Oceans Behavioral Hospital of Katy

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by the facility’s failure to ensure that the health and safety of patients were protected by providing care in a safe setting. The potential risks that were identified included: A. Fitted sheets with elastic bands. 48 of 48 beds on the unit had fitted sheets with a 1-inch-wide removable elastic band that could be used for hanging self or strangulation. Five patients were on active suicide precautions, 14 patients were on violent/homicide precautions, and one patient was on both suicide and homicide precautions. See A-0144 - Care in Safe Setting. B. Faucet over a sink in the “Treatment Room” of the Intake Department. Additionally, there was a faucet over a sink in the “Treatment Room” of the Intake Department that posed a significant safety issue as a ligature tie-off point for hanging self. A sheet was also found on the floor next to a chair in the Treatment Room. See A-0144 - Care in Safe Setting. C. Electrical outlet with no cover plate. There was an electrical outlet in bedroom 1710 with no cover plate, exposing live electrical wires. This posed a potential safety issue for 2 of 2 patients. See A-0144 - Care in Safe Setting. Collectively, these potential risks put all patients throughout the hospital at risk for harm, serious injury, and possible death.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure that patients were provided care in a safe setting. This failure was evidenced by: A. Fitted sheets with elastic bands. 48 of 48 beds on the unit had fitted sheets with a 1-inch-wide removable elastic band that could be used for hanging self or strangulation. Five patients (Patients #11, 15, 18, 24, and Patient #25) were on active suicide precautions, 14 patients (Patients #9, 10, 12, 13, 14, 16, 17, 19, 20, 21, 22, 23, 27 and Patient #28) were on violent/homicide precautions, and one patient (Patient #26) was on both suicide and homicide precautions. B. Faucet over a sink in the “Treatment Room” of the Intake Department. Additionally, there was a faucet over a sink in the “Treatment Room” of the Intake Department that posed a significant safety issue. The faucet could be used as a ligature tie-off point for hanging self by suicidal patients awaiting completion of the admission process. A sheet was also found on the floor next to a chair in the Treatment Room. C. Electrical outlet with no cover plate. There was an electrical outlet in bedroom 1710 with no cover plate, exposing live electrical wires. This posed a potential safety issue for 2 of 2 patients (Patient #23 and Patient #29). Findings were: Review of policy RTS-02, “Patient Rights Texas,” revised 9.1.2023, showed: “ ... You have the right to a clean and humane environment in which you are protected from harm ...” A. Fitted sheets with elastic bands. Staff D (RN Supervisor) provided a tour of the unit on 6.3.2026, 9:40am-10:30am. During the tour while assessing for mattresses that smelled of urine (as was alleged by Patient #7), it was observed that the mattresses in bedrooms 1604, 1606, 1703, 1705, 1708, 1709, 1710, and 1712 had fitted sheets with three main structural parts: corners, pocket depth, and a 1-inch-wide removable elastic band. The elastic band was attached to the body of the fitted sheet with stitching. Once the stitching is removed, the elastic band can be used for hanging self or strangulation. It was also noted during the tour that there were numerous fitted sheets in the clean linen closet. In an interview with Staff B (DPO) on 6.3.2026 at 10:15am, he stated that all 48 beds in the hospital had fitted sheets with an elastic band. He also stated he was aware that the fitted sheets were NOT psych-safe. Review of the “Ligature Risk Assessment / Reduction Action Plan,” dated 2.20.2026, showed that bed linen was listed under the heading of “Patient Rooms.” When the “Ligature Risk Assessment / Reduction Action Plan” was presented to the surveyor by Staff B (DPO), he stated he had “just now added” the bed linens to the document. In an interview with Staff D (RN Supervisor) on 6.3.2026 at 9:45am, he stated that the elastic band could “possibly be used as a ligature risk,” adding, “It would take time to get the band off.” In an interview with Staff O (Lead BHT) on 6.3.2026 at 9:50am, she stated the elastic band could be removed from the fitted sheet and used for self-harm. In an interview with Staff I (CEO) on 6.4.2026 at 11:45am, he stated he had taken a sheet apart and was surprised at what could be done with the elastic band. He also demonstrated how the elastic band could be removed by picking at and loosening the stitching. Patients on Violence/Homicidal Precautions and/or Suicide/Self-Harm Precautions. Patient #9. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #9 was in room 1602. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 6.3.2026 at 6:12pm showed Patient #9 is a 64-year-old female with schizoaffective disorder, bipolar type; dementia; confusion; aggression; agitation; impulsivity; and active suicidal ideation. Review of Physician Orders for Patient #9 showed Violence/Homicidal Precautions and Suicide/Self-Harm Precautions ordered on 6.3.2026. Patient #10. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #10 was in room 1603. Review of Inpatient Psychiatric Evaluation by Staff M (NP) dated 5.21.2026 at 11:35am showed Patient #10 is a 66-year-old involuntary female with severe paranoia, auditory hallucinations, crack cocaine use, HIV, and behavioral dysregulation. Diagnoses: bipolar I disorder, manic; severe methamphetamine use disorder; and severe polysubstance abuse disorder. Review of Physician Orders for Patient #10 showed Suicide/Self-Harm Precautions ordered on 5.20.2026. Patient #11. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #11 was in room 1605. Review of Inpatient Psychiatric Evaluation by Staff M (NP) dated 5.19.2026 at 9:35am showed Patient #11 is a 77-year-old involuntary female with worsening depression and suicidal ideation. Review of Physician Orders for Patient #11 showed Violence/Homicidal Precautions ordered on 5.19.2026. Patient #12. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #12 was in room 1607A. Review of Inpatient Psychiatric Evaluation by Staff M (NP) dated 5.31.2026 at 7:40am showed Patient #12 is a 79-year-old female with confusion and aggression (hitting, slapping, spitting). Diagnoses: major depressive disorder with psychotic features, Alzheimer’s with behavioral disturbances. Review of Physician Orders for Patient #12 showed Violence/Homicidal Precautions ordered on 5.30.2026. Patient #13. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #13 was in room 1607B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 6.1.2026 at 10:46am showed Patient #13 is a 62-year-old female with confusion and aggression. Diagnoses: bipolar disorder, type 1, mixed, severe and borderline personality disorder. Review of Physician Orders for Patient #13 showed Violence/Homicidal Precautions ordered on 5.30.2026. Patient #14. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #14 was in room 1611A. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.25.2026 at 11:01am showed Patient #14 is a 76-year-old female initially admitted voluntary, then changed to involuntary. She presented with confusion and aggression. Diagnoses: major depression and Alzheimer’s, severe, with behavioral disturbances. Review of Physician Orders for Patient #14 showed Violence/Homicidal Precautions ordered on 5.24.2026. Patient #15. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #15 was in room 1612A. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.29.2026 at 9:23pm showed Patient #15 is an 87-year-old female admitted following a suicide attempt with intentional overdose of an unknown quantity of oxycodone and hydrocodone. Diagnoses: major depressive disorder, moderate to severe, with suicidal ideation. Review of Physician Orders for Patient #15 showed Suicide/Self-Harm Precautions ordered on 5.29.2026. Patient #16. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #16 was in room 1613A. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.27.2026 at 8:16pm showed Patient #16 is a 73-year-old female admitted with agitation, mania, and psychosis. Diagnoses: schizoaffective disorder and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #16 showed Violence/Homicidal Precautions ordered on 5.26.2026. Patient #17. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #17 was in room 1614A. Review of Inpatient Psychiatric Evaluation by Staff M (NP) dated 5.22.2026 at 4:49pm showed Patient #17 is a 75-year-old involuntary female admitted with psychosis, delusions, aggression, insomnia, and worsening cognitive impairment. Diagnoses: bipolar I disorder, manic, severe and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #17 showed Violence/Homicidal Precautions ordered on 5.21.2026. Patient #18. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #18 was in room 1614B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.27.2026 at 7:52pm showed Patient #18 is a 77-year-old female admitted with depression and multiple suicidal statements. Diagnoses: major depressive disorder, severe and major neurocognitive disorder vascular type, mild to moderate. Review of Physician Orders for Patient #18 showed Suicide/Self-Harm Precautions ordered on 5.26.2026. Patient #19. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #19 was in room 1702. Review of Inpatient Psychiatric Evaluation by Staff M (NP) dated 5.22.2026 at 4:49pm showed Patient #19 is an 81-year-old involuntary male admitted with psychosis, delusions, aggression, and sexual inappropriate behaviors. He threatened to kill his son. Diagnoses: major depressive disorder and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #19 showed Violence/Homicidal Precautions ordered on 5.25.2026. Patient #20. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #20 was in room 1703. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.29.2026 at 1:05pm showed Patient #20 is a 78-year-old male admitted with poor impulse control, high level of aggression, attempts to hit staff, and confusion. Diagnoses: bipolar disorder, type II, depressed, severe and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #20 showed Violence/Homicidal Precautions ordered on 5.29.2026. Patient #21. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #21 was in room 1704. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.21.2026 at 2:34pm showed Patient #21 is a 78-year-old male admitted with psychosis, physical aggression, attempts to hit staff, and anger. Diagnoses: major depressive disorder, severe with psychotic features and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #21 showed Violence/Homicidal Precautions ordered on 5.20.2026. Patient #22. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #22 was in room 1707B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.28.2026 at 2:34pm showed Patient #22 is a 51-year-old male admitted with left-sided weakness following a stroke. He was agitated, aggressive and had poor impulse control. Diagnoses: major depressive disorder, severe and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #22 showed Violence/Homicidal Precautions ordered on 5.26.2026. Patient #23. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #23 was in room 1707B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.30.2026 at 4:18pm showed Patient #23 is a 63-year-old male admitted with aggression, attempts to hit staff, visual hallucinations, and confusion. Diagnoses: schizoaffective disorder, bipolar type, severe and Alzheimer’s with behavioral disturbance. Review of Physician Orders for Patient #23 showed Violence/Homicidal Precautions ordered on 5.29.2026. Patient #24. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #24 was in room 1711A. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.30.2026 at 3:43pm showed Patient #24 is a 35-year-old male admitted on an Emergency Detention status with numerous previous admissions. He had attempted suicide with approximately 90 buspirone pills. Diagnoses: schizoaffective disorder, bipolar type, severe and generalized anxiety disorder. He also had an autism spectrum disorder. Review of Physician Orders for Patient #24 showed Suicide/Self-Harm Precautions ordered on 5.29.2026. Patient #25. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #25 was in room 1714A. Review of Inpatient Psychiatric Evaluation by Staff N (NP) dated 6.3.2026 at 10:29am showed Patient #25 is a 89-year-old male admitted with suicidal and homicidal ideation and auditory and visual hallucinations. Diagnoses: major depressive disorder, generalized anxiety disorder, and adjustment disorder with depressive mood, severe. Review of Physician Orders for Patient #25 showed Suicide/Self-Harm Precautions ordered on 6.2.2026. Patient #26. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #26 was in room 1715B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 5.26.2026 at 12:40pm showed Patient #26 is a 62-year-old male admitted with suicidal ideation. He had wrapped a curtain around his neck and later wrapped a diaper around his neck in apparent attempt at self-strangulation. There had been sexual inappropriate behavior. Diagnoses: major depressive disorder and Alzheimer’s with behavioral disturbances. Review of Physician Orders for Patient #26 showed Suicide/Self-Harm Precautions and Violence/Homicidal Precautions ordered on 5.26.2026. Patient #27. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #27 was in room 1708B. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 6.1.2026 at 4:07pm showed Patient #27 is a 77-year-old male admitted with physical aggression, medication noncompliance, and confusion. Diagnoses: major depressive disorder and Alzheimer’s with behavioral disturbances. Review of Physician Orders for Patient #27 showed Violence/Homicidal Precautions ordered on 6.1.2026. Patient #28. Review of the 6.3.2026 7AM-7PM Census Form showed Patient #28 was in room 1604. Review of Inpatient Psychiatric Evaluation by Staff K (MD) dated 6.2.2026 at 9:15am showed Patient #28 is a 47-year-old female admitted with psychosis, paranoia, medication noncompliance, and drinking her own urine. Diagnoses: schizoaffective disorder, bipolar type, severe; chronic PTSD, and generalized anxiety disorder. Review of Physician Orders for Patient #28 showed Violence/Homicidal Precautions ordered on 6.1.2026. B. Faucet over a sink in the “Treatment Room” of the Intake Department. Following a tour of the unit on 6.4.2026 at 2:00pm to once more certify that the fitted sheets had been removed from the units, the surveyor was brought back to the conference room through the Intake Department. A room designated as the “Treatment Room” was observed. Inside the Treatment Room was a table, a chair, a sheet on the floor, and a faucet over a sink. The faucet had a gooseneck spout and two handles that could be used as a tie-off point, thus making it a ligature risk. The handles on the cabinets had been made ligature resistant. In an interview with Staff P (Intake RN) on 6.4.2026 at 2:05pm, she stated that registrations for admissions are conducted in the Treatment Room. When asked if patients are ever in the room alone, she stated, “It can happen. Typically, we try not to leave a patient in this room.” She also stated the patient might be in the room for 20 to 25 minutes. When asked if the patient can be monitored by video camera in the Intake Office, she stated that they could not. She also stated that the sheet found on the floor had been used by a previous patient. In an interview with Staff H (Quality Director) on 6.4.2026 at 2:10pm, he stated, “I know what she [Staff P - Intake RN] just told you, but we never leave patients alone.” Staff P (Intake RN) reiterated what she had said, “Only for very short periods of time.” Review of the “Ligature Risk Assessment / Reduction Action Plan,” dated 2.20.2026, showed: “Severity Scale: 1 = Low Risk. Surveillance and observation are considered when determining level of risk. All level 1 risks require raising staff awareness and/or in-servicing at minimum ... Front Exam Room. Faucet - severity 1. Mitigation Plan - Raise staff awareness / in-service. Comments - Under constant supervision. Patients are never left alone.” Review of MedlinePlus, a resource of the U.S. National Library of Medicine, “Brain cells are very sensitive to a lack of oxygen. Some brain cells start dying less than 5 minutes after their oxygen supply disappears. As a result, brain hypoxia can rapidly cause severe brain damage or death.” According to the University of California, Santa Barbara’s UCSB ScienceLine website, the brain can withstand three to six minutes without oxygen before brain damage occurs. Further review of “Incidence and Method of Suicide in Hospitals in the United States,” November 2018, the Joint Commission, outlines the following needs: Ligature fixture point, Ligature, and Time alone. . . 38015 C. Electrical outlet with no cover plate. Observation on 6/3/26 at 10:10 am of room 1710 showed there was an electrical outlet present which was missing its cover plate. This exposed potentially dangerous live electrical wires to the two residents currently residing in the room. In addition, the exposed outlet was visible from the hallway and other patients passing by the room on self-harm precautions might have noticed the exposed outlet when passing by the room. In an interview at the time of findings, Nurse Supervisor Staff #D, who was present in the room, acknowledged this was a safety hazard and promptly informed the director of plant operations to have the outlet fixed.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure 1 of 2 patients’ needs were met by nursing (Patient #1), as evidenced by: -A three-day delay in wound care treatment, and; -No incident report created with subsequent investigation of patient’s injuries after a family member observed patient’s condition and called 911. Findings included: Review of facility policy #NSG-39 titled “Skin/Wound Care”, last revised 10/1/23, showed that its purpose was to identify skin abnormalities and provide interventions and management for all patients upon new skin assessment findings. Wound care would then be implemented as ordered by the physician and non-physician practitioner. In addition, it stated that wounds would be photographed and located in the patients’ medical record. Review of facility policy #QAPI-004 titled “Incident Reporting”, last revised 5/1/26, showed that its purpose was to document any potential or adverse incident within the facility, including incidents involving patients. The incident would then be investigated by hospital leadership, then reviewed and discussed in “Flash” (meeting) the following day. Record review of Patient #1’s clinical chart showed the following: 79-year-old male admitted involuntarily to facility on 4/28/26 under Dr. Staff #L, due to increased anxiety, worsening aggression, and suicidal ideation with a verbalized plan to harm himself. His primary diagnosis was Major Depressive disorder with psychotic features. Initial History & Physical Exam skin assessments by PA-Staff #A showed there were no bruises, rashes, or lesions on his forearms, just older scars present. Initial Nursing Assessment on 4/28/26 plus Daily Nursing Shift skin assessments starting 4/28/26, up to and including the day shift on 5/4/26, showed there was no evidence of skin tears or wounds. Wound Care Assessment on 4/29/26 showed “No evidence of skin tears or bruising”. Then, on the 5/4/26 Daily Nursing Shift’s evening skin assessment, it showed “Wounds-see packet”. Review of provider progress notes on 5/5/26 by PA Staff #A showed “ ...skin tears of different states of healing”. Review of provider orders on 5/5/26 by PA Staff #A showed that wound care orders were made to treat the skin tears on both arms. However, wound care was not initiated until 5/8/26, and this was when wound care nursing documented the first wound care treatment. In addition, there were no photographs of the patient’s wounds in the medical records as required by facility policy. On 5/9/26, a family member of Patient #1, after previously observing the patient and becoming alarmed, called 911. EMS and police arrived at the facility and spoke with the patient. However, there was no incident report created by facility, followed by an investigation by facility afterwards. In an interview on 6/4/26 at 1:45 pm, DON Staff #G confirmed that wound care for the patient did not start until three days after the orders were made and acknowledged that care should have been started sooner. In addition, Staff #G confirmed there was not an Incident Report created but there should have been one in response to the 911 call event where police and EMS arrived at the facility for Patient #1. An investigation following an incident report could have helped facility identify the delay in treatment and possibly prevent future occurrences by determining the cause for delay.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by failure to ensure patients were provided a safe environment. More specifically, A) The facility failed to ensure that patients on Violence/Homicidal Precautions were using wheelchairs with metal armrests that could not be removed by the patient. Due to this failure, Patient #4 used the metal armrest of his wheelchair to try to burst the plexiglass window at the nurse’s station and tried to assault staff with it. This occurred on 7.17.2025. Three days earlier (7.14.2025) Patient #4 warned staff that he could use the wheelchair armrest as a weapon to “beat you to death.” No actions were put into place to mitigate this danger. Additionally, on 9.16.25, 6 of 8 patients (Patient #6, 7, 8, 9, 10, and Patient #11), on Violence/Homicidal Precautions, were observed in wheelchairs that had removable metal armrests - armrest that could have been used as a weapon to physically harm patients and staff. Two other patients (Patient #12 and Patient #13), on suicidal precautions, were observed in wheelchairs with removeable armrests. There were 22 other patients on Violence/Homicidal Precautions that were not using wheelchairs. Under the right circumstances, any one of these 22 patients could have gained access to these potentially dangerous metal armrests. Any one of 48 patients and staff had the potential to be harmed by a patient wielding a removable metal wheelchair armrest. See A144 - Patient Rights: Care in a Safe Setting. B) The facility failed to ensure that a patient (Patient #4) with a history of criminality and violence was safely screened in the Admission’s Department. Due to this failure, the safety of elderly patients and staff was compromised when Patient #4, a patient having served a 25-year prison sentence for criminal assault, removed the metal armrest of his wheelchair and attempted to break the glass enclosing the nurse’s station. He then wielded the armrest, attempting to strike staff with it. Note, the patient had been treated at another psychiatric facility just prior to this admission. At that facility, he kicked out a glass window, lacerating his right ankle. He then took a piece of the glass and threatened to cut his wrist. Following the incident, he was transferred to an emergency room for medical treatment. The transfer facility refused to allow him to return. See A144 - Patient Rights: Care in a Safe Setting. (C) The facility failed to ensure that all safety measures were utilized to protect Patient #4 from harming himself and others. Due to this failure, the patient was not administered an emergency medication during his restraint and escort to the seclusion room, following an incident in which he attempted to break the glass enclosing the nurse’s station with the metal armrest of his wheelchair. He continued to threaten staff. The facility did not administer an emergency medication - a treatment permitted by the law and designed to keep patients and staff safe. Shortly thereafter, the administrative staff phoned 911 for assistance in controlling the patient. This failure could have compromised the safety of patients and staff on the unit. See A144 - Patient Rights: Care in a Safe Setting. (D) The facility failed to thoroughly investigate an incident where a patient (Patient #1) was struck in the face. Additionally, the facility failed to ensure increased protection for this patient and all other patients after the incident. See A145-Patient Right: Free from Abuse/Harassment .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure 48 of 48 patients received care in a safe setting. This was evidenced by: A) The facility’s failure to ensure that 6 of 29 patients (Patient #6, 7, 8, 9, 10, and Patient #11), on Violence/Homicidal Precautions, were using wheelchairs with metal armrests that could not be removed by the patient. This failure had the potential to endanger 48 of 48 patients and staff. Additionally, Patient #4 had previously removed a metal armrest from his wheelchair. He attempted to break the plexiglass at the nurse’s station and assault staff members with it. Several days prior to the incident, he had stated he could beat a staff member to death with a metal armrest off his wheelchair. B) The facility’s failure to ensure that Patient #4’s 25-year history of incarceration for assault, violence, and destruction of hospital property at a psychiatric facility just prior to this admission, was factored into his admission onto a unit with a predominately vulnerable geriatric population. Violent behaviors were not listed as consideration in the Exclusionary Criteria. The patient became physically violent and verbally threatening, prompting staff to phone 911 twice for assistance in protecting the patient from harming himself and others. C) The facility’s failure to ensure that safety measures, specifically emergency medications, were utilized to protect Patient #4 from harming himself and others before the administrative staff phoned 911 for police assistance. Findings were: (A) The wheelchairs with removeable armrests. Review of policy HIM.HIPAA-02.15, “Patient Rights Texas,” revised 9.1.2023, showed: “You have the right to a clean and humane environment in which you are protected from harm.” Review of policy NSG-23, “Postural Assistive Devices,” revised 11.01.2022, showed: “The use of protective devices such as ... wheelchairs ... may be used ... 