Sun Behavioral Houston

“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 observations, interviews, and record reviews, the facility failed to ensure that 1 of 1 patients (Patient #1) was admitted into the safest, most appropriate unit based on his history of sexual abuse of his sister and sexual abuse of two male schoolmates. The Intake Department did not fully utilize the information captured in the “Child History Sexual Report” (Attachment A) provided by CPS - a report that outlined Patient #1’s sexual predatory behaviors - when staff assigned him to the Compass Girl’s unit. Additionally, the facility failed to provide a level of observation commensurate with the severity of Patient #1’s sexual predatory behaviors. The findings included: Review of policy 19609663, “Rights of Persons with Mental Illness,” last approved 1.2026, showed: “Purpose: to assure the rights of all patients admitted to SUN Behavioral Houston inpatient services are protected ... The right to a humane treatment environment that ensures protection from harm.” Patient #1 Medical Record. Review of Face Sheet showed Patient #1 was admitted on 1.14.2026 at 2:58pm. Review of “Child Sexual History Report” (Attachment A) for Patient #1 showed, “The youth is determined to have a sexual behavior problem due to their [sic] child sexual aggression designation. [He] has a pattern of touching other children and made statements his victims like it. [His] therapist indicated [he] will likely re-offend ... “[He] should be closely monitored while in the presence of any children both younger and older [and] in a room by himself ... Sexual Aggression History 12.15.2023 - victim was his 14yo sister. His mom contacted the police and filed a police report. 10.31.2023 - victim was another student on a field trip. Patient #1 touched him in his privates and then tried to touch the other student a second time. 10.28.2022 - victim after school program classmate. Patient $1 had been “grooming two children for a couple of weeks by giving them pens, money, and candy.” He touched one a boy’s penis. A police report was filed. The report was signed by Staff K (Intake RN) on 1.14.2026 (not timed). Review of Physician Orders by Staff I (MD) showed Sexually Acting Out Precautions and a Blocked Room dated 1.14.2026 at 3:23pm and 3:26pm respectively. “Comments: The patient is currently in CPS custody. While the patient denies a personal history of sexual abuse, collateral documentation from CPS (Attachment B) indicates concerns regarding impulse control and sexualized behaviors, recommending that the patient be closely monitored around other children, both younger and older, until improvement is demonstrated.” Review of Notes by Staff H (RN) dated 1.15.2026 at 8:50am showed that Patient #1 touched a peer that was standing in front of him while in the cafeteria. Once the patient returned to the unit, the nurse reminded him of expectations. He replied loudly, “Why am I even on the unit with all of these girls?”. Immediately after his response, several female peers started reporting that patient makes them feel uncomfortable as he stands too close to them. The patient’s guardian was notified. Guardian stated, “One of your staff was made aware of the severity of the situation. Did you guys not know that he has a pattern of such behavior? It is in his attachment A that was signed by one of your staff members.” Patient #1 was escorted to the boy’s unit. Review of Psychiatric Evaluation by Staff I (MD) dated 1.15.26 at 10:48am showed a 14-year-old male with thoughts of harming himself. “Earlier this am, nurse informed me that patient was trying to touch other female patients inappropriately and had to be transferred to boy’s unit.” Below average intellectual functioning. Level of observation: Routine 15-minute checks, Elopement Precautions, SAO (Potential for Sexual Acting Out Review of Physician Progress Note by Staff J (PMHNP) dated 1.16.2026 at 6:12pm showed, “Per nursing report earlier this morning, the patient [Patient #1] demonstrated inappropriate behavioral boundaries, including attempting to touch female peers inappropriately, which necessitated immediate redirection and transfer to the boys’ unit for safety and behavioral management. Since the transfer, no further inappropriate behaviors or escalation have been observed during today’s shift.” Review of Discharge Summary by Staff J (PMHNP) dated 1.19.2026 at 6:33pm showed, “He initially presented with hyperactivity, restlessness, and limited insight, with behaviors suggesting impaired judgment and poor boundaries, including an incident of inappropriate touching of female peers that necessitated transfer to the boys’ unit for safety and supervision.” Patient #2 Medical Record. Review of Psychiatric Evaluation for Patient #2 dated 1.9.2026 at 10:02am by Staff I (MD) showed a 13-year-old female with a lifetime of trauma abuse victimization - physical and sexual abuse. Review of Notes by Staff H (RN) dated 1.15.2026 at 12:27pm showed that Patient #2 reported that Patient #1 touched her while in the dining room and it made her “feel uncomfortable.” Video Surveillance Footage. Review of the video surveillance footage for the morning of 1.15.2026 showed the patients from Compass Girls Unit in the cafeteria being served breakfast. At the beginning of the footage, some of the patients had gone through the serving line and were already seated at tables, some patients were in line being served, and some patients were standing in line waiting to be served - namely Patient #1 and Patient #2. The footage captured neither the patients arriving at the cafeteria nor the patients that were already seated being served. During the viewing of the video surveillance footage on 3.3.2026 at 10:45am, Staff A (Risk Director) was asked to see the video surveillance footage for the morning of 1.15.2026 that occurred prior to the footage that was provided to the surveyor to preview. Staff A stated that prior footage was no longer available for review. Any interaction happening prior to the saved footage between Patients #1 and #2 has been lost. Additional interviews. In an interview with Staff E (Intake Director) on 3.3.2026at 11:45am, he stated: 1) Patient #1 was a walk-in, not a transfer from an emergency department. 