Cross Creek Hospital

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 47893 Based on review of documents and interview, the hospital failed to ensure the effective operation of the grievance process when the facility neither acknowledged nor made attempt to resolve a complainant’s concerns regarding quality of care as the facility policy required for 1 of 3 patient grievances reviewed (Patient #2). Findings were: A Complaint and Incident Intake (CII) submission, on behalf of Patient #2, alleged complaints had been filed via email; an attempt was made to contact the patient advocate by phone; a voicemail was left for the patient advocate; and certified mail was sent to the facility’s Chief Executive Officer (CEO). The complainant has not received any acknowledgement or response from the facility. Review of facility complaint/grievance logs for May through July 2026 reflected no complaint/grievance made on behalf of Patient #2. Review of the facility policy titled “Grievance, Patient, PR 010,” effective 01/2026, documented in part, “POLICY ... All patients and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by facility or medical staff ... The Governing Board has appointed the Patient Advocate the responsibility to execute the grievance program, in conjunction with the Grievance Committee. The Governing Board has established the membership of the Grievance Committee to include the Chief Executive Officer (CEO), Medical Director, Patient Advocate, Chief Nursing Officer (CNO), Director of Risk Management/Performance Improvement, Director of Clinical Services, and the Human Resources Director ... All patient grievances will be investigated and the results of the investigation reported back to the complainant ... ... A written complaint is always considered a grievance. This includes written complaints from an inpatient, a discharged patient, or a patient’s representative regarding the patient care provided, abuse or neglect, or the hospital’s compliance with the Conditions of Participation (CoPs) ...” In interview on the morning of 7/28/26, in a facility conference room, Chief Nursing Officer (Staff #2) and Director of Clinical Services (Staff #3) were not aware of a complaint or grievance regarding Patient #2, and reported that patient advocate, (Staff #12) was no longer employed by the facility. In interview on the morning of 7/28/26, in a facility conference room, Director of Risk Management (Staff #3) stated, The person in Quality Director position just started last week ... We all kind of stepped in. We are all advocates ... The Administrator in Training eventually assigned the patient advocate role to (Staff #11). In an interview on the morning of 7/28/26, in a facility conference room, Corporate Quality Director (Staff #8) reported that Patient Advocate (Staff #11) is new to the role, and should have returned all voicemail ... Administrator/CEO (Staff #1) was on leave February until the first part of May, 2026. Mail would have been routed to Administrator in Training. In a telephone interview on the morning of 7/28/26, Patient Advocate (Staff # 11) stated, “ ... it was the end of May or in June 2026 when I could access and start reaching out to voicemail messages (referring to the messages left on the phone of the previous Patient Advocate).” In an interview on the afternoon of 7/28/26, Administrator/CEO (Staff #1) stated she was out February 8 to May 7, 2026. Staff #1, when shown the certified mail receipt, confirmed the receipt was signed by front desk personnel. “It was probably (Staff #12), no longer employed by the facility, who was given the certified mail.””

“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: 47893 Based on review of medical records, interview, and review of facility policy, the facility failed to protect the patient’s right to make informed decisions about their care, as psychoactive medications were given to patient (#s 2, 4, and 5) without first obtaining the appropriate informed consents. This failure placed 3 of 5 patients (#s 2, 4, and 5) reviewed for informed consent at risk for not being involved in care planning and treatment decisions, and not being able to request or refuse treatment. Findings were: Review of medical record for Patient #2 reflected admission to the facility on 7/3/25 and discharge on 7/11/25. Review of Medication Administration Record (MAR) for July 2025, documented, in part, orders for Patient #2 to receive the following psychoactive medications, for which no consent was documented: - trazodone (Desyrel) 50 milligrams (mg) by mouth at bedtime (PRN - as needed) for insomnia was administered on 7/5/25, 7/6/25, 7/7/25, 7/9/25, and 7/10/25. - diazepam (Valium) 5 mg by mouth twice a day for anxiety