1. The Registered Nurse will assess the patient’s potential for injury ... and determine potential risks.” Review of a “Multidisciplinary Progress Note,” dated 7.14.2025 (not timed), by Staff E (RN Supervisor), showed: Patient #4 told Staff E, “I have nothing to lose, so I’ll kill you in a heartbeat. I’ll just pull off this wheelchair arm, go for your kneecap, hit it really hard, and once you bend over to grab it because it hurts like hell, that’s when I pull you down and beat you to death. I’m really strong.” Staff E asked Patient #4 to not be physically aggressive. The patient replied, “I can’t promise you anything.” Review of “Multidisciplinary Progress Note,” dated 7.16.2025 at 12:14pm, by Staff B (CNO), showed Patient #4 “shouting loudly without provocation” at 8:20am. He approached the nurse’s station and “punched the plexiglass window in an apparent attempt to break it.” He then removed a “handle” [metal armrest] from the wheelchair and “began striking the window with it ... The patient escalated further by using the wheelchair arm to chase a staff member ... Due to the patient presenting an immediate threat to the safety of staff and others, he was placed in seclusion.” Note - the patient was able to ambulate without the use of his wheelchair. During a tour of the unit on 9.16.2025 at 1:25pm, eleven (11) patients were observed to be in wheelchairs. Eight (8) of these patients were in wheelchairs that had removeable metal armrests. Six (6) of eight (8) (Patient #6, 7, 8, 9, 10, and Patient #11) were on Violence/Homicidal Precautions. Review of the “Inpatient Psychiatric Evaluation” and Physician Orders for the eight (8) patients that had wheelchairs with removeable metal armrests showed that six (6) of these patients (Patient #6, 7, 8, 9, 10, and Patient #11) had a history of physically aggressive and combative behavior and were on Violence/Homicide Precautions. 1. Patient #6. Review of “Inpatient Psychiatric Evaluation,” by Staff AA dated 9.6.2025 at 3:54pm, showed a 63-year-old male on an Emergency Detention Warrant with physically combative behavior towards staff, using a wheelchair to ambulate. Diagnostic Impression: unspecified psychosis and major neurocognitive disorder with psychosis. Review of Physician Orders showed Violence/Homicide Precautions ordered on 9.5.2025 (not timed) by Staff X (MD). 2. Patient #7. Review of “Inpatient Psychiatric Evaluation,” by Staff W (NP) dated 9.13.2025 at 6:06am, showed a 78-year-old male on an Emergency Detention Warrant with physically combative behavior towards staff, using a wheelchair to ambulate. He had taken a fire extinguisher out of its cabinet, wanting to use it to break the glass in a door and use it as a weapon against staff. Diagnostic Impression: major depressive disorder with unspecified psychosis and major neurocognitive disorder, Alzheimer’s type, moderate to severe with behavioral disturbances. Review of Physician Orders showed Violence/Homicide Precautions ordered on 9.11.2025 (not timed) by Staff X (MD). 3. Patient #8. Review of “Inpatient Psychiatric Evaluation,” by Staff W (NP) dated 9.13.2025 at 6:06am, showed an 80-year-old female on an Emergency Detention Warrant with aggressive and physically combative behavior towards staff. Diagnostic Impression: major neurocognitive disorder, Alzheimer’s type, moderate, with behavioral disturbances Review of Physician Orders showed Violence/Homicide Precautions ordered on 9.11.2025 (not timed) by Staff X (MD). 4. Patient #9. Review of “Inpatient Psychiatric Evaluation,” by Staff U (PA-C) dated 9.13.2025 at 11:42pm, showed a 66-year-old female on an Emergency Detention Warrant with aggressive and physically combative behavior towards staff, using a wheelchair to ambulate. Diagnostic Impression: major neurocognitive disorder, Alzheimer’s type, severe. Review of Physician Orders showed Violence/Homicide Precautions ordered on 9.12.2025 (not timed) by Staff Y (MD). 5. Patient #10. Review of “Inpatient Psychiatric Evaluation,” by Staff AA dated 8.31.2025 at 1:43am, showed a 77-year-old male on an Emergency Detention Warrant with aggressive and physically combative behavior towards staff, using a wheelchair to ambulate. He had kicked a staff member. Diagnostic Impression: major neurocognitive disorder, Alzheimer’s type, severe, with behavioral disturbances. Review of Physician Orders showed Violence/Homicide Precautions ordered on 8.29.2025 (not timed) by Staff X (MD). 6. Patient #11. Review of “Inpatient Psychiatric Evaluation,” by Staff U (PA-C) dated 9.12.2025 at 10:59am, showed a 55-year-old female on an Emergency Detention Warrant with physically aggressive behavior towards other patients and staff, using a wheelchair to ambulate. Diagnostic Impression: Schizoaffective disorder, severe. Review of Physician Orders showed Violence/Homicide Precautions ordered on 9.11.2025 (not timed) by Staff Y (MD). (B) The admission of Patient #4. Review of the exclusionary criteria used by five (5) hospitals in the Houston area for community Standard of Care comparison showed that all five (5) included violent behaviors as a consideration in the acceptance of an individual as an inpatient. Several facilities stated that they assess this variable on a case-by-case basis, but it is always addressed. Review of the hospital census for 7/10/2025, showed a census of 40 patients. There were 16 total care and 14 partial care patients. Twelve had a diagnosis of dementia. In an interview with Staff D (RN Supervisor) on 9.16.2025 at 10:58am, she stated that Patient #4 had been transferred to an emergency room from another psychiatric hospital after he injured himself while “destroying the nursing station.” She also stated that the hospital that sent the patient to the emergency room “said they didn’t want him back.” Staff D described Patient #4 as “violent,” adding, “He said he knows how to kill someone within seconds” and “He goes off unprovoked.” In an interview with Staff B (CNO) on 9.16.2025 at 12:50pm, she stated Patient #4 had been at another psychiatric hospital. After the patient sustained an injury during an episode of destruction to the nurse’s station, he was transferred to an emergency room for treatment. Once he was stabilized, the transferring facility “refused to take him back.” It was at this point that Oceans Katy accepted the patient. In an interview with Staff X (MD) 9.19.2025 at 10:27am, he stated that he knew Patient #4 from another facility, adding, “It was a big mess. [At that other facility] He attacked police staff.” The Medical Record for Patient #4. Review of “Intake Screening Part 1,” dated 7.9.2025 at 4:11pm, by Staff BB (RN, Admissions), showed Patient #4 to be a 62-year-old male patient. He had just recently kicked out a window at a psychiatric hospital prior to being admitted to Oceans Katy, cutting his right ankle. He then threatened to cut his wrist with a piece of glass from the window. The facility sent him to an emergency room for treatment of the cut. From there, he was transferred to Oceans Katy. Review of the “Level of Care Determination” [Inclusionary Criteria] identified Patient #4 as “gravely disabled.” The “Intensity of Services / Severity of Illness Criteria” included, “Threat to others requiring 24-hour professional observation, i.e., assaultive behaviors, physical threat to others, verbal threats to others, plan with intent that jeopardizes the immediate safety of others.” Violent behaviors were not mentioned in the “Exclusion Criteria.” [Reported] Weight: 208 lbs. Height 6’. Review of “Nurse-to-Nurse Transfer Form, by Staff Z (RN Director of Admissions), dated 7.9.2025 at 12:45pm showed mobility with wheelchair or walker - prefers wheelchair. Served 25 years for assault - released February 2025. Review of “Notification of Emergency Detention,” dated 7.8.2025 at 4:00pm showed that Patient #4 had “active suicidal ideation with a plan” and thoughts of harming others. Review of “Multidisciplinary Progress Note,” dated 7.10.2025 at 1:40pm, by Staff Z (Director of Admissions), showed an involuntary 62-year-old male arrived with police escort in a wheelchair. He told Staff Z, “I know how to make a weapon out of anything, and I will use it on myself if I have to. I will also use it on anyone if I need to.” He also stated, “I would never hurt a woman but if they come at me then I will or I will when they least expect it.” He presented with a 25-year history of incarceration. While he was recently at another psychiatric facility, he got angry over the staff giving him a wheelchair with only one brake. He kicked out a window and took a long piece of glass and went to stab his arm. He had received seven stitches on right ankle. He stated he heard voices “at times” telling him to hurt himself. Review of Physician Orders by Staff X (MD) dated 7.10.2025, 9:00pm showed orders for Line-of-Sight Observation, Violent/Homicide Precautions, Suicide/Self-Harm Precautions, and 1:1 Observation because “Patient is reporting in Intake wanting to kill self and ‘has been around and is able to turn anything into a weapon, and will use it on myself.’ Patient is also a danger to others. Patient stated in Intake, ‘I will also use the weapon on someone if I have to.” Review of “Inpatient Psychiatric Evaluation,” by Staff W (NP) on 7.11.2025 at 7:27am showed Patient #4 had admission diagnoses of schizoaffective disorder, bipolar type, severe and post-traumatic stress disorder, severe. He told Staff W, a female NP, “I would never hurt a woman but if they come at me then I will or I will when they least expect it.” He stated he had been incarcerated for “the past 25 years for aggravated assault with a deadly weapon.” Review of a “Multidisciplinary Progress Note,” dated 7.15.2025 at 8:47pm, by Staff E (RN Supervisor), showed: Patient #4 used a racial slur and pulled a fire alarm. Review of “Multidisciplinary Progress Note” [for 7.16.2025] by Staff T (RN) dated 7.17.2025 at 12:20pm, showed that Patient #4 became agitated [that morning]. The patient stated, “No one should get near me. Nobody take a single step. Nobody say a single word, or I will show you all what I can do.” The patient then pulled the fire alarm and began laughing, stating, See, now look at all of y’all running around because of me.” He paced in the wheelchair. He then stated, “I will have all of you killed. I just did 25 years. I’m not scared of nothing. I could kill six people and not get caught. I know people. All it takes is one call. If y’all do not give me what I want, I will take the arm rest of my wheelchair off and you’ll have no choice but to come help me and that is how I will get you and you can’t get out.” Review of “Multidisciplinary Progress Note,” dated 7.16.2025 at 12:14pm, by Staff B (CNO), showed Patient #4 “shouting loudly without provocation” at 8:20am. He approached the nurse’s station and “punched the plexiglass window in an apparent attempt to break it.” He then removed a “handle” [metal armrest] from the wheelchair and “began striking the window with it ... The patient escalated further by using the wheelchair arm to chase a staff member.” (Note - the patient was able to ambulate without the use of his wheelchair.) He yelled “profanities” and “racially charged statements.” He was “an immediate threat to the safety of staff and others.” He was placed in the seclusion room where he continued to make threats toward staff. He also made “threatening hand gestures, including multiple throat-slashing motions.” The profanity and racially derogatory language continued. Law enforcement was notified and arrived around 9:00am. He was transported from the facility by EMS at around 10:30am. C. The use of emergency medication. Review of policy MM-18, Psychotropic Medications: Emergencies,” revised 6.1.2024, showed: “Purpose: To outline the organization’s guidelines for utilization of medications to treat patients experiencing psychiatric emergencies ... Psychiatric emergency - A situation in which, in the opinion of the physician it is immediately necessary to administer medication to ameliorate the signs and symptoms or a patient’s mental illness and to prevent ... imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits.” In an interview with Staff D (RN Supervisor) on 9.16.2025 at 10:50am, she stated that she phoned 911 because they needed assistance with Patient #4, adding, “We could not manage him. He was threatening other patients and was violent. The patients were not safe.” She also stated she spoke with Staff Y (MD) who “gave the directive to phone the police.” She concluded by saying that her expectation in phoning 911 was to “transfer the patient to a higher level of care.” In an interview with Staff B (CNO) on 9.16.2025 at 12:50pm, she stated that Staff D (RN Supervisor) had phoned 911 because Patient #4 “removed a handle from his wheelchair.” She stated she also phoned 911 because the police had not shown up in response to Staff B’s request for help. In an interview with Staff X (MD) on 9.19.2025 at 10:27am, he was asked about the appropriateness of administering an emergency medication to Patient #4 considering the destructive and potentially assaultive behaviors he exhibited on 7.16.2025. At first, he stated emergency medications are given when there are psychotic symptoms. When asked about potentially assaultive and destructive behaviors in which the patient has become a danger to himself and others, he stated that staff “could have given an IM medication.” He did not provide a reason for not ordering an emergency medication for Patient #4. In an interview with Staff B (CNO) on 9.19.2025 at 11:20am, she was asked about the appropriateness of administering an emergency medication to Patient #4 considering the destructive and potentially assaultive behaviors he exhibited on 7.16.2025. She stated the patient should have been given an emergency medication. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure a patient’s right to be free from all forms of abuse (Patient #1) as shown by: A) Not thoroughly investigating an incident where a patient was struck in the face, and; B) Not ensuring increased protection for this patient and all other patients after the incident. Findings included: Review of facility policy #RTS-10 titled “PATIENT RIGHTS”, effective 1/11/16, showed that its purpose was is rectify misconduct to reduce the likelihood of recurrence and to protect patients from abuse. In addition, it stated that patients have the right to be free from physical abuse. Record review of Patient #1’s clinical chart showed the following: 76-year-old female admitted involuntarily to facility on 7/30/25 with the diagnoses of Bipolar disorder type 1, severe, mixed; Major neurocognitive disorder, Alzheimer’s type, severe, with behavioral disturbances; Dementia; Increased confusion; Delusional; History of cognitive communication deficits; Sundowning. Reason for admit was due to patient attempting elopement from her nursing facility, increased confusion and agitation. The patient was alert only to self; not to time, place, and situation, which continued for her entire stay until discharge on 8/10/25. Physician progress notes dated 8/4/25 by PA Staff #U showed “ ....patient states ‘I’ve been hurt’ but not able to elaborate ....[Patient #1] is not oriented to place, time, or situation.” Physician progress notes dated 8/5/25 at 9:35 by NP Staff #S showed “ ...skin-bruises on left cheek and eye area”. Skin and Wound Care Assessment on 8/5/25 performed by Wound Care RN Staff #T showed a picture of the patient with left cheekbone and left cheek bruises, with caption that stated “Face. Bruise. Not present on admission.” There was no explanation as to the cause of the bruise, just a picture. Further record review failed to show any information about the patient being injured, including all progress notes from nursing and physician providers. In an interview on 9/18/25 at 12:15 pm, Supervisor RN Staff #E stated that after the patient was discharged on 8/10/25, the patient’s son came to the facility on 8/12/25 and expressed he was very upset with the care his mother was provided. Record review of facility’s incident reports revealed there was an occurrence involving the patient on 8/3/25 at 4:00 pm. This report was created on 8/12/25, the same day the patient’s son came to the facility, nine days after the event and two days after the patient discharged on 8/10/25. This report showed the patient was allegedly struck on her face across her left cheek by a peer, then later said that nobody hit her. Also, there was another incident report created 8/12/25 for this same event on 8/3/25 at 4:00. It showed nearly identical information as the other report except that it identified the patient’s roommate as the other person involved in the physical altercation. In an interview on 9/18/25 at 11:30 am, MHT Staff #V stated she was the only witness to the occurrence on 8/3/25 and identified Patient #5 as the other person involved in the altercation. MHT Staff #V said she heard two patients arguing in the hallway, Patient #1 and Patient #5. When she asked Patient #1 what had happened, Patient #1 stated Patient #5 hit her face. Then, “at a later time in the day”, MHT Staff #V stated that Patient #1 said that Patient #5 did not hit her. However, MHT Staff #V stated the patient was always very confused, did not understand what was happening, and did not know where she was. Record review of Patient #5’s clinical chart showed the following: 71-year-old female admitted to facility on 7/23/25 for behavioral issues and physical aggression, after she had assaulted another resident in her nursing home. She was placed on Violence/Homicide Precautions on admission, which continued up to the date of her discharge on 8/12/25. Per therapist notes dated 7/25/25, the patient stated she got aggressive at times and would slap her spouse. Per physician progress notes dated 8/1/25, it showed “During morning rounds ....patient observed getting into a verbal altercation with peer and is observed attempting to swing at peer. Patient is impulsive and easily irritable.” Per physician notes dated 8/2/25, it showed that during an assessment in the day room, the patient was again observed to become irritable and argumentative with a peer, but then stated she never became physically aggressive with peers, despite being observed to swing at a peer the prior day. Per nursing progress notes dated 8/4/25, “Patient impulsively slaps another patient across the left cheek after an altercation between the two (this referred to the event with Patient #1 on 8/3/25). Patient redirected and educated to report any issues and not hit anyone.” Per physician progress notes dated 8/5/25, when asked about physical aggression towards peers, Patient #5 denied it. Physician notes dated 8/6/25 showed that patient became agitated when confronted with report that she was being physically aggressive with peers. Physician notes dated 8/8/25 showed “ ...observed to be easily irritable and argumentative with peers at times.” Per nursing progress notes dated 8/9/25 at 4:59 pm, the patient once more hit another peer in the face: “At about 1215, pt hit another pt in the face. Pt states ‘she was coming close to me’.” The patient remained on Close Observation Every 15 minutes throughout her entire stay, the lowest observation monitoring level for patients. In an interview on 9/18/25 at 11:45 am, PI Staff #C stated that although Patient #1 first reported she was struck in the face, she later reported she was not struck in the face. Staff #C later produced the incident report indicating a room change was completed. However, the facility could not provide evidence of room assignments and there was no indication room assignments were changed in both Patient #1 and Patient #5’s medical records per all physician orders, progress notes, and nursing progress notes. There was no evidence of a thorough investigation performed by facility for the event on 8/3/25, including review of video footage, patient or staff interviews. In addition, there was no evidence or corrective or preventative actions taken for Patient #5 being placed on closer observation to protect other patients, or other types of documented preventative actions taken to ensure increased patient safety for Patient #1 and all other patients.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 35028 . Based on observations, interviews, and record review, the facility failed to ensure that accepted standards of nursing practice and hospital policy were followed - practices and policies designed to keep patients and staff safe. The failure was evidenced by the nurse failing to obtain an emergency medication for Patient #4 after he attempted to break the glass enclosing the nurse’s station with a metal armrest he had removed from his wheelchair. He continued to wield the armrest, threatening to harm staff. The nurse did not ask the physician for an emergency medication - a treatment permitted by the law and designed to keep patients and staff safe during an emergent situation. There was an increased potential for patients and staff to be injured. Findings were: Review of policy MM-18, Psychotropic Medications: Emergencies,” revised 6.1.2024, showed: “Purpose: To outline the organization’s guidelines for utilization of medications to treat patients experiencing psychiatric emergencies ... Psychiatric emergency - A situation in which, in the opinion of the physician it is immediately necessary to administer medication to ameliorate the signs and symptoms or a patient’s mental illness and to prevent ... imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits.” In an interview with Staff D (RN Supervisor) on 9.16.2025 at 10:50am, she stated that she phoned 911 because they needed assistance with Patient #4, adding, “We could not manage him. He was threatening other patients and was violent. The patients were not safe.” She also stated she spoke with Staff Y (MD) who “gave the directive to phone the police.” She concluded by saying that her expectation in phoning 911 was to “transfer the patient to a higher level of care.” In an interview with Staff B (CNO) on 9.16.2025 at 12:50pm, she stated that Staff D (RN Supervisor) had phoned 911 because Patient #4 “removed a handle from his wheelchair.” She stated she also phoned 911 because the police had not shown up in response to Staff B’s request for help. In an interview with Staff X (MD) on 9.19.2025 at 10:27am, he was asked about the appropriateness of administering an emergency medication to Patient #4 considering the destructive and potentially assaultive behaviors he exhibited on 7.16.2025. At first, he stated emergency medications are given when there are psychotic symptoms. When asked about potentially assaultive and destructive behaviors in which the patient has become a danger to himself and others, he stated that staff “could have given an IM medication.” He did not provide a reason for not ordering an emergency medication for Patient #4. In an interview with Staff B (CNO) on 9.19.2025 at 11:20am, she was asked about the appropriateness of administering an emergency medication to Patient #4 considering the destructive and potentially assaultive behaviors he exhibited on 7.16.2025. She stated the patient should have been given an emergency medication. . 38015 Based on record review and interview, the facility failed to ensure a patient was properly assessed every 12 hours, as evidenced by inconsistent and inadequate nursing skin assessments for 1 of 2 patients (Patient #1), who had sustained a facial bruise as a result of being struck by a peer. Findings included: Review of facility policy #AS-01 effective 1/11/2016, titled “ASSESSMENT PROCESS INPATIENT”, showed that the RN will assess the patient a minimum of every 12 hours or once per shift. Record review of Patient #1’s clinical chart showed the following: 76-year-old female admitted involuntarily to facility on 7/30/25 with the diagnoses of Bipolar disorder type 1, severe, mixed; Major neurocognitive disorder, Alzheimer’s type, severe, with behavioral disturbances; Dementia; Increased confusion; Delusional; History of cognitive communication deficit; Sundowning; Paranoia. Reason for admit was due to patient attempting elopement from nursing facility, increased confusion and agitation. The patient was alert only to self; not to time, place, and situation, which continued for her entire stay. Physician progress notes dated 8/4/25 by PA Staff #U showed ....”patient states ‘I’ve been hurt” but not able to elaborate’ ....