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Based on observation, record review, and interview, the facility's Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; and that the Hospital's Conditions of Participation were met for Patient Rights, QAPI (Quality Assessment and Performance Improvement), Nursing Services, and Special Staff Requirements For Psychiatric Hospitals.

Findings included:

The facility's Governing Body failed to ensure:

1.) patients were provided an environmentally safe setting that protected the patient's physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient's emotional health and safety, including respect, dignity and comfort.

Specifically, on 8/18/25, actual patient harm was witnessed by surveyor(s) when Patient #1 used a razor blade she brought into the facility to cut (self-harm) herself. This was a second incident in a week. On 8/11/25 she was found with a razor blade after cutting herself.

The facility previously was provided an Immediate Jeopardy (citation) April 18th, 2025, for not appropriately screening patients for contraband according to policy. The facility submitted a plan of abatement, that was abated 5/13/25. Then in May 2025, the Governing Body (GB) minutes reflected that the admission times were too long and had been selected as a goal for the hospital to reduce. The plan of abatement was amended in May (5/23/25) by the facility's GB to revert back to searching patients on the units. Review of the facility's contraband Incidents had started to decline in May from 17 incidents in April, to 12 incidents in May. Furthermore, in June, contraband incidents increased from 12 incidents in May to 22 incidents in June (almost doubled). July had another increase in contraband incidents from 22 in June to 28 incidents in July without further interventions; which jeopardized patient safety, for decreased admission times.

An interview was conducted with Staff #1 on 8-21-25 at 10:35 AM. Staff #1 explained that the cycle time in April and the beginning of May was taking anywhere from 4 to 6 hours to get a patient to their unit because the hospital did not have RN coverage in the admission area. They had trained 4 nurses in the admission role, but they didn't stay in that role. That was what prompted the facility to go back to previous practice rather than continue to train and staff the RN position in admissions.

These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to Tag A0144 for specific evidence of findings.

2.) ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome.

Refer to Tag A0286 for specific evidence of findings.

3.) ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance.

Refer to Tag A0297 for specific evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for QAPI.

4.) ensure that a Registered Nurse (RN) was always available and supervision was provided for patient care units A, B, C, D, E, F, G, and H.

Refer to Tag A0395 for specific evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.

5.) ensure safe staffing levels were provided for patient care units A, B, C, D, E, F, G, and H.

Refer to Tag A1704 for specific evidence of findings

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Special Staff Requirements.

As a result of the Hospital's failures to meet the Conditions of Participation for Patient Rights, QAPI, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals; resulted in the facility's inability to meet the Condition of Participation for Governing Body.

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Based on observation, interview, and records review, the facility failed to provide to all patients an environmentally safe setting that protected the patient's physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient's emotional health and safety, including respect, dignity and comfort.

These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to Tag A0144 for specific evidence of findings.

Based on review and interviews the facility failed to.

1.ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome.

Refer to Tag A0286


2.ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance.

Refer to Tag A0297


21863

Based on review, observations and interviews the facility failed to;

1. ensure that a Registered Nurse (RN) was always available and supervision was provided for patient care units A, B, C, D, E, F, G, and H.

Refer to Tag 395

Based on review, observations and interviews the facility failed to;

1. ensure safe staffing levels were provided for patient care units A, B, C, D, E, F, G, and H.

Refer to Tag A 1704

36827


Based on observation, interview, and records review, the facility failed to provide patients an environmentally safe setting that protected the patient's physical safety, securing or removing objects that are hazardous; as well as an environment that protected the patient's emotional health and safety, including respect, dignity and comfort.

These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death; and compromised their emotional health and safety.

Findings included the following:

A) On April 18, 2025, the facility had received an Immediate Jeopardy (IJ) citation for not appropriately screening patients for contraband according to policy. As part of the abatement plan submitted, screening of patient and patient property was to be conducted in the admissions area before patients were brought through locked doors into patient care areas. This would have prevented contraband from ever entering secured patient care areas. This process was changed in May 2025, back to the original process of screening patients for contraband after they arrived in secured patient care areas.