was administered on 7/8/25 at 9:00 PM; 7/9/25 at 9:00 AM and 9:00 PM; and 7/10/25 at 9:00 AM. - haloperidol (Haldol) 5 mg by mouth twice a day for psychosis was administered on 7/8/25 at 9:00 PM; 7/9/25 at 9:00 AM and 9:00 PM; and 7/10/25 at 9:00 AM. The hospital failed to obtain consent from Patient #2 prior to administering the following medications: - Patient Own Medication (Home Med), Caplyta 42 mg by mouth daily for mood was started on 7/4/25 at 9:00 AM; however, consent was not signed until 7/10/25; medication was documented as not given on 7/9/25 and 7/10/25. - lithium carbonate (Eskalith CR) 450 mg by mouth twice a day for mood, started on 7/8/25 at 9:00 PM, was administered on 7/9/25 at 9:00 AM and 9:00 PM; and at 9:00 AM, prior to obtaining consent at 11:00 AM on 7/10/25. Review of medical record for Patient #4 reflected admission to the facility on 5/19/26 and discharge on 6/25/26. Review of MAR for June 2026, documented, in part, orders for Patient #4 to receive the following psychoactive medications, for which no consent was documented: - aripiprazole - LAI (Abilify Maintena *Patient Own Med* long acting injection 400 mg (1 SUSER SYR) intramuscularly monthly for schizophrenia was administered on 6/12/26 at 2:31 PM. - olanzapine ODT (orally disintegrating tablet) Zyprexa Zydis 5 mg by mouth every 6 hours for agitation, started on 7/11/26 at 6:01 PM, was administered 15 times between 12:01 AM on 7/12/26 and 6:01 AM on 7/16/26. Review of medical record for Patient #5 reflected admission to the facility on 5/18/26 and discharge 5/27/26. Review of MAR for May 2026, documented, in part, orders for Patient #5 to receive the following psychoactive medications: - Risperdal 1 mg by mouth One Time Only for schizophrenia was first administered on 5/19/26 at 10:31 AM; however, consent for Risperdal was not obtained until 5/25/26 at 9:00 AM. - Risperdal 2 mg twice a day for schizophrenia was started 5/20/26 at 9:00 AM and discontinued 5/25/26 at 11:53 AM. - Risperdal 2 mg twice a day for schizophrenia was started 5/25/26 at 9:00 PM and discontinued 5/26/26 at 3:25 PM. - Risperdal 2 mg twice a day for schizophrenia was started on 5/26/26 at 9:00 PM and discontinued on 5/26/26 at 9:00 PM. - Patient Own Medication (Home Med), Uzedy (Risperidone), long acting injection, 100 mg IM every month was administered 5/26/26 at 9:00 AM. - Trileptal 150 mg by mouth twice a day for dysphoric mood was started 5/22/26 at 9:00 PM; however, consent was not obtained until 5/25/26 at 9:00 AM. Trileptal 300 mg by mouth twice a day was started 5/24/26 at 9:00 PM and discontinued on 5/27/26 at 11:28 AM. In interview on the afternoon of 7/28/26, in a facility conference room, Chief Nursing Officer (Staff #2) confirmed: - for Patient #2, no consent was found for trazodone HCL (Desyrel). - for Patient #2, no consent was found for diazepam (Valium). - for patient #2, no consent was found for haloperidol (Haldol). - for Patient #2, Caplyta was administered daily from 7/4/25 to 7/8/25; however, consent was not obtained until 7/10/25. - for Patient #2, lithium carbonate, (Eskalith CR) was first administered on 7/8/25 at 9:00 PM; however, consent was not obtained until 7/10/25 at 11:00 AM. - for Patient #4, CNO confirmed no consent was found for the administration of Ability long acting injection on 6/12/26. - for Patient #4, CNO confirmed no consent was found for the administration of Zyprexa Zydis every 6 hours for agitation between 6/12/26 ant 6/16/26. - for Patient #5, CNO confirmed Risperdal was first administered on 5/19/26; however, consent was not obtained until 5/25/26. Trileptal was started on 5/22/26 for dysphoric mood; however, consent was not obtained until 5/25/26. In interview on the afternoon of 7/28/26, in a facility conference room, Chief Nursing Officer (Staff #2) stated, “It was brought to my attention that some nurses think medication continued from home (Patient Own Medication - Home Med) means medication does not require consent. All psychoactive medications require consent.” Review of facility policy titled, “Informed Consent, Medication, PR 032,” effective 01/2026 documented in part, “POLICY All patients who have psychotropic medication ordered and legal representatives of patients who have psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication. Except in emergency situations or cases of court ordered medication, informed consent will be obtained prior to administering psychotropic medication. PROCEDURE - The requirement for informed consent applies to psychoactive medications, consent must be obtained for each individual medication, not by medication class. - Informed consent will be secured prior to the initial dose of medication except in an emergency ...””

