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Based on record review and interview, the facility failed to inform 1 of 1 patients' representative (Patient #2) of a change in health status, as shown by the facility's failure to notify the guardian after the patient was assaulted and injured by another patient, resulting in an injury.


Findings included:


Record review of Patient #2's clinical chart showed Nursing Progress notes dated on 11/4/24 at 6:47 with the entry "the patient was attacked by another patient and sustained a minor lip injury". His lip was "dried" and an ice pack was applied for treatment.

Medical multidisciplinary progress notes dated 11/4/24 at 9:15 am made by the patient's doctor, Staff #F, showed that the patient had an "altercation" in the morning and was hit in the mouth, sustaining a "busted" left lower lip. His lip was swollen and presented with old, dried blood on it. Vaseline and ice were prescribed.

Further review of all Patient #2's medical records failed to reveal the patient's guardian was ever notified of the incident that resulted in the patient being injured.

In an in interview on 3/6/25 at 2:30 pm while reviewing Patient #2's records, CEO-Staff #A confirmed there was no evidence the patient's guardian was ever informed of the patient's injuries.

Based on record review and interview, the facility failed to provide a safe environment for 6 of 16 patients (Patient #'s 1, 5, 7, 8, 9 & #10) from 2/24/25 through 2/26/25, as evidenced by staff not effectively monitoring and preventing patient-on-patient aggression. This failure resulted in patient injury (Patients #1 and #11).


Findings included:


Review of facility policy #POC-N149 titled "Levels of Observation", last revised 5/2000, showed patients will be closely observed and monitored for safety. Level of patient observation is based on assessment, which includes assessing for potential assault and aggression. The various levels include "One-to-One", with staff member constantly within arm's reach of patient; "Q5 Minute Observations", with staff member monitoring patient every 5 minutes, or "15 Minute Observations", the minimum level for all patients, where a patient is monitored every 15 minutes. The policy also states that staff may consider the need to move an aggressive patient or intended victim to another unit for safety. In addition, the patient at risk should be assessed for room monitoring, where staff sit outside a patient room to ensure patient safety.

Record review of Patient #1's clinical records showed the following:

14-year-old male, admitted 2/17/25, discharged 2/25/25. Diagnoses were Disruptive Mood Dysregulation disorder, Autism, Attention Deficit Hyperactivity disorder. Reason for admission; threatening peers, homicidal ideation towards others, punching walls, destroying property. He was placed on 15 Minutes Observations monitoring.

Review of Restraint/Seclusion orders and accompanying nursing notes from the day of admission, dated 2/17/25 at 6:56 pm, showed the patient became violent, provoking peers, pushing chairs, banging on doors, banging on the nursing station. He was given an intramuscular injection (IM) of emergency psychoactive medications to control behavior-Thorazine 50 mg and Benadryl 50 mg.

Review of Restraint/Seclusion orders and accompanying nursing notes dated 2/21/25 at 6:08 pm, showed patient had grabbed an object from the nursing station, hit Patient #5 with it, and was punching doors and windows. He was subsequently given IM emergency psychoactive medications again-Thorazine 50 mg and Benadryl 50 mg, then placed in seclusion (note; four days later, on 2/25/25, Patient #5 then physically attacked Patient #1-see below).

Review of nursing progress notes dated 2/24/24 at 12:20 pm, showed the patient was then hit by a different peer, Patient #11. The notes read "punched him on the face and he started having nose bleeding", after Patient #1 was talking loudly and banging on glass windows, apparently aggravating Patient #11. Dr-Staff #F was contacted and ordered a medical consult and first aid treatment. Patient #11 then complained of right hand pain from punching Patient #1, was x-rayed, and diagnosed with Right 5th Metacarpal (hand) Fracture. He was sent to Memorial Hermann Hospital Southwest on 2/25/25, treated, given a splint, then returned to facility.