2) The Attachment A document was reviewed during the Intake process. 3) The bed assignment for Patient #1 was made by Staff G (Intake Clerk). 4) To have put Patient #1 on the Compass Boy’s unit, another boy would have had to have been moved to the Compass Girl’s unit, adding, “He [Patient #1] was moved the next morning to the boy’s unit.” [NOTE: This move was after the alleged incident with Patient #2.] 5) He does not know if a one-on-one was considered for Patient #1. In an interview with Staff D (Medical Director) on 3.3.2026 at 12:35pm, he stated: 1) Patient #1 needed to be placed on a one-on-one at the time of admission. 2) A bedroom should have been provided for Patient #1 on the Boy’s Compass unit even if it meant moving a more appropriate boy to the Girl’s Compass unit. 3) More of the video surveillance footage should have been saved for the investigation.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 35028 . Based on observations, interview, and record review, the facility failed to ensure that the parents or representatives for 10 of 10 adolescent patients (Patient #3, 10, 11, 12, 13, 14, 15, 16, 17, and Patient #18) were provided with a “Consent to Treatment with Medications” form for each medication. This failure resulted in parents or representatives not being provided with the information needed to make informed decisions regarding care - information such as: 1) Consequences of not taking the medication, 2) Benefits of the medication, and 3) Potential side effects of the medication. This practice was incongruent with the facility’s policy on medication consents. Findings were: Review of policy 19238227, “Medication Consent,” Patient Rights Area, last approved 11.2025, showed, “It is the policy of the Hospital to obtain consent for treatment with psychoactive medication ... For children and adolescents, all medications require consent ... Procedure: The treating provider or designee must present this information about psychoactive medication in simple, non-technical language ... The beneficial effects expected because of treatment with the medication. The probable health and mental consequences to the patient if not taking the medication ... and side effects ... The patient and ... legal representative must also be provided a summary of this information in writing also with an offer to answer any questions concerning treatment ... Documentation of Informed Consent - Informed consent for the administration of psychoactive medication will be evidenced by a completed copy of the consent form.” Record review of the Consent to Treatment with Medications forms showed that multiple medications were listed on one form for 10 of 10 adolescent patients (Patient #3, 10, 11, 12, 13, 14, 15, 16, 17, and Patient #18). The form did not provide information about each psychoactive medication in simple, non-technical language. The form did not provide beneficial effects expected with the medication, probable health and mental consequences if not taking the medications, or side effects. Patient #3. The Consent to Treatment with Medications included Tylenol, Omnicef, Vistaril [used to treat anxiety], MOM, Intuniv [non-stimulant used to treat ADHD - attention deficit hyperactivity disorder], Lexapro [antidepressant], and Benadryl [can be used to treat insomnia]. Patient #10. The Consent to Treatment with Medications included Prozac, Tylenol, Vyvanse [stimulant used to treat ADHD], Vistaril, MOM, Catapres [used to treat anxiety], Abilify [antipsychotic], Depakote DR [mood stabilizer], Benadryl, and Zyprexa [antipsychotic]. Patient #11. The Consent to Treatment with Medications included Tylenol, Neosporin, Vistaril, Zoloft [antidepressant], MOM, and Benadryl. Patient #12. The Consent to Treatment with Medications included Prozac [antidepressant], Tylenol, Vistaril, MOM, Revia [can be used to target compulsive behaviors], and Neosporin. Patient #13. The Consent to Treatment with Medications included Tylenol, Miralax, Vistaril, Linzess [used to treat irritable bowel syndrome], Benadryl, and MOM. Patient #14. The Consent to Treatment with Medications included Tylenol, Maalox, Vistaril, MOM, and Benadryl. Patient #15. The Consent to Treatment with Medications included Tylenol, Vistaril, MOM, and Abilify. Patient #16. The Consent to Treatment with Medications included Symmetrel, Adderall XR [stimulant used to treat ADHD], Tylenol, Risperdal, Vistaril, MOM, and Benadryl. Patient #17. The Consent to Treatment with Medications included Tylenol, Concerta [stimulant used to treat ADHD], Vistaril, and MOM. Patient #18. The Consent to Treatment with Medications included Tylenol, Vistaril, MOM, and Benadryl. In an interview with Staff A (RM/QD) on 2.12.2026 at 1:00pm, she stated that the facility’s consent form for medications lists all medications on one form, adding, “We need a separate consent form for each medication.” In an interview with Staff E (RN) on 2.12.2026 at 1:41pm, he stated he was familiar with the “Consent to Treatment with Medications” form. He stated that he provides side effects to the patient “off the top of my head.” He stated that a consent form that included information about each psychoactive medication in simple, non-technical language, along with the beneficial effects expected with the medication, probable health and mental consequences if not taking the medications, or side effects would be helpful. In an interview with Staff N (RN) on 2.12.2026 at 2:48pm, he stated that a consent form that included information about each psychoactive medication in simple, non-technical language, along with the beneficial effects expected with the medication, probable health and mental consequences if not taking the medications, or side effects was needed. .”