“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: 31690 The facility failed to ensure that the hospital had an organized nursing service that provided 24-hour nursing services as evidence by: 1. Based on review of documentation and interview the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient, Patient #1, in accordance with current standards of practice. An RN failed to reassess a patient based on the patient’s needs and acuity, failed to ensure that a patient was provided q15 minute observations as ordered by the physician and determined in the treatment plan, and failed to ensure that patient observations were monitored and documented as ordered. Cross refer to A0395 RN Supervision of Nursing. 2. Based on interview and record review the facility failed to provide appropriate treatment for a patient, Patient #1, at risk for suicide when his refusal of medications, barricading himself in his room, and the treatment team were planning to get a court order requiring the patient to take his medications, were not addressed in the treatment plan. The patient barricaded his room the following night and committed suicide. Cross refer to A0396 Nursing Care Plan.”

“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: 31690 Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient in accordance with current standards of practice. An RN failed to reassess a patient, Patient #1, based on the patient’s needs and acuity, failed to ensure that a patient was provided q15 minute observations as ordered by the physician and determined in the treatment plan, and failed to ensure that patient observations were monitored and documented as ordered. Findings included: Review of the Texas Board of Nursing rule §217.11. Standards of Nursing Practice reflected: (1) “Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ... (D) Accurately and completely report and document: (i) the client’s status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client’s status; ...” Review of the facility policy “ObservSmart Rounding Policy”, last reviewed/revised 1/2023, reflected: “ ...5. Unit Nurse: The unit nurse is responsible for ensuring all assigned staff are meeting the hospital’s compliance goals. This is best accomplished by completing his/her assigned rounding while monitoring the feedback bar of their assigned staff throughout the shift. Entering information onto the compliance log and giving constructive feedback ensures that every employee is working to improve patient safety outcomes as stated in the PI Plan. 6. Rounders: It is the responsibility of each BHT [Behavioral Health Technician] to assure the previous BHT has logged out. If not, it becomes the oncoming BHT responsibility to log out previous BHT and log themselves in. 7. Routine Rounds: Regular 15 minute [sic] safety rounds are done throughout each shift on every patient until the patient is discharged. Patients admitted through Admissions to an inpatient unit will be passively logged out during the admission process. Active rounds will begin once the patient is escorted to his/her assigned unit. At that time, the unit BHT will immediately login the patient and begin rounding. 8. Bedroom Observations: Staff must, always day or night, enter the patient’s room to ensure their wellbeing by monitoring for breathing (rise/fall of the chest) prior to confirming an observation ...” Review of Patient #1’s medical record reflected “a 54-year-old man with bipolar I disorder (current episode depressed with psychotic features) and alcohol dependence, was admitted involuntarily on 15 June 2025 for active suicidal ideation and converted to voluntary status the following day. His medical history included COPD, hepatitis C, cirrhosis complicated by hepatocellular carcinoma, hypertension, pancytopenia and thrombocytopenia. Ongoing conflict with his sister over their father’s care was a significant psychosocial stressor. He had two prior suicide attempts earlier in 2025 and an extensive history of psychiatric and substance-use treatment.” Review of physician order, dated 6/15/25 at 9:00 am reflected “Suicide Risk - Moderate per orders...” Review of Patient #1 nurse’s note, dated 7/2/25 02:27 am, reflected the following “ ... Became agitated. He blocked his room with another bed to prevent staff from monitoring him. In and out of his room Pacing. and paranoid. monitored and redirected. Will continue to monitor.” Review of the nurse’s note, dated 7/3/25 at 08:51, am reflected the following “ ... in and out of his room to the day room. AAOX4 (Alert And Oriented times 4). denies SI (Suicidal Ideations), HI (Homicidal Ideations), or AVH (Auditory Visual Hallucinations). Blocked his door again, but this time he is just quietly doing it because of his delusions and Paranoia. Compliant with all his medications. will continue to monitor. @2100 (9:00 pm) Pt. went to the dayroom get some drink give his medications. 2130 (9:30 pm) came back to the day room and ask for his Permethrin cream. I told him I don’t have it for the moment i will just bring it to his room 2200 (10:00 pm) knocking at his door told him I got his cream he push [sic] back the door when I open it. Start cursing. 12 MN (12:00 am) tech informed me that he start [sic] barricading his room. ask another Tech for help and tried to open it but failed. inform supervisor [sic] 0300 (3:00 am) Tech last felt that he was pushing back [sic] 0430 (4:30 am) 2 tech were able to unlock the door and notify Rn seen pt. on the floor upon assessment. I ran to tell the supervisor that we have a code blue. 0431 (4:31 am) called code blue 0435 (4:35 am) CPR started. 