Further review of nursing progress notes dated 12/24/25 at 12:50 pm, just 30 minutes later, showed Patient #1 was punched again, this time by another different peer, Patient #8. Patient #1 was reportedly still loud, banging glass of door, and aggravated this other peer. When Patient #1's guardian was called and informed of these incidents, she requested that Patient #1 be moved to another unit but her request was denied: Nursing progress notes from RN-Staff #G showed "[Guardian] requested patient moved to another unit but informed is the only adolescent boys unit. Requested to move him to girls unit will continue to monitor". (Note: Patient #8 also had a previous physical altercation with another different peer, Patient #12, the day prior, 2/23/25 at 7:20 pm, and had sustained a bloody nose).

The next day, Patient #1 was punched again (the third time in two days, from three different peers). Nursing progress dated 12/25/25 at 7:52 am showed that Patient #5 (who Patient #1 had previously hit on 12/21/25) walked into Patient #1's room "and started punching him".

Record review of Patient #5's clinical chart showed he also had a history of violence and he was involved in at least two other incidents with two other patients: On 2/24/25 at 9:00 am, he has a physical confrontation with Patient #9, and on 2/26/25 at 1:25 pm, he had another physical aggression incident with Patient #7, who needed first aid as a result.

In an interview on 3/6/25 at 12:20 pm, RN-Staff #G was questioned about her knowledge regarding Patient #1. She stated he was autistic, violent, and very difficult to redirect because he would not listen to staff. He did not like to be with other children and acted immature at times, and would ask for his stuffed animal. She added that the first boy who hit him "really hurt himself" (he broke his hand) and the second boy who hit him just 30 minutes later gave the patient a bloody nose. The third boy who hit the patient the following day just entered his room and started punching him after Patient #1 allegedly called him a derogatory name and aggravated him. Staff #G also stated that Patient #1 was never on One-to-One or Q5 Minutes Observations for added safety, just on Every 15 minutes Observations like most patients. Staff #G never asked the patient's doctor to move him to a different unit or increase close observation monitoring, even after the patient's guardian made the request to move the patient to another unit.

Based on observation, interview, and record review, the facility failed to deliver nursing care that demonstrated competence in the documentation of dietary intake on the observation rounds. This negligence was evidenced by the facility's failure to ensure staff consistently documented the dietary intake on 9 of 10 adolescents and children (Patient # 1, 3, 4, 14, 15, 16, 17, 18, and Patient # 19).

Findings were:

Patient #4.
Review of the Psychiatric Evaluation for Patient #4 by Staff N (MD) dated 12/14/2024 at 12:20 PM showed: "picky" appetite, "he only eats what he wants," high energy level, sleep is not good.
Impression: Disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, Von Willebrand's Disease [a genetic bleeding disorder].

Review of Nursing Admission Assessment - Youth for Patient #4 by Staff O (RN) on 12/13/2024 at 7:30 PM showed: Weight 47 lbs. Height 59 inches.


Review of Observation Sheets showed the documentation of dietary intakes was missing for the following 9 patients on these days.
Patient #1 - Incomplete 2/17, 18, 19, 20, 21, 22, 23, 24, and 2/25/2025.
Patient #3 - Incomplete 12/9, 11, 12, and 12/13/2024.
Patient #4 - Incomplete 12/14, 15, 16, and 12/17/2024.
Patient #14 - Incomplete 3/3 and 3/5/2025.
Patient #15 - Incomplete 3/3 and 3/5/2025.
Patient #16 - Incomplete 3/5/2025.
Patient #17 - Incomplete 2/27, 2/28, 3/1, 3/2, 3/3, 3/4, and 3/5/2025.
Patient #18 - Incomplete 3/3, 3/4, 3/5/2025.
Patient #19 - Incomplete 2/10 and 2/11/2025.
Further breakdown of this data showed that 34 of 48 meals (70%) were not documented on the Observation Sheets. There were:
19 instances in which dietary intake for all three meals was not documented.
3 instances in which dietary intake for two meals was not documented.
13 instances in which dietary intake for one meal was not documented.