“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 1 of 1 patients (Patient #3) received care in a safe setting as evidenced by the facility’s failure to conduct an investigation into the circumstances in which Patient #3, a 12-year-old on suicide precautions, had a shoestring hidden in her bedroom under the mattress - an item the patient identified as something that could be used for self-harm. Because an incident report was not completed by the nurse, the Risk Manager did no know of the incident. Findings were: Review of policy 18119525, “Contraband and Restricted Articles,” Admissions Area, last approved 5.2026, showed: “Purpose: To ensure a safe environment ... Policy: Items, which are considered a danger or potential danger to patients and others, will be locked in the secure location ... Procedure: On admission, patient will have ... belongings checked ... The following is a list of items that are not allowed during the hospital stay ... 6. ... strings ... 19. Shoes ... strings” Review of policy 19395886, “Incident Report Protocol,” Risk Management Area, last approved 1.2026, showed: “Department managers/supervisors shall ensure that all incidents involving patient, staff or visitor injury, occupational illness or property damage have an incident report completed. Procedure: Incident reports are to be filled out for any unusual or dangerous occurrence ... It is essential that the appropriate hospital leadership is notified of significant events ... Additionally, the CEO, Risk Management Director and Medical Director are notified for events that are high risk events as defined by the hospital ... The incident report should be completed as soon as possible after the incident has occurred and supervisor notified.” Record review of the Psychiatric Evaluation by Staff F (Attending MD) dated 1.5.2026, 7:31pm, showed: Chief Complaint: “Wanting to kill myself by cutting my left arm with a razor blade.” History of suicide attempts. History of self-harm by cutting her arms. Past Psychiatric Treatment History: Kingwood one week ago following a suicide attempt. Past Medical History: laceration on right leg. Depressed mood. Active suicidal ideation. Judgment impaired. Diagnoses: Major depressive disorder, severe; attention deficit hyperactivity disorder; post-traumatic stress disorder Close Visual Observation each shift. Suicide/Self-Harm Precautions. Record review of Physician Orders by Staff K (Admitting MD) showed the following precautions ordered on 1.5.2026 at 4:29am: High Alert Suicide Risk, Suicide/Self-Harm Precautions, Close Visual Observation. The orders were cosigned by Staff F (Attending MD) on 1.5.2026 at 6:54pm. Record review of the Daily RN Assessment Note 7pm-7am by Staff H (RN) on 1.11.2026 at 7:45pm showed: Suicide/Self-Harm Precautions. “Patient [#3] told her mom during visitation that she has something in her room to hurt self. Staff went to patient’s room to check, and a shoestring was found under patient’s mattress.” There was no documentation of an assessment by Staff H that would answer the questions of how, when, where, or why. In an interview with Staff H (RN) on 2.19.2026 at 10:10am, she stated that the mother of Patient #3 phoned her at the beginning of the shift with the information that the patient had something in her room to harm herself. Staff H checked under the mattress “because sometimes patients hide snacks under their mattress.” Staff H found a shoestring under the mattress. She stated she took the shoestring to the nurse’s station, adding she did not know the current whereabouts of the shoestring. She also stated that Patient #3 would not disclose where she got the shoestring. Staff H (RN) also stated that within a two-hour period, the patient could change her answer to the question, are you having any suicidal thoughts? Staff H concluded by saying she did not report the incident to the Nursing Supervisor or the attending physician and that an incident report was not logged into the computer system. In an interview with Staff A (RM/QD) on 2.12.2026 at 12:00pm, the surveyor shared the note written by Staff H (RN) dated 1.11.2026 at 7:45pm. In that note, Staff H (RN) documented the incident with the shoestring. Staff A (RM/QD) stated that this was the first time she had heard about the shoestring. In another interview on 2.19.2026 at 10:17am, Staff A (RM/QD) stated she did not get an incident report from Staff H (RN) about the shoestring. She reiterated that had she known about the shoestring, an investigation would have been conducted, adding that, unfortunately, she could not capture the necessary information needed to do a thorough investigation at this point. In an interview with Staff F (Attending Physician) on 2.12.2026 at 12:22pm, she stated she knew nothing about the shoestring, adding, “Had I known, I would have charted it.” Record review of the Discharge Summary by Staff F (MD) dated 1.12.2026 at 1:14pm showed that Patient #3 was discharged on 1.12.2026, the day after the shoestring incident. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure 1 of 1 patients (Patient #3) received care that was free of neglect. A) This negligence was evidenced by the facility’s failure to provide a safe discharge. Specifically, the patient, a 12-year-old female with a history of cutting behaviors, was discharged home with documented suicidal ideation. Within 48 hours of discharge, she cut her neck and forearm with scissors, requiring treatment at Texas Children’s Hospital. B) Additionally, this negligence was evidenced by the facility’s failure to ensure that an investigation was conducted when Patient #3 alleged sexual assault by her roommate. Patient #3 told a therapist of the assault. The therapist did not complete an incident report. Because there was no incident report that would trigger an investigation, no investigation was conducted. Findings were: A) Discharge of Patient #3. Record review of the Intake Assessment by Staff L (Intake RN) dated 1.5.2026, 4:20am, showed a 12-year-old female stating she wanted to kill herself “by cutting my left arm with a razor blade.” The Columbia-Suicide Severity Rating Scale - Intake Screening: She stated she has wished she were dead and has had thoughts of killing herself. She also has had thoughts of how to kill self - cut her left arm with a razor blade. She disclosed an intention of acting on these thoughts of killing herself and has worked out the details. The Intake Screening showed a HIGH RISK with a history of self-harm. Risk Factors included feelings of hopelessness and a history of suicide attempts. She was hospitalized at Kingwood Pines December 2025. Her impulse control was poor. Record review of the Psychiatric Evaluation by Staff F (Attending MD) dated 1.5.2026, 7:31pm, showed: Chief Complaint: “Wanting to kill myself by cutting my left arm with a razor blade.” History of suicide attempts and self-harm by cutting her arms. Past Psychiatric Treatment: Kingwood Hospital one week ago following a suicide attempt. Depressed mood. Active suicidal ideation. Judgment impaired. Diagnoses: Major depressive disorder, severe; attention deficit hyperactivity disorder; post-traumatic stress disorder Close Visual Observation each shift. Suicide/Self-Harm Precautions. Review of the Discharge Summary by Staff F (MD) dated 1.12.2026 at 1:14pm