Incident reports were reviewed on 8-19-25. Incident reporting showed that in May, there had been a drop in incidents of contraband found in secured patient care areas. There were 17 reported incidents in the month of April. That decrease to 12 in the month of May.

After changing back to previous practices that had been part of the original IJ, incidents for June increased to 22, almost double. No action was taken by the facility in response to this increase.

Review of incident reporting showed in July that incidents of contraband again increased to 28. Again, no action was taken by the facility in response to this increase.

Governing Body meeting minutes were reviewed on 8-20-25. Review of the meeting minutes from May 6, 2025, showed that the Governing Body had selected "cycle times" for admissions as a goal in order to reduce the amount of time it was taking to get a patient to the unit. Cycle time referred to the time starting from when a patient arrived at admission until a patient was on their assigned unit.

An interview was conducted with Staff #1 on 8-21-25 at 10:35 AM. Staff #1 explained that the cycle time in April and the beginning of May was taking anywhere from 4 to 6 hours to get a patient to their unit because the hospital did not have RN coverage in the admission area. They had trained 4 nurses in the admission role, but they didn't stay in that role. That was what prompted the facility to go back to previous practice rather than continue to train and staff the RN position in admissions.

Observations on 8-18-25, at 12:45 PM actual patient harm was observed by surveyor(s). Patient #1 observed with injuries to both lower arms. Patient #1 ' s forearms with linear, parallel lacerations (wounds) of varying lengths (approximately 2 to 3 inches) to each forearm. Patient #1 had approximately 12 to 13 wounds that demonstrated recent erythema, dried/coagulated blood present; consistent with sharp force trauma, and another approximate 12 to 13 wounds on each arm that were scabbed/healing. In addition, there was older, linear, parallel, and perpendicular scarring on both forearms.

Interview with Patient #1 on 8-19-25 at 1:15 PM stated that she had brought two razor blades to the unit she was assigned by hiding them in the waistband of her clothing. She further stated last week on 8-11-25 she was found by hospital staff with a razor blade after cutting her lower arms. Staff put her into paper scrubs and took her clothing from her. Patient #1 said the staff must not have searched her clothing because when she received them back it still had the other razor blade in the waistband and then today she retrieved the second razor blade and cut her lower arms again.

During an interview with RN #8 on 8-18-25 at 2:25 PM stated when contraband checks were performed on the units, the Registered Nurse must leave the unit to go to the treatment room, behind a locked door inbetween two units to assess and search the patient. RN #8 confirmed that while off the unit, there was not a Registered Nurse readily available to provide patient care in an emergency or supervise the Licensed Vocational Nurse and non-licensed staff. This presented a risk to safe patient care as an RN should always be readily available.

B) A tour of the facility was conducted on 8-19-25 at 11:30 AM with Staff #7 with the following observations:

1) In an outdoor common area where patients were observed to be able to congregate, a large bin was observed with an empty plastic bag laying in the bottom of it that could be easily picked up by a patient, hidden on their person to be brought back to the unit and then used for suffocation.

2) In an outdoor common area where patients were observed to be able to congregate, a beanbag toss game board was observed with rope handles that could be untied by a patient, hidden on their person to be brought back to the unit and used as a ligature for self-harm or to harm others.

3) Throughout the common outdoor areas, the paths and sidewalks were decorated with rocks that were small enough for a patient to easily pick up and hide on their person to be brought back to the unit. They could then be slipped into a piece of clothing like a sock and used as a weapon to attack staff and other patients.

4) Throughout the common outdoor areas, broken pieces of paving tiles were observed along the edge of the sidewalks. Some pieces of tile had sharp edges that could be picked up by patients and used for self-harm or to harm others.

5) The building that housed Unit A and Unit B was toured on 8-19-25 at 11:32 AM with Staff #7. A storage closet was observed with yoga mats stored in it. The yoga mats were soiled and stained on both sides of them. Staff #7 confirmed that patients did use the yoga mats, and that staff were supposed to clean them after every use. If patients wanted to participate in yoga, they had no choice but to use soiled and stained equipment, contributing to a loss of respect and dignity.