In an interview with Staff A (CEO) on 3/6/2025 at 3:00 PM, she stated staff are to document on the Observation Sheets the percent of meals eaten for breakfast, lunch, and dinner on all patients.

In an interview with Staff G (RN - Youth Services) and Staff I (LVN - Youth Services) on 3/6/2025, 11:35 AM - 11:55 AM, they stated that it is the Mental Health Technicians (MHT) that usually monitor the percent of meals eaten, documenting that percent on the Observation Sheets. They also stated the staff members escorting the patients to the cafeteria take the Observation Sheets with them. The plates are checked by staff members before being discarded. Staff I (LVN) explained that some patients do not have cafeteria privileges and eat their meals on the unit. Staff follow the same protocol of assessing the percent of food eaten and documenting this on the Observation Sheets. Staff G (RN) stated it is her expectation that the staff she oversees document the percent of meals eaten on the Observation Sheets. She concluded by stating she did not know that completion of this section of the Observation Sheets was being neglected.

Based on observation, interview, and record review, the facility failed to ensure Clinical Services staff members documented factual and historical information in the development of the Psychosocial Assessment. This omission was evidenced by the facility's failure to ensure:
a) A parent or legal guardian was contacted to provide significant aspects in the development of the Psychosocial Assessment for 3 of 8 children (Patient #4, 19, and Patient #21).
b) An Individual Therapy session was conducted for 8 of 8 patients (Patient #4, 19, 20, 21, 22, 23, 24, and Patient #25.)
c) A Family Therapy session was conducted for 2 of 8 patients (Patient #4 and Patient #19).
d) Members of the Clinical Services Department were properly trained in the development of the Psychosocial Assessment.

Findings were:

a) Psychosocial Assessment

Record review of the policy "Procedure on Psychosocial Assessments" policy number POC - C112, last review 2/2024, showed the following.
Purpose ... To provide current background data on the patient which includes stressors contributing to dysfunction and strengths or supports contributing to recovery ... A regular or updated Psychosocial Assessment shall be completed within 72 hours of admission ... All Psychosocial Assessment shall be completed only by staff credentialed in this area, or by staff supervised by credentialed staff ... All psychosocial [assessments] will be signed by an LMSW or LCSW.

Review of an educational handout (not dated or timed) that was provided by Staff L (Director of Clinical Services - DCS) on 3/6/2025 at 3:00 PM showed:
In accordance with the psychosocial assessment (PSA) process.
Families are contacted within 48 hours of admission to schedule a time to complete the PSA, schedule family therapy session an address weapon safety.
In the event a guardian is unreachable, the clinician must leave a message, document in a progress note and reattempt prior to the end of day.
After several attempts and no contact has been made, clinician must document on a progress note and then seek guidance from the Clinical Director ...
PSA is completed with the guardian or family member authorized to provide collateral information regarding the PSA.

Review of the Psychiatric Evaluation by Staff N (MD) on 12/14/2024 (dictated at 12;20 PM and transcribed at 4:40 PM) showed that the adoptive mother reported that the biological mother used alcohol while pregnancy with Patient #4 and had been diagnosed with a bipolar disorder and "other mental health issues." She also abused drugs. The biological father was "a heavy drug user" as well as alcohol abuse.

Review of the Psychosocial Assessment completed by Staff K (Licensed Professional Counselor Associate - LPCA) on 12/14/2024 at 10:53 AM for Patient #4 showed that the Psychosocial Assessment was completed from information collected from the 7-year-old patient and the Intake Assessment. The patient's mother was not contacted. Staff K (LPCA) documented that it was "unknown" if the biological father and mother had a history of alcoholism, drug abuse, and mental illness. This documentation was not consistent with the documentation found in the Psychiatric Evaluation by Staff N (MD) - documented above. The Psychosocial Assessment was co-signed by Staff P (LMSW).