0438 (4:38 am) called 911 0445 (4:45 am) EMS arrived a took over CPR. 0502 CPR stopped.” The patient was deceased. Review of the Patient #1’s monitoring sheet, dated 7/3/25 night shift, reflected the patient was on q15 minute observations with fall precautions and suicide risk-moderate. Documentation from 12:00 am-04:53 am reflected the patient was in his bedroom and the patient was asleep. There was no documentation related to the patient being barricaded in his room and the tech was unable to visualize the patient. During an interview, on the afternoon of 7/9/25, Staff #12, MD, reported that she was not notified about Patient #1 barricading himself in his room. She continued that had she known she would have increased his observations. When asked if staff typically notify her during the night about patient issues, she reported that none of the nurses have any problem calling her. She continued that the nurses will even call her if one of the other physicians doesn’t answer. During an interview, on the morning of 7/9/25, Staff #6, House Supervisor, reported that on the night of the incident he was not told about the Patient #1 barricading his room. He continued that he made rounds around 1:00-1:30 am on that unit and that he spent most of the night working at the nurses’ station for that unit. He continued that around 4:30 am the nurse “called me to tell me that the patient was found on the floor and to call a code. The patient was on the floor, and there was no pulse. The tech cut the scrubs off the patient’s neck because they were wrapped so tight. When EMS [Emergency Medical Services] arrived, they took over the code.” During a telephone interview, on the morning of 7/9/25 and the afternoon of 7/10/25, Staff #5, BHT, reported that around midnight she noticed that Patient #1 had barricaded himself in his room. She continued she and the nurse, and another tech tried to get the door open but couldn’t. “I told the nurse to let the house supervisor know what was going on. Later in the night she just acted like nothing was going on. At around 4:30 am I told her that we need to get the house supervisor. [Staff #7] asked what was going on and then he got the door open.” When asked why she was documenting that she saw the patient she reported that “When I kept trying to go into his room his beacon would trigger that I was with him. I put that he was asleep so it would keep me up with my patients. I was relying on my nurse to get help and she didn’t follow through.” During a telephone interview, on the evening of 7/8/25, Staff #7, BHT, reported that he was working on another unit the night of the incident. He had gone to the geriatric unit to have his lunch. He overheard the staff discussing the patient barricading himself in his room and that they couldn’t get him to open the door. At this point he went to the patient’s room and pushed the door until he was able to get into the patient’s room. At this point he saw the patient on the other side of the bed. He told the nurse to call a code. He reported that the patient had wrapped his scrub pants around his neck. It was so tight we had to cut it off in three spots for the nurses to be able to perform CPR. During an interview, on the afternoon of 7/9/25 Staff #1, CNO verified these findings.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 31690 Based on interview and record review the facility failed to provide appropriate treatment for a patient ,Patient #1, at risk for suicide when his refusal of medications, barricading himself in his room, and the treatment team were planning to get a court order requiring the patient to take his medications, were not addressed in the treatment plan. The patient barricaded his room the following night and committed suicide. Findings include: Review of Patient #1’s medical records reflected the patient is a 54-year-old male admitted involuntarily following medical clearance at another facility due to active suicidal ideation with a specific plan to harm himself using a cleaver. Review of the physician orders dated 6/15/25 at 08:00 reflected “Observation Q 15-Suicide Mod QSHIFT_12 HOURS Suicide Risk - Moderate per orders, Request Type: Now”. No new orders were found related to observations. Review of physician progress notes, dated 6/27/25, reflected “Reportedly he asked his sister to bring a gun so he can shoot himself. He is still isolating refusing to take the antipsychotics. According to the staff he was calling a lawyer, and he was preoccupied about it. No management problems noted.” No new orders for patient monitoring were found. Review of the nurse’s note dated 7/2/25 reflected in part “Pt. report PTSD [post-traumatic stress disorder] and Anxiety 8/10 observed to have hallucinations when he ran into another Pt’s room saying, “they are here”, inability to sleep. Pt. refused his Trazadone. Became agitated. He blocked his room with another bed to prevent staff from monitoring him. In and out of his room Pacing. and paranoid. monitored and redirected. Will continue to monitor.” Further review of an addendum nurse’s note, dated 7/2/25 at 02:27, reflected “Pt Pacing going to another Pt’s room. Redirected at times. He blocked his room with the extra bed preventing