6) The entrance door to Unit B was observed to have a window in the door. The wooden trim around the window was observed to be broken with missing pieces. The broken pieces were taped. The taped long piece on the right of the window was loose. If pulled off, the sharp pointed end could be used as a stabbing instrument for a patient to harm self or others.

7) The entrance to the nurses' station on the Unit A was a half-door. Staff #7 confirmed all nurses' station doors were the same type on all units. The door had a slide-type handle on the inside of the nursing station. Patients could reach over the half-door and slide the handle open to easily access the nurse's station. The short wall to the nurse's station was low enough for patients to be able to reach over and grab items from the countertop near the wall. The wall was low enough for patients to easily jump over.

RN Staff #8 and RN Staff #13 were interviewed on 8-19-25. Both described multiple instances of patient excursions into the nurses' station. Staff #8 stated they had just had an incident the day before of a patient running into the nurse's station. Staff #8 and Staff #13 both reported that they don't normally put in an incident report for that unless it involves a serious incident such as an assault/aggressive actions. Both reported that excursions into the nursing station happen often. Staff #13 stated that she is always worried about it because it's a dangerous situation and, even though administration has been asked many times, nothing has been done to improve the security of the nurses' station.

8) Staff #8 and Staff #13 both said there were times when nursing staff were on the unit providing patient care and the nurses' station was unattended. During those times, patients had the ability to just walk into the nurses' station and access to available items.

Observations conducted on 8/20/25 at 3:25 PM in the nurses station of Unit A revealed the RN (#15) left the unit through the locked door into the hallway of Unit A and Unit B, leaving LVN (staff #18) alone in the unit without an RN present while she went to complete an admission in the treatment room. RN #15 returned at 3:31 PM (6 minutes later).

Further observations at 3:46 PM, RN (#15) left the unit through the locked door into the hallway of Unit A and Unit B, leaving LVN (staff #18) alone in the unit without an RN present. Then at 3:49 PM, LVN #18 left the unit through the locked door into the hallway of Unit A and Unit B; leaving the unit without a licensed nurse present or an RN. Approximately 30 to 45 seconds later, RN #15 returns to the unit at 3:50 PM.

Observation of the nurses' stations showed numerous items readily available to patients. Smoking material to include lighters were kept in an unsecured drawer. Spray cans of chemicals were observed inside of a cabinet. Together, those items could be used to create a blowtorch to harm other patients and staff or start a fire.

Some of the other items patients had access to included:

a) hazardous cleaning chemicals and wipes,

b) cell-phone charging cords that posed a ligature risk,

c) telephone cords on the landlines that posed a ligature risk,

d) heavy items such as hole punches and fire extinguishers that could be used to bludgeon someone,

e) fire extinguishers could be used to spray someone in the face and incapacitate them,

f) sharp metal items such as staples and paper clips that could be used for self-harm,

g) tape dispensers with serrated metal edge to cut tape. The serrated edge could be used for self-harm.

h) pens that could be used to stab someone,

On 8-20-25, review of incident reports revealed that excursions into the nurses' station were not being reported as a separate incident. The lack of tracking, trending, and analyzing of this dangerous condition created an environment where patients continued to have access to the nurses' station and items inside it.

9) Patient snacks (fresh fruit) were observed stored in open milk crates on the dirty nurses' station floor in Unit A. Water was stored in open pitchers under the nurses' station counter where unknown substances could accidentally contaminate it or a patient could reach it and contaminate it. One open pitcher was observed to be sitting under the counter next to a container of patient urine. Sandwiches were observed stored in a cabinet where chemicals were also stored. These unsanitary conditions create a health risk and contribute to a loss of respect and dignity for patients who are forced to live with them.

10) The glass window in the upper part of the door leading to the bedrooms had been broken where something hit the edge, and from that spot, there were with 6 long cracks spread out across the glass in curved lines from the edge toward the middle and lower part of the glass. The backside of the cracks were sharp to the touch posing a safety hazard.

11) The smoking area of Unit A was observed on 8/18/25 at 1:20 PM with no receptacle for cigarette butts available on a wooden deck. The wood on the deck was observed to be weathered and dried. Cigarette butts were littered and discarded all throughout the area; between the boards of the deck and under the deck, presenting a fire hazard.