[patient] is not oriented to place, time, or situation.” Physician progress notes dated 8/5/25 at 9:35 by NP Staff #S showed “ ...skin-bruises on left cheek and eye area.” Skin and wound care assessment on 8/5/25 performed by RN Staff #T showed a picture of the patient with left cheekbone and left cheek bruises and a caption that stated “Face. Bruise. Not present on admission.” There was no explanation as to the cause of the bruise, just a picture. Record review of facility’s incident reports revealed an occurrence involving the patient on 8/3/25 at 4:00 pm, created on 8/12/25 (two days after the patient discharged on 8/10/25). This report showed the patient was allegedly struck on her face across the left cheek by a peer (the patient later said that nobody hit her). Also, there was another incident report created 8/12/25 for this same event on 8/3/25 at 4:00. It showed nearly identical information as the other report except that it was her roommate that struck the patient. In an interview on 9/18/25 at 11:30 am, MHT Staff #V stated she was the only witness to the occurrence on 8/3/25. She said she heard two patients arguing in the hallway, Patient #1 and Patient #5. When she asked Patient #1 what happened, she replied that Patient #5 hit her face. However, at a later time in the day, Staff #V stated, Patient #1 said that Patient #5 did not hit her, changing her story. MHT Staff #V also stated she was confused why the patient later said she wasn’t hit, but also said the patient was very confused and did not understand what was happening or where she was. Further record review of Patient #1’s daily nursing shift assessments showed that nurses failed to document bruises and/or wounds consistently and accurately after the patient reported she was hurt to the Physician Assistant on 8/4/25 and after the bruises were recognized by both the Nurse Practitioner (NP) and Wound Care Nurse on 8/5/25. In addition, the assessments did not specify any information or give any explanation about the bruises/wounds, including description, cause, and location. The following were daily nursing assessments for the skin: 8/3/25, AM shift: Bruises-Yes, Wound-Yes 8/3/25, PM shift: Bruises-No, Wound- Yes 8/4/25, AM shift: Bruises-No, Wound-Yes 8/4/24, PM shift: Bruises-No, Wound-Yes 8/5/25, AM shift: Bruises-No, Wound-Yes 8/5/25, PM shift: Bruises-No, Wound-No 8/6/25, AM shift: Bruises-No, Wound-No 8/6/25, PM shift: Bruises-Yes, Wound-Yes 8/7/25, AM shift: Bruises-No, Wound-No (8/7/25 PM shift, unable to find in chart) 8/8/25, AM shift: Bruises-No, Wound-Yes 8/8/25, PM shift: Bruises-Yes, Wound-No 8/9/25, AM shift: Bruises-No, Wound-Yes In an interview on 9/18/25 at 12:20 pm during record review of Patient #1’s skin assessments, RN Supervisor Staff #E acknowledged that the skin assessments were not accurate and did not adequately address and explain the patient’s bruises. Nursing progress notes dated 8/10/24 at 6:45 am stated the patient became difficult to arouse, had a blood pressure reading of 164/94, and a heart rate of 130/minute. She was then transferred out to an emergency room via 911 for “a higher level of care”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 Based on observation, interview, and record review, the facility failed to protect the rights of 2 of 2 patients (Patient #1 and Patient #4). Patient #1. The facility failed to provide care in a safe setting through the review and analysis of a fall by Patient #1, a 67-year-old involuntary male patient, weighing 97 lbs. and described as “extremely cachectic” and in need of total care. He presented for admission with a history of three cerebrovascular accidents, stroke, traumatic brain injury, and transient ischemic attack. His presentation on admission was of such concern that he was transferred out by 911 for medical clearance (altered mental status, left ear bloody discharge, suspicion of sepsis), and then returned to the facility. On the day of the fall, he had been in the day room in a recliner for twelve hours. He was “found on the floor bleeding.” He sustained a laceration over his left eye and skin tear on his left shoulder after he “fell from a recliner” during change of shift report. He was transferred by 911 to an emergency room to evaluate his injuries. He was never returned to the facility. The facility neither investigated the specifics of the fall to determine the presence or extent of any safety issues. See A0144 - Patient Rights: Care in Safe Setting. Patient #4. The facility failed to protect the rights of Patient #4, a 68-year-old involuntary female patient, subject to a court order to administer psychoactive medication, who was “incapable of making rational decisions to maintain safety of herself or others” This negligence was evidenced by the facility’s failure to ensure Patient #4 had a written discharge order prior to being released from the facility, as well as discharge arrangements completed by a discharge planner in collaboration with the receiving facility. Additionally, Patient #4, wearing only blue disposable scrubs, was transported to a homeless shelter in the facility’s van that was driven by a facility employee. The van driver removed the patient (whom he described as “rambling”) from a transportation wheelchair, lowed her onto the sidewalk, handed her a discharge packet, and drove away. See A0145 - Patient Rights: Free from Abuse/Harassment for details.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 Based on observation, record review, and interview, the facility failed to provide care in a safe setting for 1 of 1 patients (Patient #1). This negligence was evidenced by the facility’s failure to ensure a review and analysis was completed of a fall from a recliner by Patient 1 resulting in a 911 transfer to a medical facility to evaluate and treat a head injury sustained during the fall. Findings were: Patient #1. Review of the Face Sheet: Admission 2/12/2025. Discharge 2/17/2025. Intake referral form by Staff DD (RN - Intake Department) dated 2/12/2025 at 8:22 PM showed: Patient depressed, threatening to harm self with a knife, angry, screams all day and night. History of three cerebrovascular accidents - last in December 2024 with major brain bleed, emphysema, transient ischemic accidents, traumatic brain injury in 2019 from motor vehicle accident, hypertension, hyperlipidemia. Small skin tears in various places. Needs assistance with bathroom, shower, dressing. Needs assistance sitting to stand and ambulation. Complete assistance. Bladder and bowel incontinence. Exclusion Criteria: no items checked. Administrator Accepted: Staff A (CEO) Accepting Physician: Staff F (Attending MD) Involuntary Admit: Emergency Detention Warrant. Review of legal documents showed: Application for Emergency Detention, Certificate of Preliminary Medical Examination, Order of Emergency Apprehension and Detention (dated 2/12/2025), and Emergency Apprehension and Detention Warrant executed 2/12/2025 at 10:09 PM. “The patient is depressed, agitated, aggressive towards others, disorganized, refusing care, is likely to cause serious harm self and others.” Review of the Preadmission Evaluation & Medical Clearance Screening by Staff AA (MD - telemedicine) dated 2/12/2025 at 6:09 PM showed: 67-year-old male involuntarily admitted with depression and threats to harm himself with a knife. Past medical history: chronic obstructive pulmonary disease, emphysema, cerebrovascular accident, stroke, traumatic brain injury, transient ischemic attack. Review of Physician’s Orders by Staff F (Attending MD) dated 2/12/2025 at 9:00 PM showed: Fall Precautions and Bleeding Precautions. Skin Assessment by dated 2/12/2025 (not timed and author not identified) showed the following conditions were present on admission: “left hip open wound,” “upper left arm open skin tears,” “left ear skin tear,” “right forearm generalized open skin tears and bruises,” “old bruises all over his left hand,” “right hand old bruises,” and “chest old bruises.” Review of Admit Nursing Assessment by Staff Z (RN) dated 2/13/2025 at 3:56 AM showed, a 67-year-old male, weighing 97 lbs. The following items were checked: unclean, malodorous, oriented to person only, restless, agitated, threatening. Unable to walk. History of pneumonia. Incontinent. Total assist. Needs wheelchair. Review of the Edmonson Psychiatric Fall Risk Assessment on 2/13/2025 at 2:43 AM by Staff Z (RN) showed an assessment score of 111. [Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.] Review of Plan of Care, developed 2/13/2025, showed problem #2 was “a risk for falls related to orthostatic changes, cognitive deficit, motor deficit as evidenced by a fall risk score 111, limited mobility, shuffling gait or unsteady gait, poor balance or motor function.” Interventions were: “Keep pathways clear ... assist with ADLs [Activities of Daily Living] ... implement walk program and assess footwear safety.” Review of Face-to-Face Visit e-signed on 2/13/2025 at 3:08 PM by Staff BB (PA-C) and on 2/23/2025 at 10:03 PM by Staff CC (MD) showed: “extremely cachectic [a state of wasting or emaciation],” “cursing and uncooperative,” “attempted to hit provider, has skin tears all over forearm, poor hygiene, encrusted bloody drainage from left ear,” “refusing to eat since yesterday, scab over skin where PEG tube [percutaneous endoscopic gastrostomy - feeding tube] was removed. Staff extremely concerned about change in mentation. No intake since yesterday.” “Patient sent out by 911 for altered mental status, left ear bloody discharge, suspicion of sepsis [a life-threatening medical emergency caused by the body’s extreme response to an infection].” Review of Physician Orders on 2/13/2025 at 10:41 AM showed: “Transfer to Memorial Hermann Hospital for change in mental status.” Review of Face-to-Face Visit e-signed on 2/14/2025 at 7:42 PM by Staff BB (PA-C) and on 2/23/2025 at 10:03 PM by Staff CC (MD) showed: Patient returned from ER [emergency room]. Oral antibiotics for possible urinary tract infection. Uncooperative, combative, refusing to eat. Review of RN Daily Shift Assessment - 7AM-7PM by Staff G (RN) dated 2/17/2025 at 9:28 AM showed: Patient ambulates with wheelchair. Total care. Requires assistance with feeding. Combative. In dayroom sitting in recliner. Patient is high fall risk. Review of Skin Assessment by dated 2/17/2025 (not timed and author not identified) showed “left lower extremity open [wound] not present on admission,” “left eye laceration [were] not present on admission,” and “left shoulder laceration not present on admission.” Review of Progress Note by Staff G (RN) dated 2/17/2025 at 7:48 PM showed: “Around 7:23 PM during nurse’s report, Mental Health Technician interrupted report states ‘Emergency patient fell from recliner and is bleeding from the head.’ Nursing staff find [sic] patient on the floor bleeding, upon assessment staff note[d]: patient has a cut on left eye lid and skin tear on left shoulder. ... 911 called ... patent taken to Memorial Hermann.” Review of the Observation Check Sheet / Graphic Flowsheet with entries by various MHTs for Patient #1 showed he was sitting in the day room in a recliner on 2/17/2025 from 6:45 PM until 7:30 PM, the time the fall occurred. Further analysis of the form showed he was in the dayroom from 7:00 AM until the fall except for being in his room at 1:00 PM and entries for meals. There were no aggressive behaviors documented. Review of Physician Orders on 2/17/2025 at 7:31 PM showed: “Transfer patient to Memorial Hermann ER for fall. Bleeding from head.” Review of Progress Note by Staff S (RN) dated 2/18/2025 at 3:04 AM showed: Patient at Memorial Hermann Katy - Scan of the head showed brain bleed.” In an interview with Staff B (DON) on 3/19/2025 at 2:15 PM she stated she did not know the final outcome of Patient #1 following the 911 transfer to a medical facility following the fall. Additional information. In an interview with Staff A (CEO), Staff B (DON), Staff C (RM), and Staff I (Intake Director) on 03/28/2025 at 10:15 AM, they stated that an investigation into Patient #1’s fall was not conducted.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35028 Based on observation, record review, and interview, the facility failed to provide care for 1 of 1 patients (Patient #4) that was free of abuse. This negligence was evidenced by the facility’s failure to ensure Patient #4, a) Had a written discharge order prior to being released from the facility; b) Had prior discharge arrangements completed by the discharge planner in collaboration with the receiving facility; c) Was clothed in garments other than disposable scrubs when she was transported in the facility’s van to a shelter; and d) Was left in a safe environment when removed from a wheelchair and lowered to a sidewalk outside of a shelter by the van driver, even though she was a significant fall risk. Findings were: First admission of Patient #4. Review of the Face Sheet showed: Admission 2/19/2025. Discharge 2/26/2025. Review of the legal documents showed: “ Emergency Apprehension and Warrant executed 2/19/2025. “ Certificate of Preliminary Medical Examination by Staff M (MD) dated 2/18/2025 showed psychosis, delusions, somatic preoccupation, paranoia, aggression, deterioration of her mental and physical state. “ Order of Protective Custody and Notice of Hearing dated 2/20/2025. Hearing date set for 2/28/2025. Review of the Preadmission Evaluation & Medical Clearance Screening by Staff O (MD) dated 2/19/2025 at 2:24 AM showed: 68-year-old female with paranoia and delusions (“other people controlling her, trying to kill her, and defecating / urinating through her vagina”). “Unkept, disheveled with dried feces and urine on clothing.” Review of Physician’s Preadmission Examination Orders by Staff O (MD) dated 2/19/2025 at 2:24 AM showed violent / homicide precautions, elopement precautions. Review of Physician Orders by Staff F (Attending MD) dated 2/19/2025 at 11:44 AM showed PRN Haldol, PRN Zydis, Risperdal BID, and Depakote BID. Review of the Medication Administration showed routine and PRN medications were never given. [Haldol, Zydis, and Risperdal - antipsychotic medications. Depakote - mood stabilizer] Review of the Admit Nursing Assessment by Staff N (RN) signed 2/19/2025 at 6:15 AM showed: “Agitation, verbal and physical aggression, paranoid, delusional, refusal of medications.” Review of Edmonson Psychiatric Fall Risk Assessment by Staff S (RN) dated 2/19/2025 at 5:44 PM showed a “FALL RISK SCORE of 142. Fall risk = score of 90 or greater. Fall precautions.” [Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.] Review of six Face-to-Face Visits by Staff Q (NP), co-signed by Staff F (Attending Physician), showed the following information was documented verbatim in each of the six visits dated 2/20, 2/21, 2/22, 2/23, 2/24, and 2/25/2025: “Assessment: Schizoaffective disorder, bipolar type, severe. Justification for continued stay: Does not appear capable of making rational decisions to maintain safety of self or others. Not at baseline. Inpatient psychiatric level of care medically necessary. Noncompliant with medications.” Further review of the six Face-to-Face Visits dated 2/20, 2/21, 2/22, 2/23, 2/24, and 2/25/2025 showed the following variances in the documentation. 