staff to monitor him. Staff opened his room and sat at his door to monitor. Pt. become agitated keep banging his door trying to block his door. Supervisor notified. Advised to call on call MD for order. Called On call Doctor at 0105. Ordered PRN meds IM. Pt, explained of the action of the medication and consented without struggle. Gently and carefully administered to his right ventrogluteal without any struggle. Pt. still get up out of bed Pacing in the hallway. Redirected when needed. Vitals refused. Will continue to monitor.” Further review of Patient #1’s treatment plan showed no increase in monitoring or change in care plan after this incident. Review of the Physician discharge summary, dated 7/3/25, reflected in part: “The team decided that he was doing better and decided was decided to be discharged. His sister was supposed to pick him up and he asked his sister to bring him a gun, as he believed people were waiting for him outside the hospital, when she comes to pick him up. His discharge was canceled because the team and the sister felt it was not safe for him to discharge and the discharge was canceled. Patient was delusional that all his family members were slaughtered, and it was coming on the news. It was explained that family was in contact, and they were safe, but he was paranoid. He was recommended long-acting injection, but he refused and agreed to take it by mouth. At that point team decided to do involuntary and file opc (order of protective custody) and get court-ordered medications if he refuses. Due to his paranoia and delusions his discharge was canceled 2nd time, and he was started on Invega 6 mg at HS because of his delusions. He started taking for couple of days. His sister was happy about it. His sister he was kept updated during his stay. He was also started on permethrin topical for scabies and his room was blocked he was barricading himself in his room. He was agitated and he was given emergency medications on 7/01. On 07/03 he was found unresponsive in the early hours. The writer was notified in the morning. Staff called 911 and did CPR but was unsuccessful and they were not able to revive, and he was pronounced dead.” During an interview, on the afternoon of 7/9/25, Staff #12, MD, reported that she was not notified about Patient #1 barricading himself in his room. She continued that had she known she would have increased his observations. When asked if staff typically notify her during the night about patient issues, she reported that none of the nurses have any problem calling her. During an interview, on the afternoon of 7/9/25 Staff #3 reported that there was no incident report or notification related to Patient #1 barricading his door reported. During an interview, on the afternoon of 7/9/25, Staff #1, CNO, verified these findings.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47893 Based on review of facility documents, clinical record review and interview, the facility failed to ensure 1 of 2 patients (Patient #1) had the right to participate in the development and implementation of his or her plan of care. Findings included: Facility document titled, “Patient Rights,” dated 01/2024, stated in part, “The right to participate actively in the development and periodic review of an individualized treatment plan (extending to a parent or conservator of a minor, and the legal guardian of the person, when applicable) ... Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate ...” Review of patient #1’s clinical record revealed: - Laboratory report for a blood specimen collected 12/17/24, documented in part, “ ... Current Result and Flag: Potassium 8.0 mEq/L [milliequivalents per Liter, a normal potassium 3.5-5.2 mEq/L], Critical ... Reference Interval (3.5 - 5.2) ...” -“Physician’s Order,” dated 12/18/24, documented in part, “ ... Request Type: NOW, Comments: STAT (immediate) EKG (electrocardiogram - a test that measures the heart’s electrical activity), Indication: hyperkalemia (a high level of the electrolyte potassium in the blood) ...” - “Nursing Note,” dated 12/19/24, documented in part, (an undated and untimed) “Addendum: Patient refused EKG x 2 (twice). Vital signs WNL (within normal limits). Medical provider notified will continue to monitor.” - “Interdisciplinary Treatment Plan Master Sheets,” dated 12/15/24, documented in part, “ ... (undated) Problem: Impaired metabolism related to hyperkalemia as evidenced by medical history of K+ (potassium) 8.8 ... Patient Assets (Strengths) included:, “patient #1 [a minor] reports [parent] is supportive ...” Review of patient #1’s clinical record revealed no documentation of parent’s participation in the development and implementation of patient #1’s plan of care (including notification of parent regarding laboratory results and patient refusal of EKG test), until 12/20/24, when patient #1 was discharged. In interview on the morning of 2/18/25, in a facility conference room, (Staff #1), Nurse Manager stated, “Labs 12/17/24 - potassium 8.0, labs 12/18/24 - potassium 8.8. 12/20/24 - [Patient #1’s parent] on the way to pick up [patient #1] for discharge, notified [patient #1] needed to go to hospital per physician’s order for critical lab value.” In interview on the afternoon of 2/18/25, in a facility conference room, (Staff #10), Chief Nursing Officer (CNO) stated, “In discharge care plan, brought up to [patient #1’s parent] about patient refusing EKG twice ...””