showed: Mental Status at Time of Discharge [and] summary of psychiatric condition at the time of discharge: “Had thoughts of killing herself today. ‘I overthought about school and bullying.’” In an interview with Staff F (MD) on 2.12.2026 at 12:22pm and 2.13.2026 at 8:53am to discuss the Discharge Summary, she stated that Patient #3 had thoughts of suicide that would “come and go.” She also stated that Patient #3 was “overthinking about hurting herself, school, and bullying” and “there were body image concerns.” Review of the H&P by Staff M (MD) initiated on 1.14.2026 and electronically signed on 1.15.2026 at 12:47am at Texas Children’s Hospital, showed: Suicidal ideation, history of depression, anxiety with multiple prior inpatient psychiatry stays. Pending placement in inpatient facility. Patient had “cut forearm and neck with scissors and expressed suicidal ideation with mother.” He noted, “superficial lacerations over neck, forearm.” B) No investigation of alleged sexual assault by Patient #3. Review of policy 18538446, “Abuse and Neglect Reporting,” Patient Rights Area, last approved 7.2025, showed: “Patients have the right to be reasonably free from ... sexual ... abuse ... Procedure: Management of Suspected Abuse/Neglect: Cases of suspected sexual abuse ... or neglect will be given priority and will be investigated thoroughly ... Any allegation of suspected abuse or neglect that is peer to peer will result in immediate separation of the peers and may include separation to another unit if necessary.” Census Sheet dated 1.6.2026 at midnight showed: Room 318-A - Open bed Room 318-B - Patient #3 Census Sheet dated 1.7.2026 at midnight showed: Room 318-A - Patient #19 Room 318-B - Patient #3 Record review of a Note by Staff I (LMSW), dated 1.7.2026, 9:23am, showed: At the end of group time, Patient #3 reported that her peer “forced herself on me. She kissed me”. The patient also stated that this happened “Monday [1/5 - day of admission] in the room when she was putting on deodorant.” In an Interview with Staff I (LMSW), on 2.11.2026 at 11:15am, she stated that during group on 1.7.2026, Patient #3 stated she had a problem with a peer. After group, Patient #3 stated her roommate was making her uncomfortable, adding that the nursing staff had already changed her room assignment that day. Staff I (LMSW) also stated: “ She documented that Patient #3 reported, “A peer forced herself on me. She kissed me.” “ She did not know if Patient #3 had spoken to a staff member about the incident. “ She reported the incident to a Mental Health Technician and an RN, adding, “I think it was Staff D (RN).” (On 2.19.2026 at 7:15am Staff I (LMSW) stated she did not remember which RN she reported the incident to.) “ She reported the incident to Staff J (DCS - Director of Clinical Services). “ She did not complete an incident report, assuming Staff D (RN) would complete the report. In an interview with Staff D (RN) on 2.18.2026 at 3:30pm, she stated she knew nothing about the allegation of sexual inappropriateness made by Patient #3, adding that Staff I (LMSW) did not tell her of Patient #3’s allegations. Staff D (RN) also stated that had she know of the allegations, she would have spoken with the patient, informed the doctor and the nursing supervisor, and moved Patient #3 or her roommate to another room. In an interview with Staff J (DCS) on 2.19.2026 at 9:00am, she stated that Staff I (LMSW) reported to her the allegation of sexual inappropriateness made by Patient #3. She also stated that Staff I (LMSW) stated the nurse would complete the incident report. In an interview with Staff A (RM/QD) on 2.19.2026 at 9:30am, she stated an investigation into the sexual allegations made by Patient #3 was not completed by her because she was never informed of the incident. She also stated that it was the responsibility Staff I (LMSW) to fill out the incident report since she was the staff member that was provided firsthand information by Patient #3. .”

“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 observation, staff interviews, and record review, the facility failed to ensure that 1 of 1 RNs (Staff H) reported pertinent information to the nursing supervisor and completed an incident report when Patient #3 was found to have a shoestring hidden in her bedroom under the mattress - an item the patient identified as something that could be used for self-harm. Due to this failure, an investigation into this incident was not conducted. Findings were: Review of policy 19395886, “Incident Report Protocol,” Risk Management Area, last approved 1.2026, showed: “Department managers/supervisors shall ensure that all incidents involving patient, staff or visitor injury, occupational illness or property damage have an incident report completed. Procedure: Incident reports are to be filled out for any unusual or dangerous occurrence ... It is essential that the appropriate hospital leadership is notified of significant events ... Additionally, the CEO, Risk Management Director and Medical Director are notified for events that are high risk events as defined by the hospital ... The incident report should be completed as soon as possible after the incident has occurred and supervisor notified.” Review of policy 18119525, “Contraband and Restricted Articles,” Admissions Area, last approved 5.2026, showed: “Purpose: To ensure a safe environment ... Policy: Items, which are considered a danger or potential danger to patients and others, will be locked in the secure location ... Procedure: On admission, patient will have ... belongings checked ... The following is a list of items that are not allowed during the hospital stay ... 6. ... strings ... 19. Shoes ... strings” Record review of the Daily RN Assessment Note 7pm-7am by Staff H (RN) on 1.11.2026 at 7:45pm showed: Suicide/Self-Harm Precautions. “Patient [#3] told her mom during visitation that she has something in her room to hurt self. Staff went to patient’s room to check, and a shoestring was found under patient’s mattress.” There was no documentation of an assessment by Staff H that would answer questions of how, when, where, or why. In an interview with Staff H (RN) on 2.19.2026 at 10:10am, she stated that the mother of Patient #3 phoned her at the beginning of the shift with the information that the patient had something in her room to harm herself. Staff H checked under the mattress “because sometimes patients hide snacks under their mattress.” Staff H found a shoestring under the mattress. She stated she took the shoestring to the nurse’s station, adding she did not know the current whereabouts of the shoestring. She also stated that Patient #3 would not disclose where she got the shoestring. Staff H (RN) also stated that within a two-hour period, the patient could change her answer to the question, are you having any suicidal thoughts? Staff H concluded by saying she did not report the incident to the Nursing Supervisor or the attending physician and that an incident report was not logged into the computer system. In an interview with Staff A (RM/QD) on 2.12.2026 at 12:00pm, the surveyor shared the note written by Staff H (RN) dated 1.11.2026 at 7:45pm. In that note, Staff H (RN) documented the incident with the shoestring. Staff A (RM/QD) stated that this was the first time she had heard about the shoestring. In another interview on 2.19.2026 at 10:17am, Staff A (RM/QD) stated she did not get an incident report from Staff H (RN) about the shoestring. She reiterated that had she known about the shoestring, an investigation would have been conducted, adding that, unfortunately, she could not capture the necessary information needed to do a thorough investigation at this point. .”