1) 2/20/2025, not timed (e-signed 2/21/2025 at 5:00 PM) - “Agitation, physically and verbally aggressive, loud. Insomnia. Combative with care. Paranoia, delusions (people able to change appearance), psychosis. Poor judgment. Unsteady gait with chronic leg pain.” 2) 2/21/2025, not timed (e-signed 2/22/2025 at 5:56 PM) - Paranoid, delusional (people change appearance with cell phones). Verbal and physical aggression, combative with care. Ambulates with wheelchair. Poor judgment. 3) 2/22/2025 at 6:10 PM - “Refusing psychotropic meds.” 4) 2/23/2025 at 3:44 PM - “Agitated, paranoid, delusional (being poisoned), loud, yelling profanities, combative with care, not responding to assessment questions. Poor judgment.” 5) 2/24/2025 at 5:20 PM - “Refusing psychotropic meds. Angry, demanding, yelling, cursing and foul language toward staff. Delusional (someone stole her purse). Unprovoked physical aggressive. Combative with care. Per nurses: screaming, disruptive to milieu during lunch. Poor judgment.” [Documentation of an emergency medication immediately follows.] 6) 2/25/2025, not dated (e-signed 2/27/2025 at 1:02 PM) - “Refusing psychotropic meds. Profane language. Yelling. Delusional. Paranoid. Ambulates with wheelchair. Poor judgment.” Emergency medication documentation by Staff U (RN) dated 2/24/2025 at 1:23 PM - 2:12 PM showed: Patient screaming, disrupting milieu, disrupting milieu, “got everyone riled up,” attempted to throw food at staff, noncompliant with medications. Haldol 5mg, Benadryl 50mg, and Ativan 2mg given intramuscularly. (This was also documented in the Physician Orders and the Medication Administration Record.) [Haldol - antipsychotic. Benadryl - antihistamine given to prevent side effects of the antipsychotic. Ativan - anti-anxiety medication. These three medications are often given in combination.] Record review of Petition for Order to Administer Psychoactive Medication signed by Staff F (Attending Physician) dated 2/24/2025 showed: “Patient is subject to an order dated 2/28/2025 for court-ordered in-patient mental health services. Diagnosis: Schizoaffective disorder, bipolar type, severe. Patient is paranoid suspicious, guarded, saying people are trying to poison her. Yells, screams, curses at staff and peers irritable, anxious, refuses mediation.” In an interview with Staff E (Court Liaison) on 3/13/2025 at 5:02 PM, she stated there was no force medication hearing for Patient #4, adding that the patient was discharged before this hearing could be completed. Review of Edmonson Psychiatric Fall Risk Assessment by Staff T (RN) dated 2/25/2025 at 6:12 PM showed a fall risk score of 94. Fall risk = score of 90 or greater. [Edmonson Psychiatric Fall Risk Assessment - a tool used to identify and assess fall risks in psychiatric patients, considering factors like medication use, diagnosis, ambulation, nutrition, and sleep patterns.] Review of Physician Orders by Staff F (Attending MD) signed 2/27/2025 at 7:50 AM showed: “Discharge patient, routine, fair condition, with a guarded prognosis to Star of Hope Shelter.” [Star of Hope Mission - homeless shelter for men, women, and children.] Review of Discharge Summary by Staff F (Attending MD) on 2/27/2025 at 11:16 PM showed a discharge date of 2/26/2025. “Discharge diagnosis: Schizoaffective disorder, bipolar type, severe. Refused all psychiatric medications during her stay. Disheveled / soiled clothes. Uncooperative, agitated, refused to answer questions. Verbally aggressive. Loud. Disorganized thoughts. Irrational / intrusive thoughts. Insight / judgment fair. Motor activity slowed, unsteady / abnormal gait, needs assistive device.” Discharge Criteria [that was met]: “Improved social functioning; medication compliance; decreased depression, mania, anxiety, and psychosis. Improved mood and affect. Improved motivation for treatment. Improved coping skills. Patient will discharge to shelter. Patient would like to schedule her own aftercare appoints. Patient was discharged as she has been refusing her psychiatric medications during stay.” [Schizoaffective disorder, bipolar type - a mental health condition characterized by symptoms of both schizophrenia and bipolar disorder, specifically involving periods of mania or hypomania alongside depressive episodes, along with psychotic symptoms like hallucinations and delusions.] In an interview with Staff F (Attending MD) on 3/14/2025 at 11:00 AM concerning Patient #4, 1) He stated the patient would “scream and yell at me,” never took oral medications, ambulated in a wheelchair because of her risk of fall, and was still on an involuntary status when discharged. 2) He said he filed for court-ordered medications, but the patient was discharged before this was completed. He reviewed the discharge criteria he had checked in the Discharge Summary. He then said that two of the checked criteria were wrong: “medication compliance” and “improved motivation for treatment,” adding, “What does it matter?” The documentation in the Face-to-Face Visit from the previous day (2/25/2025) was reviewed with Staff F. Items of particular interest included: “Does not appear capable of making rational decisions to maintain safety of self or others. Not at baseline. Inpatient psychiatric level of care medically necessary. Noncompliant with medications.” After reviewing these items, he stated, “She was not a danger to herself or others. She was disturbing the milieu. I let her go.” Review of Physician Orders by Staff F (Attending MD) signed 2/27/2025 at 7:50 AM showed: “Discharge patient, routine, fair condition, with a guarded prognosis to Star of Hope Shelter.” Review of Transition Plan and Continuity of Care Documentation by Staff D (Discharge Planner) on 2/25/2025 at 4:24 PM showed: “Method of Transmittal: Hard copy to transport personnel. Enclosed: transition record, discharge medication, crisis safety plan. Discharge date: 2/26/2025 at 10:00 AM. Scheduled discharge. Discharge to shelter. Mode of transportation at discharge: Facility transportation.” In an interview with Staff G (RN) on 3/13/2025 at 1:12 PM, she stated the patient was discharged to The Star of Hope, adding that the patient left the unit between 7:30 and 8:00 AM. In an interview with Staff K (RN Supervisor) on 3/13/2025 at 1:12 PM, she stated she took the Verbal Order from Staff F (Attending MD) for discharge of Patient #4 on 2/26/2025 at 11:37 AM, adding she called the physician for a discharge order because the patient had left the hospital and “There was no order for discharge in the chart.” Review of the Transition Plan and Continuity of Care Documentation by Staff D (Discharge Planner) on 2/25/2025 (not timed) showed that a hard copy was provided to Transport Personnel. Patient #4 was discharged to Star of Hope Shelter with three documents: Transition Record, Discharge Medication, and Crisis Safety Plan. The patient was to follow up with Staff W (MD) for medications. No appointment had been made for follow-up with that physician. Further review of the document showed that Staff D (Discharge Planner) witnessed the patient’s signature of the Transition Plan and Continuity of Care form and e-signed the form on 2/25/2025 at 4:24 PM. In an interview with Staff L (Transportation Driver) on 3/13/2025 at 3:09 PM, he stated that when Patient #4 was discharged on 2/26/2025 to the Star of Hope, she was in blue hospital scrubs. He stated he was given a “transportation sheet” that identified the destination of the patient. The patient was “rambling, talking, but not really saying anything. Cursing and used ‘the N-word.’” Staff L was observed to be an African American male. He also stated he removed the patient from the wheelchair, lowered her to a “raised curb near grass,” and left her there, adding he did not speak to any staff member inside the Star of Hope. He did speak to a security officer that drove by while he was unloading the patient. He concluded by saying the patient was “rambling” and refused to sign the transportation paperwork. In an interview with staff at The Star of Hope (Staff P) on 3/17/2025 at 1:55 PM, she stated: 1) The doors open for women at 7:00 AM and men at 7:30 AM. 2) Admission is dependent on availability. 3) Individuals must be able to do everything for themselves. 4) Facilities need to get clearance with The Star of Hope before a patient is sent to them. 5) The driver of the transport van got Patient #4 out of the van in a wheelchair and placed her on the ground in front of the building. 6) She ran outside and told the driver of the van, “You cannot do that.” 7) The driver of the van drove away with the patient sitting on the sidewalk in blue scrubs. In an interview with Staff B (DON) on 3/14/2025 at 10:10 AM, she stated patients may be issued blue disposable scrubs. Observation of the scrubs showed Fluid-Resistant Multilayer Spun-bond Disposable Scrubs, blue. In an interview with Staff A (CEO) on 3/13/2025 at 5:18 PM, he stated a patient should not be discharged in disposable scrubs. He also stated the facility has donated clothes available for patients. In an interview with Staff C (RM) on 3/14/2025 at 9:00 AM, she stated that they have a “boutique” that has clothing available to patients in need, adding that the facility can purchase items if needed. The “boutique” was observed on 3/19/2025 at 2:00 PM. Numerous items of clothing were hanging on racks - both male and female - and a shelf housed dozens of shoes. In an interview with Staff C (RM) on 3/13/2025 at 3:56 PM, she stated that during the morning huddle on 2/27, the team questioned why Patient #4 had been discharged on 2/26/2025 only to be readmitted back into the hospital. Readmission of Patient #4 on 2/26/2025. In an interview with Staff I (Intake Director) on 3/13/2025 at 12:20 PM, she stated Patient #4 was dropped off at the hospital by a taxi on 2/26/2025 at 2:25 PM. She also stated she saw the patient sitting outside in blue hospital scrubs, having been deposited by a taxi driver who offered no information to hospital staff. In an interview with Staff V (RN) on 3/13/2025 at 3:15 PM, she stated the patient was readmitted into the hospital on 2/26/2025 wearing the same blue disposal scrubs that she had been discharged in just hours earlier. She also stated she did not believe the patient should have been discharged. Review of Pre-Admission Patient Screening showed Patient #4 was admitted into Ocean’s Hospital of Katy on 2/26/2025. (Time not documented.) The referring facility was identified as Oceans Katy. Review of the admission screening by Staff X (Admission Screener) on 2/26/2025 at 2:25 PM showed: Patient #4 was a homeless female that arrived from a shelter to the hospital with increased agitation and verbal/physical aggression toward staff. She was “talking to a person not there ... responding to internal stimuli, increased mood swings. Going from labile to verbally/physically aggressive in a matter of a few minutes ... aggressive to staff.” History of traumatic brain injury. Staff X also documented: a) “Patient not able to do activities of daily living without assistance. Has physical disability - uses a walker.” b) Patient needed “assistance with ambulation and bed mobility.” c) “Bladder and bowel incontinence.” d) “Patient gravely disabled requiring intensive, comprehensive, multi-modalities of treatment to include 24-hour a day medical supervision and coordination because of mental and emotional decompensation.” e) “Chronic and continuous self-destructive behaviors.” f) “Command hallucinations directing to harm self or others with a risk of acting on this.” g) “Cognitive impairment.” h) “Hallucinations, delusions, mania.” i) “Dementing disorder that requires evaluation and treatment of a psychiatric co-morbidity.” j) “Emergency detention warrant was filed.” Review of the Inpatient Psychiatric Evaluation by Staff F (Attending Physician) dated 2/27/2025, e-signed at 1:03 PM showed a “68-year-old female with a history of schizoaffective disorder, bipolar type. “Upon evaluation on 2/27/2025, patient ... lying in bed ... yelling and screaming ... uses wheelchair to ambulate ... uncooperative ... Patient presents with paranoid delusions and psychosis. Patient was discharged to a shelter on 2/26/2025 and brought back due to continued psychosis ... continues to refuse psychiatric medications.” Disorganized thoughts. Irrational / intrusive