“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: 47893 Based on review of clinical record, review of facility documents, staff interview, and review of accepted standards of practice, the facility’s Nursing Services failed to provide care in an organized manner when, Patient #1’s nursing progress notes did not indicate when labs were drawn, when STAT labs were ready to be picked up by the lab, and STAT EKG was refused by Patient #1, a minor without notification to their parent. Facility policy and procedures for documentation were not implemented. The current nursing practices placed patients at risk of critical laboratory findings not being communicated or addressed and delay in the diagnosis and treatment of medical conditions before symptoms develop or worsen. Findings included: Patient #1’s clinical record revealed: -an order for a routine blood draw, Comprehensive Metabolic Panel (CMP- provides information about metabolism and certain chemicals in your body) on 12/16/24 at 7:00 am, per lab documentation, this sample was collected on 12/17/24 at 6:23 am. CMP was viewed by the provider on 12/18/24 at 4:23 pm with a critically high potassium value of 8.0 mEq/L [milliequivalents per Liter, a normal potassium 3.5-5.2 mEq/L]. According to the lab documentation, this critical lab resulted at multiple dates and times, as early as 12/18/24 at 6:35 am and as late as 12/19/24 at 6:35 pm. There was no nursing progress note on when the lab was drawn and no critical lab result notification documented by the nursing staff. -on 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7 (Basic Metabolic Panel - provides information about fluid balance, metabolism, and how well your kidneys are working). The lab report revealed the sample was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am (about 44 hours later). BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L. There was no nursing progress note when the lab was drawn nor that the lab was notified there was a stat lab ready to be picked up. -on 12/18/24 at 4:30 pm, a STAT EKG was ordered with an indication of hyperkalemia; however, this EKG was not completed. Nursing note by Staff #5, RN, dated 12/19/24, stated in part, “Addendum (undated and untimed): Patient refused EKG x2. Vital signs WNL. Medical provider notified will continue to monitor.” There was no documentation Patient #1’s parent or guardian, was notified of the provider’s ordered EKG. In an interview on the afternoon of 2/18/25, Staff #5, RN, stated, the “MD and parent” should be notified if a minor refused an EKG. Staff #5 reported they completed the addendum later on the afternoon of 12/19/24 and verified there was no date and time when the addendum was completed. In an interview on the afternoon of 2/18/25, Staff #10, Chief Nursing Officer, stated, “On 12/19/24, (Patient #1) refused EKG twice ... In discharge care plan, brought up to mother about patient refusing EKG twice” and verified the parent was not notified when Patient #1 refused EKG. Review of the facility provided policy, “Compliance with Accurate and Timely Documentation Policy,” (undated) documented in part, “ ... Policy Statement: It is the policy of the hospital that all documentation must be accurate, complete, and finalized before the end of the assigned shift. This ensures continuity of care, compliance with regulatory standards, and maintenance of high-quality patient care... Timely Completion: Late entries must be clearly marked as such and include the date and time of entry...” Review of (undated) facility-provided procedures included: -Document titled “Lab Process Updates” stated in part, “#1 Nightshift will collect and prepare green bag with all labs. #2 A Progress Note Must Be Completed For All Lab Draws ... Document: # (number) of attempts, site, patient tolerance and/or if patient refused. #3 For Critical Labs, be sure to notify the physician but also complete the Critical Lab Note in [the electronic medical record] and complete the Critical Lab Log” - Document titled “Nursing Communication!!” stated in part, “2. Labs a. There is currently a request for a template to be made by [the electronic medical record software] so that lab draws can be documented. b. Until then, create a progress note ... below is an example: Location of draw (site): (Right arm, left arm ...); number of attempts: (1, 2, 3+); type of draw: (Venipuncture, Finger Stick, Other:___); gauze and bandage applied - yes or no; patient tolerance (good, fair, or poor); complications noted (none, bruising, hematoma, or other); interventions taken (if complications occurred: ____) ...Miscellaneous items: ...Critical Lab Books: a. ...Please make sure you are documenting critical labs. b. It is also good practice to make a note: CRITICAL LAB RESULT NOTIFICATION ...” According to NIH (National Institute of Health) National Library of Medicine, National Center for Biotechnology Information, “STATPEARLS, Hyperkalemia,” article found at ncbi.nlm.nih.gov, stated in part, “ ... Hyperkalemia defined as a serum or plasma potassium level above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5 mEq/L. While mild hyperkalemia is usually asymptomatic, high potassium levels may cause life threatening cardiac arrhythmias, muscle weakness, or paralysis ... The first test that should be ordered in a patient with suspected hyperkalemia is an ECG (electrocardiogram) since the most lethal complication of hyperkalemia is cardiac condition abnormalities which can lead to dysrhythmias and death ... Patients with hyperkalemia need cardiac monitoring, and nurses should be familiar with ECG features of hyperkalemia, which are often the first to appear...””