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 35028 . Based on observation, staff interviews, and record review, the facility failed to ensure 1 of 1 patients (Patient #3) was provided a re-evaluation of her condition to identify changes that required modification of the discharge plan. Specifically, the patient, a 12-year-old female with a history of self-mutilation/cutting behaviors, was discharged home with documented suicidal ideation in the Discharge Summary. Within 48 hours of discharge, she cut her neck and forearm with scissors, requiring treatment at Texas Children’s Hospital. Findings were: Record review of the Intake Assessment by Staff L (Intake RN) dated 1.5.2026, 4:20am, showed a 12-year-old female stating she wanted to kill herself “by cutting my left arm with a razor blade.” The Columbia-Suicide Severity Rating Scale - Intake Screening: She stated she has wished she were dead and has had thoughts of killing herself. She also has had thoughts of how to kill self - cut her left arm with a razor blade. She disclosed an intention of acting on these thoughts of killing herself and has worked out the details. The Intake Screening showed a HIGH RISK with a history of self-harm. Risk Factors included feelings of hopelessness and a history of suicide attempts. She was hospitalized at Kingwood Pines December 2025. Her impulse control was poor. Record review of the Psychiatric Evaluation by Staff F (Attending MD) dated 1.5.2026, 7:31pm, showed: Chief Complaint: “Wanting to kill myself by cutting my left arm with a razor blade.” History of suicide attempts and self-harm by cutting her arms. Past Psychiatric Treatment: Kingwood Hospital one week ago following a suicide attempt. Depressed mood. Active suicidal ideation. Judgment impaired. Diagnoses: Major depressive disorder, severe; attention deficit hyperactivity disorder; post-traumatic stress disorder Close Visual Observation each shift. Suicide/Self-Harm Precautions. Review of the Discharge Summary by Staff F (MD) dated 1.12.2026 at 1:14pm showed: Mental Status at Time of Discharge [and] summary of psychiatric condition at the time of discharge: “Had thoughts of killing herself today. ‘I overthought about school and bullying.’” In an interview with Staff F (MD) on 2.12.2026 at 12:22pm and 2.13.2026 at 8:53am to discuss the Discharge Summary, she stated that Patient #3 had thoughts of suicide that would “come and go.” She also stated that Patient #3 was “overthinking about hurting herself, school, and bullying” and “there were body image concerns.” Review of the H&P by Staff M (MD) initiated on 1.14.2026 and electronically signed on 1.15.2026 at 12:47am at Texas Children’s Hospital, showed: Suicidal ideation, history of depression, anxiety with multiple prior inpatient psychiatry stays. Pending placement in inpatient facility. Patient had “cut forearm and neck with scissors and expressed suicidal ideation with mother.” He noted, “superficial lacerations over neck, forearm.” .”

“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: 37490 Based on record review and interview, the facility failed to ensure delegated nursing care was provided per physician orders and facility policy for 2 of 3 patients (ID#s 1 and 9 ). Findings include: Review of facility policy titled “Plan for the Provision of Nursing Care,” showed the following: GOAL OF NURSING CARE ASSIGNMENT: Nursing care assignments, regardless of the reporting relationship of the nursing providing such care, shall be appropriate with the qualifications and competency of the individual and shall be designed to meet the identified nursing care needs of patients. A registered nurse shall assess nursing care needs. The Nurse Executive The Nurse executive directs the implementation of the nursing policies and procedures, nursing standards, and nurse staffing plan(s). -A Registered Nurse assigns nursing care for each patient to other nursing personnel in accordance with the patient’s needs and the qualifications and competence of the nursing staff available. This assignment will be documented on the shift assignment sheet for each unit. ASSIGNMENT OF STAFF TO PROVIDE NURSING SERVICES: D. Nursing staff assignments are required to be completed for each shift. These assignment are critical to ensure each team member knows their duties for the shift. Some examples of assignments include (but is not limited to), who is responsible for: -documentation of patients -administering medications -completing close 15 minutes observations to monitor 1:1 or CVO patients, if there are any present on the unit -monitoring visitation -leading and co leading groups designating employees who are to respond to hospital wide medical/behavioral -emergencies and or codes. -completing and documenting vital signs -when employees are assigned to take their breaks All nursing staff (RN,LVN and MHT) are required to obtain shift report as they come onto their hift (for each unit). The assignment sheet is expected to be completed during shift report, for all oncoming nursing team members, and distributed at the end of shift report, so everyone is aware of their assignments. The Mental Health Technician and/or the nurse are also expected to conduct environmental safety rounds each shift to ensure the safety of the unit. After shift report the oncoming MHT (or nurse) will make a round with the off going MHT (or nurse), to do safety rounds and ensure that the unit is safe. Both staff members are responsible to sign the sheet indicating the round has been completed. This is to be completed at each change of shift. PROCEDURE: ... Based on census and patient acuity, the needs of each unit are evaluated on a shift or partial shift basis by the Staffing Coordinator, in collaboration with the charge nurse, in order to provide optimal patient care that is fiscally sound. Staffing adjustments, which may include additional staff, cancellation of staff or reassignment of staff, are made by the Staffing Coordinator and schedules are updated as necessary. 