thoughts. Delusions. Insight and judgment poor. Unsteady / abnormal gait. Does not appear capable of making rational decisions to maintain safety or safety of others.” Record review of Seclusion & Restraint Packet by Staff Y (RN) dated 3/5/2025 at 8:28 AM showed: Patient #4 “out of control, attempting to attack staff ... spit in [nurses] face ... profanities ... physical hold for about 3 minutes.” Thorazine 50mg, Benadryl 50mg, and Ativan 2mg given intramuscularly. [Thorazine - antipsychotic. Benadryl - antihistamine given to prevent side effects of the antipsychotic. Ativan - anti-anxiety medication. These three medications are often given in combination.] Review of Court-Ordered Mental Health Services signed on 3/10/2025 at 8:57 AM by the Judge, showed Patient #4 was likely to cause serious harm to self or others and was suffering from severe and abnormal mental, emotional, or physical distress with inability to make rational and informed decisions about treatment. Review of Petition for Order to Administer Psychoactive Medication dated 3/10/2025 for court-ordered in-patient mental health services to include antidepressants, antipsychotics, anxiolytics/sedatives/hypnotics, and mood stabilizers. Staff F (Attending Physician) wrote, “The patient is is paranoid, suspicious, guarded, saying people are trying to poison her. She yells, creams, curses at staff and peers. She is irritable, anxious refusing medication ... The patient will continue to be psychotic, violent if she does not receive psychotherapeutics to help her with her psychosis. This impedes her ability to be independent and affects her quality of life.” Review of Psychiatric Progress Note by Staff F (Attending Physician) dated 2/28/2025 e-signed at 4:28 PM showed: “In a wheelchair ... signs of psychosis ... appears to be responding to internal stimuli ... non adherent with all psychiatric medications ... Delusional ... Inpatient psychiatric level of care prescribed is medically necessary.” Review of Psychiatric Progress Note by Staff F (Attending Physician) dated 3/13/2025 e-signed 2:45 PM showed Patient #4 “easily agitated ... continues to exhibit signs of psychosis and delusions ... continues to refuse oral medication and is receiving injection as per medication commitment.” Additional Information. In an interview with Staff C (RM) on 3/19/2025 at 3:25 PM, she stated investigations, such as root cause analyses, are initiated by the Risk Manager. She also stated that there had not been an investigation into the discharge of Patient #4 though there had been a discussion on the afternoon of 3/14/2025 about conducting an RCA [Root Cause Analysis]. In an interview with Staff A (CEO), Staff B (DON), Staff C (RM), and Staff I (Intake Director) on 03/28/2025, they stated they did not have any additional verbal information or supporting documentation concerning Patient #4. They said they did not.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 35028 Based on record review and interviews, the facility failed to ensure that an unresolved patient care grievance made by a family member of 1 (Patient #2) of 3 patients was forwarded to the Patient Advocate for investigation and/or further actions for resolution. This failure resulted in the daughter requesting an early discharge for Patient #2. Findings showed: Review of Policy Number RTS-04, “Patient Grievance Process,” revised 09/01/2024 and approved by the Governing Body, showed: “The policy applies in all Oceans Healthcare facilities. Purpose: To provide an internal process that establishes guidelines for: “ Submission of a patient and/or family’s grievance allegation to the facility “ Timely review and investigation of the allegation “ Provision of a response ... Policy: ... Each facility has identified an individual to serve as the facility Patient Advocate who is responsible for the follow up and response to grievances submitted by a patient or caregiver ... Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient’s rights ... Procedure: ... 2. Depending on the nature of the complaint, the staff will offer resolution at the time the complaint is made, and if resolved, report the encounter to the Patient Advocate. The complaint with resolution will be logged on the ‘Complaint/Grievance Log’ with no additional action. 3. If no resolution is made by staff present at the time of the complaint, the Patient Advocate is notified, and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately ... Review of the Complaint Log for October and November 2024 showed that a complaint from Patient #2, or any family member of Patient #2, had not been recorded on the log. In an interview with Staff D on 12/12/2024, 10:03am-10:14am, she reviewed the progress notes, identified herself as the author, and stated that Patient #2’s daughter expressed concerns over the inability to get fundamental medical equipment - a raised or elevated toilet seat and a walker to assist with ambulation. Staff D also said she did not pass this complaint to any other discipline. In an interview with Staff H (Patient Advocate) on 12/12/2024, 9:30am-9:40am, she stated she did not receive any correspondence from Staff D (Director of Clinical Services) concerning a complaint or grievance made by Patient #2 or any family member of Patient #2. She also stated she should be notified of any complaint or grievance made to clinical staff members by a patient or caregiver.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure two patients (Patient #1 and #15) were not neglected during the discharge process, as shown by the facility: a. transporting two patients (Patient #1 & 15) from the facility to wrong nursing home/personal care home facilities during discharge, along with wrong medications and belongings; b. failing to generate an Incident Report and perform a subsequent investigation for the occurrence, despite having knowledge of the event; c. not following up with receiving facilities at the time of patient discharges for two patients (Patient #1 & 15) to give nurse-to-nurse reports, ensuring safe and effective continuity of care, and; d. failure to document corrective action to prevent future occurrences. Findings included: Review of facility policy #QAPI-004 titled “Incident Reporting”, last revised 8/1/24, showed that one of the purposes of staff writing incident reports was to document potential adverse Patient Incidents discovered. The policy’s definition of Patient Incident is anything that is out of the expected norm for the patient. In addition, the policy states that any staff member who discovers or who has direct knowledge of an incident involving a patient must complete an incident report before leaving the facility at the end of the day or the end of their shift. Review of another facility policy, #PC-18, titled “Discharge Planning: Transition Record”, last revised 10/1/24, showed that the facility shall finalize the patients’ post-treatment care plans with the facility that the patient is being transferred to, for the purposes of meeting their ongoing needs for care and services. Record review of facility’s Incident Report log for August, September and October of 2024 revealed there were no entries or investigations involving Patient #1 or Patient #15. In an interview on 12/12/24 at 10:15 am, Director of Clinical Services (DCS)-Staff #D stated there was an issue with Patient #1’s discharge: When he was transported via Oceans Katy’s van, he apparently “switched belongings and identity” with another patient and was transported to the other patient’s nursing home. The other patient, in turn, was brought to Patient #1’s personal care home. Staff #D added that she did not know the name of the other patient but was told he looked similar to Patient #1. Oceans Katy then received a call from the facility where Patient #1 was brought, a nursing home where the unknown patient was supposed to be. Staff #D then stated there was no incident report done or investigation made by Oceans Katy but would have expected one to have been done for the occurrence. In an interview on 12/12/24 at 10:30 am, Director of Nursing (DON)-Staff #B stated Patient #1 impersonated another patient while in Oceans’ transport van and was brought to the other patient’s nursing home. Further interview with Staff #B revealed she did not know the name of the other patient either and would have expected an Incident Report to have been generated, followed by an investigation. Staff #B also acknowledged that if an incident report was done and an investigation performed, the facility could have determined who the other patient was and attempted to ensure his safety. When questioned about any corrective actions the facility had taken to prevent future occurrences, Staff #B stated that pictures of the patients were now being given to the transport drivers, but this was not documented or placed in any facility policies. In an interview on 12/12/24 at 11:00 am, CEO-Staff #A stated he knew about the event but did not recall who the other patient was that switched identities with Patient #1. Staff #A also stated that after learning of the event, he arranged to have the patients transported to the correct facilities. He also stated that Oceans Katy could have handled the situation better, which included performing an investigation. Staff #A then subsequently performed a search of patients who discharged on 9/12/24 that were present in the van with Patient #1 and presumably determined, through the process of elimination, that the other person was most likely Patient #15. In an interview on 12/12/24 at 12:40 pm, Driver-Staff #P also stated that Patient #1 and another patient switched identities and when he called out Patient #1’s name just before dropping him off, the other patient responded, but Staff #P did not recall who this other patient was either. He also stated that Patient #1 was dropped off with the other patient’s medications and belongings and the other patient was dropped off with Patient #1’s medications and belongings. When questioned if Staff #P believed the other patient was Patient #15, he stated the name sounded very familiar and believed it was the same person. Record review of Patient #1’s medical records showed he was involuntarily admitted to the facility on 8/30/24 and discharged on 9/12/24. His final diagnoses where Dementia, Unspecified, and Schizoaffective disorder. There was no information documented about the patient being transferred to the wrong facility at discharge. Record review of Patient #15’s medical records showed he was voluntarily admitted to the facility on 8/31/24 from a nursing home and discharged on 9/12/24. His diagnoses were Dementia (assessed by his attending physician on 9/11/24 to be Major Neurocognitive disorder, vascular type) and Bipolar disorder, type II. There was no further information about the patient being transferred to the wrong facility at discharge. Record review of Patient #1’s and Patient #15’s medical records revealed Nursing Progress Notes that were identical, written by RN-Staff #O, both dated 9/12/24 at 6:57 pm. The note(s) documented that the patients discharged facility on 9/12/24 at 4:45 pm with their discharge medications and transported by Oceans Katy. RN-Staff #O also documented that the nurses at the “receiving hospital” (no name of nurses or facilities listed) were called to give nurse-to-nurse reports (no times specified when the calls were made) and there was “no response” by the other facilities. There was no further information subsequently documented and no follow-up calls indicating additional attempts were made to contact the other facilities. In addition, there was no indication this lack of contact was ever communicated with other Oceans Katy staff, such as another RN or supervisor. There was no documentation of any follow-up or attempted follow-up with the other facility to ensure continuity of care for Patients #1 & 15. During the interview on 12/12/24 at 10:35, DON-Staff #B acknowledged there should have been more of an effort by RN-#O or other nurses to follow through with contacting the receiving facility. Staff #B also stated the nurse who was supposed to give nurse-to-nurse report was currently out of the country and was not available for interview.”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 35028 Based on record review and interview, the facility failed to ensure that Clinical Services staff documented in the medical record of 1 (Patient #2) of 2 patients concerns raised by family during a family therapy session. This failure resulted in the patient’s daughter requesting an early discharge of Patient #2 who was actively experiencing paranoid delusions, auditory hallucinations, and visual hallucinations. Findings showed: Review of a Family Therapy Session Note dated 10/08/2024, 12:18pm, by Staff D (Director of Clinical Services) for Patient #2 showed: “Therapist spoke to daughter about patient’s admission and concerns. Daughter expressed several concerns about mother’s admission and care including concerns for physical limitations. She shared that patient has always struggled with mental health as evidenced by verbal aggression, flucuating [sic] moods, paranoia, delusions, high anxiety and AVH [auditory and visual hallucinations]. Patient reported AVH to daughter as recently as today, of ‘2 men standing over her bed saying they were going to take her.’ Therapist updated daughter of patient’s current treatment, medication compliance and aftercare plan. Daughter requested early discharge for patient.” Review of Family Therapy Session Note dated 10/10/2024, 4:13pm, by Staff D for Patient #2 showed: “Therapist spoke to patient and daughter about treatment progress and discharge plans ... Patient and daughter struggled to comprehend the reason for Patient’s admission and continued stay. They were minimizing of her behaviors, paranoia, delusions and AVH of ‘men’ ... Daughter will pick up and transport patient at time of discharge.” In an interview with Staff D on 12/12/2024, 10:03am-10:14am, she reviewed the progress notes, identified herself as the author, and stated that Patient #2’s daughter expressed concerns over the inability to get fundamental medical equipment - a raised or elevated toilet seat and a walker to assist with ambulation. Staff D also said that her documentation of the family session was insufficient in that she failed to document the specifics of the complaints voiced by the daughter. Staff D concluded the interview by saying that at the end of the Family Therapy session, the daughter did indeed request an early discharge of her mother from the facility. Review of Policy Number NSG-02, “Documentation,” revised 01/01/2023 and approved by the Governing Body, showed: “This policy applies to all Oceans Healthcare facilities ... Purpose: ... To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as a part of a legal document ...” Review of Policy Number AS-13, “Guidelines for Timely Completion of Clinical Task/Required Documentation” revised 06/01/2023 and approved by the Governing Body, showed: “This policy applies to all Oceans Healthcare facilities ... Purpose: To provide for an effective system to communicate tasks and documentation requirements. It is also a process to ensure follow up and accountability for completion of these tasks. Policy: The hospital ensures that patient care is documented in a complete and timely manner ... Procedure: ... Family ... contacts ... should be documented accordingly in the medical record.” In an interview with Staff B (Director of Nursing) and Staff M (Nursing Supervisor) on 1/12/2024, 12:58-1:15pm, Staff B stated that complaints made to other disciplines by patients or family members concerning nursing care need to the communicated to a member of Nursing Services.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure nursing notes that monitored the patient’s condition and were available for physician review, were entered promptly and accurately in the patient’s records for 1 of 3 patients (Patient #3), as shown by: A. Three consecutive nursing assessment progress notes signed several days after nursing assessment completed, two days after the patient discharged to an emergency room via 911 EMS; B. Inconsistency with documented nursing assessment notes with physician notes, and; C. Inaccurate vital signs documented as done three hours after the patient had already discharged facility via 911 EMS. Findings included: Review of facility policy #NSG-02 titled “Documentation”, last revised 1/1/23, showed that the purpose of documentation was to provide a chronologically continuous account of the patient’s progress to help increase communication among care providers; Nurses are to document the patient’s progress every 12-hour shift. A. Nursing Assessment Notes not entered promptly into records: Record review of Patient #3’s medical chart showed the following: 85-year-old male admitted involuntarily to facility on 8/7/24 from nursing home. Reason for admission was due to decline in mental status; refusing meals and medications; assaultive; combative. Discharge Summary from Dr.-Staff #D showed that on 8/12/24 at 8:47 am, the patient was transferred to Memorial Herman Hospital Katy’s ER via 911 after he was observed in facility dayroom with change in mental status, looking pale, unable to respond to questions, with unstable vital signs including labored breathing. Record review of three consecutive nursing assessments revealed they were performed and signed in a timely manner. However, each of the three assessments had entries for the Nursing Note narrative portion showing patient progress, signed three, four and five days after the assessments were done, and after partrient had already transferred to an ER via 911 EMS. Records were reviewed in two separate types of computerized formats in an attempt clarify times and dates of entries. Both formats failed to show whether there were original nursing notes made at the same time the assessments were done, if there were original nursing notes made during the original assessments and then amended or added to, or, if all the nursing notes were made at the later dates stamped after the assessments were done. It was unclear what notes were available for the physician to review in real time for monitoring patient progress while the patient was still in the facility: The 8/10/24 morning shift Nursing Assessment was done and signed on 8/10/24 at 3:21 pm by RN-Staff #G. However, the Nursing Note, which was part of the nursing assessment, was signed four days later by RN-Staff #G on 8/14/24 at 10:08 am, two days after the patient had discharged to ER. The 8/10/24 evening shift Nursing Assessment was done and signed on 8/10/24 at 9:44 pm by RN-Staff #H. However, the Nursing Note, which was part of the nursing assessment, was signed five days later by RN-Staff #H on 8/15/24 at 2:52 am, three days after the patient had discharged to ER. The 8/11/24 morning shift Nursing Assessment was done on 8/11/24 at 3:01 pm by RN-Staff #G. However, the Nursing Note, which was part of the nursing assessment, was signed three days later by RN-Staff #G on 8/14/24 at 10:03 am, two days after the patient had discharged to ER. In addition to the nursing assessment notes, record review of the Multidisciplinary Progress notes for Patient #3 (separate from, and not contained in the Nursing Assessment notes) showed an entry for the date 8/10/24 by RN-Staff #G: “NP rose notified about patients’ poor appetite, plan of care ongoing” However, it was signed on 8/14/24 at 10:07 am, after the patient emergently discharged on 8/12/24 at 8:47 am. Further record review of Patient #3’s Multidisciplinary Progress notes showed an entry for the date 8/11/24 by RN-Staff #G: “Incoming nurse notified about poor appetite and several attempts to feed patients which proved abortive and follow up required”. However, it was signed on 8/14/24 at 10:06 am, after the patient emergently discharged on 8/12/24 at 8:47 am. In an interview on 8/3/24 at 1:45 pm, DON-Staff #B acknowledged that although the nursing assessments were completed, the notes at the end of the assessments from Staff #G and #H were dated at later times. B. Inconsistent documentation with Nursing Assessment notes: Record review of Patient #3’s clinical records showed there were three Psychiatric Progress Notes from Dr.-Staff #D made on 8/9/24, 8/10/24 and 8/11/24. These three notes showed the physician reviewed Nursing Assessment notes and included them in his progress notes, which were identical verbatim, including the exact same format and structure of the nursing notes (‘copied and pasted’): Psychiatric Progress notes from 8/9/24 included and used the identical 8/9/24 morning shift Nursing Assessment notes, signed 8/9/24 at 10:45 am by RN-Staff #K. And also, Psychiatric Progress notes from 8/10/24 included and used the identical 8/9/24 evening shift Nursing Assessment notes, signed 8/9/24 at 11:30 pm by RN-Staff #H. However, Psychiatric Progress notes from 8/11/24 included all the identical information from the 8/11/24 Nursing Assessment morning shift notes, with the following exception: Per psychiatric notes; “meals consumed-fair appetite”. Per Nursing Notes signed late by RN-Staff #G on 8/14/24 at 10:03 am; “meals consumed-poor appetite,; accepted ensure and coffee but refused solid food” In an interview on 8/3/24 at 1:45 pm, DON-Staff #B acknowledged that although the nursing assessments were completed, the notes at the end of the assessments from Staff #G and #H were dated at later times. C. Inaccurate vital signs documented: Further record review of Patient #3’s clinical records revealed per face sheet and clinical notes, that patient left facility via EMS ambulance at 8:37 am on 8/12/24: Medical progress note from NP-Staff #F dated 8/12/24, signed 9:20 am, read: “8/12/24- found patient with RESP distress, O2 sat < 87% and congestive, less alert. nurse reported that patient has been not eating for past 2 days but VS stable. ordered gave to transfer to hospital via 911”. Discharge Summary from Dr.-Staff #D showed: “Patient transferred to hospital to Memorial Hermann Katy on 8/12 at 8:47am due to change in mental status. Pt was found in dayroom looking pale and unstable. Vitals were abnormal at, 02 sat below 90, HR 126, Labored breathing R-22, BP unable read, BS 154. unable to respond to assessment questions. It was reported that patient had refused food X 3days. Pt refused medications this am and at bedtime.” However, record review of Vital Signs document in Patient #3’s chart, containing all vital signs records recorded during entire patient stay, showed vital signs taken on 8/12/24 at 11:44 am, entered by MHT-Staff #J (three hours after patient left facility): BP 141/88, 97% O2, 80 pulse, Resp=18, Temp 97.1.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 43549 Based on interview and record review the facility failed to protect a patient from a physical assault causing injury for one of one patient with bruises and lacerations (#1) reviewed. Patient #1, a 91 y/o male, oriented to self only with a past medical history of Heart failure, Diabetes, Glaucoma, Alzheimer’s, Dementia and Mood disorder. Occurrence Report 2/29/24 at 06:49 by RN #P stated patient #15 stated patient #1 was coming into his room and refusing to leave despite “persuasion.” Patient #1 was refusing “so he punched him in the face.” Occurrence Report documentation indicates attack occurred at 05:45 am, the prior 6pm to 6 am shift but was documented by staff from the oncoming shift. Actions taken post -incident has “Supervisor notified” marked. No physician or family notification was marked. No indication if the victim was injured was documented. No follow-up resolution was documented. Progress Note 2/29/23 at 06:06 am by RN # R read patient was attacked on his forehead by a peer. Swelling noted on the left forehead. First aid care provided. Vital signs taken. Charge nurse made aware of incident. Daily RN Shift Assessment dated 2/29/24 by RN #Q at 12:41 pm listed interventions as Fall precautions and Q 15-minute checks. Nursing and provider notes 2/30/24 indicate the roomate was moved to another room. Patient #1’s record did include any safety interventions for wandering or hepling him identify his room form others. When interviewed 4/4/24 at 11:45 pm staff # J, Registered Nursing stated every 15 minute rounds are adequate for monitoring all patients unless they are on 1:1 precautions.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to notify a patient of their rights as shown by the facility not informing a patient they may be released from involuntary treatment when their emergency detention warrant expired (Patient #B). Findings included: Review of facility policy titled “Admissions Voluntary And Involuntary Texas” #PC-06, last revised 3/1/21 showed that the facility would explain and document the explanation of the patient’s rights with regard to involuntary treatment and services as they relate to the patient. Record review of Patient #B’s medical records showed that on 8/7/23 she was admitted to the facility voluntarily. The facility then filed with the courts an application of Emergency Detention requesting a mental health warrant, which was subsequently issued by Judge Jason Cox on 8/7/23. The mental health warrant expired after 48 hours yet the patient was still being treated in the facility afterwards. In an interview on 11/16/23 at 2:30 pm, Facility Court Liaison-Staff #14 stated that the facility should have filed for an Order of Protective Custody (OPC) which if approved by a magistrate judge, would have allowed the facility to continue to legally hold and treat the patient involuntarily against their will after the mental health warrant expired. However, there was no evidence an OPC was ever filed, so after the mental health warrant had expired, the facility should not have held the patient and should have communicated this to the patient. Further record review of Patient #B’s medical records failed to show any documentation the patient was informed of her right to leave the hospital after her mental health warrant had expired, as there was no legal basis to hold and treat the patient any longer.”