Additionally, review of two other Psychosocial Assessments (Patient #19 and Patient #21) showed that Staff K (LPCA) made one unsuccessful attempt to reach a parent or legal guardian. There was no documentation of a follow-up phone call. Finally, each of these Psychosocial Assessments showed that the family was not a source of the information used to write the assessments.

In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated the following.
1) The Psychosocial Assessment is to be completed within 72 hours.
2) For children and adolescents, the parent must be contacted.
3) If the therapist is unable to reach the parent, several attempts are to be made "throughout the day," with attempts "every single day" until the parent is reached.
4) She is to be notified by the therapist if the parent cannot be reached by phone.

In an interview with Staff M (Associate Director of Clinical Services - ADCS) on 3/6/2025 at 10:20 AM - 10:35 AM, Staff M stated parents should be involved in the development of the Psychosocial Assessment. He also stated that multiple phone calls should be made to reach a parent.


In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following.
1) The Psychosocial Assessment is to be completed within 72 hours.
2) She reviews the Standardized Intake Assessment and interviews the patient in the development the Psychosocial Assessment.
3) She seeks additional information for the completion of the Psychosocial Assessment - information that is not found in the Standardized Intake Assessment, such as "strengths and limitations, weapons in the house, and current abuse." A child's parent or legal guardian would need to be contacted to obtain this information.
4) Her attempt to reach Patient #4's adoptive mother on 12/14/2024 was unsuccessful, as were her attempts to reach a parent for Patient #19 and Patient #21.
5) If she is unsuccessful reaching a parent or legal guardian for information needed to complete the Psychosocial Assessment, the policy is to "make another attempt after 7 days," adding that she "may" attempt again after 7 days.


b) Individual Therapy.
c) Family Therapy.

In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following.
1) She did not conduct a Family Therapy session with Patient #4 and his adoptive mother because she did not reach the parent on 12/14/2024.
2) The Psychosocial Assessment is the Individual Therapy session.

In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated the Psychosocial Assessment is not the Individual Therapy and that individual and family therapy sessions are to be completed on all patients.

Review of a Progress Note by Staff K (LPCA) dated 12/14/2024 at 12:16 PM showed an unsuccessful attempt made on 12/14/2024 at 11:31 AM to contact the adoptive mother "to discuss a Discharge Safety Plan and conduct a Family Therapy session" for Patient #4. During further review of the medical record, the following items were not found: a follow-up phone call to the adoptive mother, an Individual Therapy session, and a Family Therapy session.

Review of the medical records for Patient #19 and Patient #21 showed that a Family Therapy note was not found.

Review of the medical records for Patients #4, 19, 20, 21, 22, 23, 24, and Patient #25.


d) Staff training in the development of the Psychosocial Assessment.

Review of TAC, Title 22 - Examining Boards, Part 30 - Texas Board of Examiners of Professional Counselors, Chapter 681 - Professional Counselors, Rule §681.91 - LPC Associate License shows:
(5) (i) An LPC Associate must continue to be supervised after completion of the 3,000 hours of supervised experience and until the LPC Associate receives his or her license. Supervision is complete upon the LPC Associate receiving the LPC license.

In an interview with Staff K (LPCA) on 3/5/2025 at 2:20 PM, she stated the following.
1) LPCA is a Licensed Professional Counselor Associate.
2) As an LPCA, she is still under supervision of licensed counselors.

In an interview with Staff L (DCS) on 3/6/2025 at 3:00 PM, she stated that new-hire orientation does not cover the completion of form "WHO-121," The Psychosocial Assessment and that she is currently revamping that process. She also stated that Professional Counselor Associates are hired by the facility and that licensed counselors provide oversight and sign off on their assessments.

In an interview with Staff L (DCS) on 3/5/2025 at 3:10 PM, she stated Staff K (LPCA) will need to be removed from the children's unit because she is "too green."