24-hour staffing schedules are posted on each unit. Master copies of all schedules, daily staffing sheets and acuity reports are kept on file in the hospital Nursing Office for a period of three (3) years. -Variance between projected needs and actual staffing are described, acknowledged and justified according to census and acuity. Review of facility policy titled “Levels of Observation and Precaution Levels,” showed the following information: POLCY: All patients will be routinely observed in compliance with physician orders and prescribed protocols. PROCEDURE: 1. The physician shall order one of three levels of observation at time of admission and may change the level of observation if the patient’s condition warrants a change. The level of observation is to be documented on the close 15-minute observation sheet daily or when any changes are made. When changes are made, the date and time must be documented as well ... -Q15 minute -Close Visual Observation -One-to-one 7. Close Visual Observation (CVO) Patients to score a moderate or high alert will Be further evaluated for the need for CVO or 1:1 Level of observation ... If the patient is placed on CVO, the below applies: -Staff will maintain close visual observation. Through direct visual observation period. This direct observation will include the ability to maintain visualization of the person to maintain safety for the identified reason for the CVO Level of observation. -When patients, shower, change clothes or use the bathroom, The staff will remain outside of the bedroom or bathroom door with the door slightly open for visual observation. Of the patient. Staff will maintain the patient’s privacy as much as possible; However. The safety of the patient must be the main consideration. Record review of Nursing assignments sheet dated 11/26/25 7a-7p showed the following: Satff ID# 54 was the registered Nurse (RN) that shift. Q15 min Observation Rounds and CVO from 7a-3p was assigned to Mental Health Technician (MHT) staff ID# 58. Q15 min Observation Rounds and CVO from 3p-7p was assigned to Mental Health Technician (MHT) staff ID# 57. Patient ID#s 1, 9 and 10 had CVO observation level assigned. Review of medical record for patient ID#1 showed the following: Physician Order dated 11/21/25 5:06 am Close Visual Observation (CVO) Every Shift, Reason: Moderate Suicide Risk, Comments: within line of sight. Rounding sheets dated 11/26/25 showed no precaution or observation level documented. At 5:17 PM the patient was documented to be calm and in the shower by staff ID# 57. Review of medical record for patient ID#9 showed the following: Physician Order dated 11/25/25 7:46 pm Close Visual Observation (CVO) Every Shift, Reason: Moderate Suicide Risk, Comments: within line of sight. Rounding sheets dated 11/26/25 showed no precaution or observation level documented. At 5:17 PM the patient was documented to be calm and in the shower by staff ID# 57. Both patients being observed in the shower by the same staff at the same time in rooms down and across the hall from each other. Interview with staff ID # 55 on 1/12/2025 at 1:43 pm stated that line of site by one staff member would not be possible at the same time in these rooms, due to location and room layout.”

“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: 37322 Based on observation and interview the facility failed to insure the right to wear suitable clothing which is neat, clean, and well-fitting for 1 of 1 patients (ID#25) on the male Bridges unit. Patient (ID#25) was observed on 4/23/25 at 11:10 am seated in the unit dayroom. The patient called this surveyor over to speak to him and pointed out his dirty tattered clothing. His T-shirt was visablly soiled, with a lateral tear on the bottom from the hem to above the navel area and was approximately eight inches in length, from his abdomen and upper groin area. His knit pull-on slacks were soiled and stained in multiple places with an emitted foul odor like urine. The patient stated he was admitted in these clothes and had none other. He stated he had asked several staff if he could change into clean clothes but did not get a response. He stated he was told by an unknown male staff that there were no scrubs in his size and he would have to where the clothes he arrived in. The patient asked if there were donated clothes in the facility he could wear and stood up. He confirmed that he was approximately 6’3” and 350 lbs. The two unit nurses (ID#L,T) were asked on 4/23/25 at 11:25 am if they were aware of the patients (ID#25) soiled and torn clothing. Both responded they were aware but had no clothes. They stated they had not considered checking if there were donated clothes because he was such a large man and left it at that. When asked how he was to shower and be clean in the clothes he had they did not respond. This surveyor asked them to check and to please find the patient something to change into. They said they would work in it. Patient (ID#25) was observed on 4/25/25 at 1:55 pm on Bridges unit in the same torn dirty clothing. Upon interview the patient (ID#25) who stated no one had approached him about getting clean clothing. The unit nurse (ID# L,T ) was asked on 4/25/25 at 2:05 pm if there were any clean clothes available for patient (ID #25) soiled and torn clothing. The nurse responded there had been no attempt to get clothing for patient (ID#25) that he knew of. When interviewed 4/25/25 at 4:00 pm staff (ID#D) Chief Nursing Officer stated the facility did not have clothing to fit patient (ID#25) who she thought was a size 5X. When asked if she expected the patient to wear the same dirty clothes during his hospitalization she was silent. After a few minuted she responded “Will I guess we can get something from a store.””

“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, interview, and record review, the facility failed to provide services necessary to protect 2 of 2 patients (Patient #1 and Patient #2). This was evidenced by the facility’s failure to ensure that observation rounds were conducted every 15 minutes during the early morning of 2/18/2025. During this timeframe, Patient #1 and Patient #2 leveled allegations that sexual misconduct had transpired between them. Findings were: Review of policy 17820416 - Levels of Observation and Precaution Levels, last reviewed 03/2025, showed: All patients will be routinely observed in compliance with physician orders and prescribed protocols ... Staff will observe patient and document on the Patient Observation Record every 15 minutes. Review of the Accountability Flow Sheet (Patient Observation Record) for Patient #1 on the Children’s Unit showed the following entries documenting the date and time, and staff member making the entry. 2/17/2025 - 11:31 PM, 1:02 AM = 31 minutes. Staff Q (MHT) 2/18/2025 - 2:46 AM, 3:11 AM = 25 minutes. Staff Q (MHT) 2/18/2025 - 6:17 AM, 6:41 AM = 29 minutes. Staff Q (MHT) 2/18/2025 - 6:43 PM, 7:13 PM = 30 minutes. Staff O (MHT) Review of the Accountability Flow Sheet (Patient Observation Record) for Patient #2 on the Children’s Unit showed the following entries documenting the date and time, and staff member making the entry. 2/18/2025 - 2:46 AM, 3:11 AM = 25 minutes. Staff Q (MHT) 2/18/2025 - 4:01 AM, 4:29 AM = 28 minutes. Staff Q (MHT) 2/18/2025 - 5:48 AM, 6:16 AM = 28 minutes. Staff Q (MHT) 2/18/2025 - 6:43 PM, 7:13 PM = 30 minutes. Staff O (MHT) 2/18/2025 - 11:46 PM, 12:19 AM = 33 minutes. Staff Q (MHT) Patient #1. Review of the Psychiatric Evaluation by Staff J (MD) dated 2/13/2025 at 9:41 AM showed Patient #1 was a 9-year-old male admitted from a residential treatment facility for mood issues, anger, homicidal thoughts, and suicidal thoughts with a plan to stab himself. Review of Nursing Note by Staff G (RN) dated 2/18/2025 at 8:02 PM showed that Patient #1 reported sexual contact between himself and Patient #2 during the night. Patient #2. Review of the Psychiatric Evaluation by Staff X (MD) dated 2/19/2025 at 1:12 AM showed Patient #2 was a 9-year-old male admitted with anger and aggression and homicidal thoughts. Review of Nursing Note by Staff G (RN) dated 2/18/2025 at 7:24 PM showed that Patient #2 reported sexual contact between himself and Patient #1 during the night.”

