnel #7 continued to sit at a table in the day room. The video reflected Patient #2 exited room 220 at 01:02 PM and Personnel #7 returned Patient #2 to room 220 at 01:07 PM. The video reflected that patient #1 exited room 220 at 01:18 PM and leaned against a chair in the day room. The video reflected Patient #2 exited the room at 01:19 PM and approached the nurse’s station. At 01:30 PM Personnel #9 was observed leaving the nurse’s station and walking toward the day room and Patient #1 and Patient #2. There was no evidence that any staff was in direct visualization with the patients between 12:04 and 01:02 and observed them according to the physician-ordered precaution level. The facility’s policy titled Patient Observations, reviewed 08/11/22 reflected...”One-to-One Observation(1:1) Patients on 1:1 observation require continuous around the clock supervision until discontinued by a physician’s order. Staff assigned to perform 1:1 observation shall maintain continual visual observation with the ability to immediately respond...” During an interview on 02/14/24 beginning at 10:36 AM Personnel #1 stated that Personnel #7 and Personnel #8 assigned to provide 1:1 observation for Patient #1 and Patient #2 did not follow hospital policy. Patients #1 and #2 should have been in Personnel #7’s and Personnel #8’s line of sight at all times. Personnel #1 stated that when Personnel #8 exited the unit, Personnel #9 should have taken their place for 1:1 observation. Personnel #1 stated when Patient #2 approached the nurse’s station at 01:30 PM he told Personnel #7 that Patient #1 had touched him inappropriately. 2. Patient #1. On 02/05/24 the Medication Administration Record (MAR) reflected Patient #1 received Hydroxyzine 25mg PO (by mouth) at 06:38 PM. The medication was not listed on the PRN (as needed) and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented. On 02/06/24 the MAR reflected Patient #1 received Tylenol 325mg PO at 02:13 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented. Patient #3. On 02/05/24 the MAR reflected Patient #3 received Ibuprofen 400mg PO at 01:00 PM and 06:40 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented. The policy titled Medication Management reviewed 01/2024 reflected...”4.2 The nurse who administers the ‘PRN’ medication will document, in the appropriate section of the patient record, the purpose for which the medication was given. During an interview on 02/14/24 at 03:02 PM Personnel #2 verified the above findings.”