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 47893 Based on review of accepted standards of practice, clinical records, review of facility documents, and staff interview, the facility failed to ensure laboratory services were available 24 hours a day, for 1 of 1 patient (patient #1), when: A. A mechanism for reporting critical lab value results was not established and Patient #1 did not receive results of critical lab values timely. B. STAT labs were ordered and drawn on 12/18/24 but did not result until 12/20/24. The facility did not have a procedure for timelines for processing and reporting STAT labs. The facility’s failure to specify and operationalize timelines for reporting critical results place patients at risk of delayed medical diagnosis and intervention. Findings include: A. Review of patient #1’s clinical record revealed: -An order for a routine blood draw, Comprehensive Metabolic Panel on 12/16/24 at 7:00 am, was collected on 12/17/24 6:24 am. CMP was viewed by the provider on 12/18/24 at 4:23 pm with a critically high potassium value of 8.0 mEq/L. There were multiple dates and times that critical labs were resulted for this lab, as early 12/18/24 at 6:35 am and as late as 12/19/24 at 6:35 pm. At an unknown date and time, the lab report documented, “Called/faxed to Staff #11, RN on 12/19/24 at 3:54 pm for test Potassium.” Interview with Staff #1, Nurse Manager, on 2/19/25 revealed Staff #11 is an LVN and was not working on 12/19/24. Staff #1 was unable to determine when or whom the lab reported the critical result. The provider saw the critical lab value but there was no documentation this critical result was reported to patient care staff. -At 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7 which was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am. BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L. The provider saw the critical lab value but there was no documentation this critical result was reported to patient care staff. During an interview on the morning of 2/18/25, Staff #1, Nurse Manager, reported since Patient #1, the lab notifies her of any critical lab values and faxes reports to a central location, staffed by nurses 24 hours a day, 7 days a week. Policies or procedures related to timeframes for reporting critical lab values were requested and were not provided. B. Review of facility-maintained documents for the provision of laboratory testing services revealed a laboratory quick reference with contact information. There were no resources, processes, or policies, regarding the collection, courier pick-up, delivery, and timeframes for STAT specimens. Review of patient #1’s clinical record documented at 12/18/24 at 4:26 pm, the provider ordered a STAT BMP7. The lab report revealed the sample was collected on 12/18/24 at 5:29 pm but did not result until 12/20/24 at 9:35 am (about 44 hours later). BMP7 was viewed by the provider on 12/20/24 at 10:06 am with a critically high potassium value of 8.8 mEq/L. In interview on the morning of 2/18/25, in a facility conference room, Staff #1, Nurse Manager, reported procedures for specimen collection, handling and preparation for courier pickup was in place for STAT laboratory testing. Specimens for STAT testing are picked up by courier and delivered to a laboratory provider at another location; however, the facility did not provide information to indicate what time the courier picked up Patient #1’s sample nor when it was delivered to the processing lab. In an interview conducted the morning of 2/19/25, in a facility conference room, Staff #8, facility Medical Director, stated, “Prefer to receive STAT lab results within a few hours.” There were no policies or procedures related to timeframes for any specific tests, including the collection, courier pick-up, and delivery for STAT specimens.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 28421 Based on document review and interview, it was determined that the facility failed to comply with the Texas Administrative Code, Title 25, 414.404 (a)(2) regarding patient and/or legally authorized representatives participating in treatment planning. Findings were: Facility policy entitled “Treatment Planning” stated in part: “The nursing staff is responsible for developing the Initial Treatment Plan within twenty-four (24) hours of admission (TAC 411.47). The Treatment Plan shall be completed no later than seventy-two (72) hours after admission ... Patients (and/or their guardians when appropriate) will be invited to participate in treatment team meetings. The patient (or guardian/legally authorized representative) shall be given the opportunity to have input in the development of the Treatment Plan. This shall be accomplished by the clinical staff meeting with the patient to review the recommendations of the treatment team.” Review of the medical record of patient # 1 revealed no completed treatment plan within the designated 72 hour period. No parental involvement was noted. This was confirmed in an interview with the Director of Nurses on 10/28/24.”