“MEDICAL STAFF - BYLAWS CFR(s): 482.12(a)(3) [The governing body must] assure that the medical staff has bylaws. This Standard is not met as evidenced by: 46010 Based on observation, interview and record review, the facility failed to ensure that thorough physician assessments/patient encounters were documented by the physician performing and completing Certificate of Medical Examinations (CME) to obtain an Order of Protective Custody (OPC) on 4/5 patients reviewed (Patient ID #1, 12, 26 and 28). Findings included: Observation of Camera footage with Director of Risk Staff ID #A on 11/13/2024 at 1:15 pm. Camera footage of security cameras labeled 2 West and 2 South was reviewed for date 11/12/2024 with Staff ID #A. She confirmed there was no evidence of Physician Staff ID #K on the Womens Connections unit where patient ID #12 was bedded on 11/12/2024. Record Review of Medical Staff Rules and Regulations, last revised 10/24, stated “5.3 Member Responsibility for Medical Record. 5.3.1 Attending members are responsible for ensuring that the medical contains all such information as may be necessary to prevent harm to patients in the Hospital or to others. 5.3.2 Attending Members are responsible for ensuring that the following are dated, timed, documented legibly, and in chronological order in each patient’s medical record: admission information, orders for consultations, medications ....” It further stated “5.6 Progress Notes 5.6.2 Progress notes involving subjective interpretation of the patient’s progress should be supplemented with a description of the actual of actual behavioral observed. 5.6.3 A progress note shall be recorded at each visit by the Member making the visit and dated.” Record Review of Electronic Medical Record performed: Patient ID #1 Certificate of Medical Examination completed by Staff MD # K on 09/25/24. No progress note or assessment located for Staff MD #K in the medical record for Patient ID #1’s medical record. Patient ID #12 Certificate of Medical Examination completed by Staff MD # K on 11/12/24. No progress note or assessment located for Staff MD #K in the medical record for Patient ID #12’s medical record. Patient ID #26 Certificate of Medical Examination completed by Staff MD #K on 10/30/2024. No progress note or assessment located for Staff MD #K in Patient ID #26’s medical record. Patient ID #28 Certificate of Medical Examination completed by Staff MD #K on 11/3/2024. No progress note or assessment located for Staff MD #K in Patient ID #27’s medical record. These findings were confirmed by Director of Risk Staff ID #A with record review on 11/13/2024. Record Review of Human Resource Badge Fob for Staff Physician #K demonstrated he did not utilize his badge fob to enter or exit the Women’s Pathways unit, where Patient ID #12 was bedded on 11/12/2024, the date he completed Certificate of Medical Examination form for Patient ID #12. Interview with Court Liaison Staff ID #M on 11/12/24 at 11:35 pm. She stated that the paperwork for order for protective custody must be obtained early in the day in order to facilitate getting it to the courts before they close. She stated the process is she asks attending psychiatrists who round early in the day to assist with completing the process. She stated that the physician completing the certificate of medical examination may not be the patient’s attending physician. She stated that since the intake psychiatry consult/assessment is performed via telemedicine, that she needs an on-site physician to sign the paperwork. Telephone Interview with Attending Psychiatrist Staff ID #K on 11/12/24 at 1:35 pm. He confirmed that he performed patient assessment for purposes of certificate of medical examination for Patient ID #12. He confirmed that he does not document his assessments or patient engagements related to signing for order of protective custody, if the patient is not assigned to him as the attending of record. He stated that the process is that the facility’s court liaison Staff ID # M will call or text him to assist with obtaining order of protective custody paperwork certificate of medical examinations because he “rounds early.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure that registered nurses evaluated nursing care for a patient, as evidenced by 3 of 4 Nursing Assessments not addressing a patient’s condition (Patient #1). Findings included: Review of facility policy #16527162 titled “Nursing Re-assessment of a Patient”, last revised 12/2021, showed that a change in a patient’s condition will be documented on the Daily Nursing Assessment within the patients’ electronic health record. Also, any abnormal findings are to be documented on the RN Narrative section of the Daily Nursing Assessment. Record review during time of survey of Patient #1’s clinical chart showed the following: Patient was admitted to facility on 9/9/24 from Texas Children’s Hospital after self-harming by inserting a safety pin into her urethra (urinary tube) and having it lodge partially into her bladder. She needed surgery to remove it. The patient also had a history of other self-harm behaviors. History and Physical Exam dated 9/10/24 showed the reason for admit was “presented to ED with safety pin in her partially in the urethra and bladder”. Initial Psychiatric Exam dated 9/10/24 showed the patient’s diagnoses were Bipolar disorder, severe with psychosis; Post Traumatic Stress disorder; Autism Spectrum disorder. Mental Health Technician (MHT) progress notes dated 9/15/23 at 2:05 from MHT-Staff #K, revealed the patient claimed she inserted her plastic patient wristband into her urethra and could not remove it. The notes showed that patient stated “ ...my peepee hurts I just stuck my green band up there and its stuck”. A nursing progress note dated 9/15/24 at 2:35 PM by RN-Staff #F showed the patient reported “I stuck my band up my pee hole”. The notes further showed that per her physician, the patient should continue to be monitored. Nursing Assessment on 9/15/24 day shift signed at 4:04 PM by RN-Staff #F, showed “GU (genitourinary)/Renal: Reports no problem or burning during urination”. Nursing note narrative in Nursing Assessment failed to address follow-up assessment about the wristband Nursing Assessment on 9/15/24 evening shift signed at 8:43 PM by RN-Staff #G, showed “GU/Renal: Reports no problem or burning during urination”. Nursing note narrative in Nursing Assessment also failed to address any follow-up information regarding the wristband. MHT progress notes from MHT-Staff #J on 9/15/24 at 10:44 PM, showed the patient complained that her “private part was hurting because she tried to put her greenband inside herself”. Staff advised her to sit on the toilet to try to remove it but the patient reported it was in too far. The next nursing assessment addressed the wristband issue; Nursing Assessment on 9/16/24 morning shift signed at 9:38 AM by RN-Staff #H, showed that the patient complained the green band was still inside her, it was burning, and her doctor was considering transfer to the emergency room. The GI/GU portion of the assessment showed “Pt stated stuck green band to her pee hole”. However, the next following Nursing Assessment, again, failed to address anything about the wristband; Nursing Assessment on 9/16/24 evening shift signed at 8:37 PM by RN-Staff #I, showed “GU/Renal: Reports no problem or burning during urination”. Nursing note narrative in Nursing Assessment failed to address any follow-up information about the wristband still lodged inside the patient’s urethra. Further record review of nursing progress notes (not part of the shift’s nursing assessment) dated 9/16/24 signed by RN-Staff #I at 10:12 PM, showed the patient spoke with her father, reported that the wristband was stuck inside her, and complained that nothing was done about it. The father then requested to speak with RN-Staff #I and demanded that the patient be sent to the ER. The patient was then sent to Texas Children’s Hospital via ambulance at 8:30 PM “per father’s request”. Review of a subsequent nursing progress note entry on 9/17/24 signed by RN-Staff #L at 8:14 AM, showed that X-rays were performed at the ER, an object was found inside her bladder, and the patient was waiting for a surgical procedure to remove it. In an interview on 9/25/24 at 9:30 AM, CNO-Staff #B acknowledged that the three shifts of nursing assessments did not address or contain any follow-up information regarding the patient having a foreign object inside her urethra, despite the patient claiming that her wristband was stuck inside her since the early afternoon of 9/15/24. In an interview on 9/25/24 at 1:50 PM, RN-Staff #F stated that the patient gave the impression she placed the wristband in her vagina and was unaware of notes made by other staff, including MHT-Staff #K, showing the wristband was stuck inside her. In an interview on 9/25/24 at 2:00 PM, RN-Staff #I stated the patient had never complained to her about pain and was unaware the wristband was stuck inside of her; she only found out after the father had complained to her on the phone.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 38387 Based on review of patient charts and confirmed in interview, the facility failed to ensure patients with allergies were not exposed to the allergen resulting in anaphylaxis reaction for one of ten patients (Patient #B) reviewed. Findings included: Patient #B admitted involuntarily on 03/16/2024 “after reportedly experiencing suicidal thoughts per collateral with a plan to cut with razor due to experiencing stressors consisting of the following: ‘loss of my job, loss my boyfriend of 5 years, moved back home with my parents’.” In review of the initial psychiatric evaluation on 3/16/2024, allergies were assessed for “peanuts, reaction: swelling.” Review of nursing notes on 05/17/2024 “At 0825 pm patient approaches the nurse’s station stating that she has a peanut allergy which she claimed was due to having inhaled the peanut while other peers were eating peanut [butter] sandwich, patient complained of tight throat and difficulty breathing, vital signs were taken, BP 142/86, HR 104, 02 Sat at 90%, T 98.1, RR 16, oxygen 2 L started, [Staff #6] notified, ordered 50 mg of Benadryl IM now, code was called, due to patient’s complaints of tight throat, and bilateral wheezing, 911 was called at 0827, and arrived at 0830 pm, administered Epipen, and Albuterol via face mask, at 0841 patient was transferred to ...hospital awake and oriented.” In an interview with Staff #1 and Staff #3 on 5/24/2024 at 11:10 AM, they stated that the facility had no process in place to ensure there were no cross contamination for food allergens in the unit and/or the kitchen. Staff #1 did provide an email dated 3/20/2024 that stated that peanut butter would no longer be served, but no approved changes to the menu or facility processes had been established.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 38387 Based on record review and interview the facility failed to ensure a qualified dietician approved patient menus. Findings included: A review of the patient menus provided to this surveyor revealed the facility used a 3-week rotating patient menu plan. The menus provided included the following hand written substitutions for protein and sides with no documentation of approval. Week 1 Sunday Breakfast ‘sausage’ Tuesday Breakfast ‘grits’ Tuesday Lunch ‘chicken fried steak’ Wednesday Breakfast ‘oatmeal’ ‘egg patty’ Wednesday Dinner ‘turkey tetrazzine’ Week 2 Sunday Lunch ‘bbq pork’ Tuesday Lunch ‘ice cream’ Week 3 Sunday Lunch ‘veggie rice’ Monday Lunch ‘scallop potato’ Friday dinner ‘chicken etoufee’ An interview with Staff #3 on 05/24/2024 at 11:00 AM in the kitchen confirmed the above findings.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 38387 Based on record review and interview the facility failed to have a therapeutic diet manual approved by the dietician readily available to medical, nursing, and food service personnel. Findings: After multiple requests on 05/24/2024 for the approved therapeutic diet manual, one was not provided for review by the survey exit date of 05/29/2024. During an interview on 05/24/2024 with Staff #3, she stated she was unaware of any approved diets. She stated that they can offer chicken breast or fish as requested but that substitutions are not in writing and/or approved.”