“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: 28421 Based on document review and interview, it was determined that the facility failed to comply with the Texas Administrative Code, Title 26, 568.61 (c) (2) regarding informed consent for medications. Findings were: Facility policy entitled “Informed Consent” stated in part: “In accordance with state law and accreditation standards, a written, dated, and signed informed consent is obtained from the patient or the patient’s legal guardian (when applicable) for participation in or for the use or performance of the following: 1. Release of information 2. Authorization for admission, including, but not limited to: a. consent to treatment b. emergency medical and dental treatment c. disclosure of required HIV/AIDS testing d. consent to photograph 3. Use of audio-visual equipment 4. Medication which has potential for abuse (usually considered Schedule II medication) 5. Psychoactive Medication 6. Research medication and therapy (Cross Creek Hospital does not use research medication and/or therapy)” Review of the medication administration record dated 9/13/24 through 9/16/24 of patient # 1, revealed no documented consent for hydroxyzine (vistaril). This medication was given all three days. This finding was confirmed by the DON on 10/28/24.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 33326 Based on interview, record review, and observation the facility failed to promote safety, and detect hazardous events and circumstances when (1) one out of (7) seven patients medical records reviewed, after Patient #1 reporting an incident while in the facility, the facility did not complete an incident report for the incident. This failure places patients at risk of injury due to the the facility’s lack of tracking and analyzing all incidents. Findings include: An observation made on the morning of 4/16/24, in the inpatient conference room, revealed Patient #1 sitting in a chair wearing a long-sleeved light gray sweater; there were several small smears of bright red lines on the right sleeve and upper neck. Patient #1 had a dark red, approximately ½ cm (centimeter) wound to her left lower lip. During an interview, on the morning of 4/16/24, in the inpatient conference room, when asked about the stained sweatshirt and sore on the lip, Patient #1 stated in part, “My roommate (Patient #4) threw water on me, then held my face between her thighs, she started slapping my face with her thighs. She (Patient #4) said she did it to her previous roommate. She (Patient #4) tried to choke me and cut my lip; staff came in when I yelled; I was moved to another unit.” During an interview, on 4/16/24 at 10:00 am in the facility conference room, when informed of an incident on 4/8/24, between Patient #1 and Patient #4 and asked to see the incident report. Staff #1, CNO stated, I can’t find an incident report for 4/8/24. There should be an incident report.” Review of the facility provided policy Incident Reporting (Reviewed, 01/2020) reflected, “POLICY: It is the policy of Cross Creek Hospital to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss. 2.0 PURPOSE: The Incident Report is a risk management tool that raises awareness of potential exposures to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan. An “incident” is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. It results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility, or visitor(s) at the facility. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury up to death. The Incident Report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility. 3.0 PROCEDURE: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/workday. 3.1. Supervisor will review the Incident Report for legibility, completion, signature and date. Supervisor will notify Risk Manager of a serious incident as well as take the lead in investigating non-serious incidents. 3.2. The Incident Report will be routed to the facility Risk Manager within 24 hours of incident. 3.3. If the incident involves a patient, staff must chart relevant information in the patient’s medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an “error” or that an Incident Report was completed ...””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 33326 Based on record review and interview the facility failed to accurately document (1) one out of (7) seven medical records reviewed for having an incident while in the facility. The nursing staff did not document Patient #1’s facial injury. This failure placed a patient with injuries at risk of not being assessed, treated, and monitored for adequate healing. Findings include: Review of the facility provided policy, Documentation Protocol (reviewed 01/2023) reflected, “POLICY: Cross Creek Hospital records, reports, charts, and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided, patient interactions, and all financial records and transactions. Every staff who creates or reviews documentation in a medical record or responds to or implements orders or directives contained in a medical record, ensures the medical record complies with this Protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon. PURPOSE: To assure accurate and timely documentation; to provide a means of communication between healthcare providers; to provide a legal record to protect the patient, the facility and health care team; and, to provide information in the medical record for performance improvement. PROCEDURE: 1. All patient medical record entries are to be: o legible, o complete, o timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and consistent with facility policies and procedures ...” Review of Patient #1’s Nurse’s Note, dated 4/13/24 at 11:30 pm, reflected in part, “Lidocaine patch used for back pain. Patient was attacked by roommate.” The skin assessment did not indicate the bleeding lower lip. During an interview, on the morning of 4/17/24 in an administrative conference room, Staff #1, CNO (Chief Nursing Officer) was informed of Patient #1 reporting the event to the surveyor and the surveyor’s observations of her bloody shirt and busted lip. When asked where the nurse would document the event in the patient records. Staff #1, CNO stated, “He didn’t write the busted lip, he would have written it here. (indicating the nursing narrative.)”