Interview with staff #10 on 8/18/25 at 1:22 PM stated the receptacle was "took out yesterday because patients were trying to get the cigarette butts out of the container."

Further observations of this smoking area on 8/19/25, 8/20/25 and 8/21/25 revealed a cigarette receptacle had not been available to discard cigarette butts.

12) A tour of the Unit D was made on 8-19-25 at 3:15 PM with Staff #7. The unit was observed to have vulgar graffiti drawings, and graffiti that had the appearance of gang related graffiti that was allowed to remain on the walls of the day room. Graffiti such as this could create fear in some patients and contribute to a loss of respect and dignity for patients who are forced to live with them, negatively impacting their emotional well-being.

13) The drop-down ceiling was observed to be accessible to patients from the counter in the nurse' station. This could go undetected because of the lack of visibility of the area if nursing staff were all on the other side of the unit providing patient care and the nurses' station was left unattended. Contraband could be hidden under the ceiling tiles for later retrieval or metal framework pulled down to use as a weapon to hurt others. A ceiling tile in that area had been lifted and not set back into place. It was unknown who accessed the ceiling tile.

14) The windows to the doors leading to outside had been broken. Plywood had been placed over the broken windows. Sharp ends of screws were sticking out of the plywood that could be used by a patient for self-harm/cutting of self.

15) The seclusion room door had broken plexiglass in the window. The corner was broken and could be easily pulled off. The sharp edges could be used as a cutting instrument to harm self or others.

16) The plexiglass for the seclusion room door was installed with hex-head bolts rather than tamper-resistant hardware. Hex-head bolts provide a surface for patient to be able to work the bolts out use for self-harm.

17) Decorative bricks on the wall were missing and/or had mortar missing. This created voids in the walls where patients could hide contraband.

C) A transitioning female patient was assigned to Unit A. She was assigned a room with two other females. However, she was sleeping in the living area at night. Review of Patient #2's Psychiatric Evaluation, with a date of assessment blank, date of Admission 8/9/25 revealed Patient #2 was "a 36-year-old transgender male to female admitted" for service on Unit A.

Observations of Unit A on 8/18/25 at 12:30 PM revealed the unit had been separated into two different units with males (12 patients) on one side, and females (9 patients) on the other side with the door locked in between the two areas.

Review of the unit's (A) bed assignment on 8/18/25 revealed Patient #2 was assigned a room with two other female patients but would "sleep out" in the unit living area.

Interview was conducted with Patient #4 on 8/18/25 at 12:35PM. Patient #4 stated that she had concerns on behalf of Patient #2 because she assists Patient #2 into her bed (mattress) on the floor in the living area, because staff will not help her. Patient #4 said that Patient #2 sleeps on the floor in the living area, "day room", on her mattress because she has seizures and might fall off the bed. In addition, staff will not help her to go to the bathroom when needed.

Interview with Patient #1 on 8/18/25 at 12:45 PM stated she has seen Patient #2 have seizures, but the staff do not believe her, so "they just let her" seize, stating she is "obviously faking it," and "does it for attention". Patient #1 said that Patient #2 had a 1 to 1 staff assigned after an incident but the assigned 1 to 1 staff would not help her on the floor on to her mattress from her wheelchair, so Patient #4 helped her from her wheelchair to the bed. Patient #1 said Patient #2 sleeps in the day room so that staff can "keep an eye on her."

During an interview with Patient #2 on 8/18/25 at 1:25 PM, Patient #2 was observed with female features, however, spoke with a deep voice such as a male. Patient #2 stated she had been at the facility over 30 days and has "seizures." Patient #2 confirmed she slept in the day room at night on a mattress on the floor because she "might roll out of bed." Patient #2 also confirmed staff do not assist her to the bathroom and she will, "pee on myself."

Interview on 8/20/25 at 3:00 PM with RN #15 stated she thought Patient #2 "sleeps out" due to the belief of, "the way she sleeps, for safety." RN #15 stated there should be a Physician's Order for Patients that "sleep out." However, after review of Patient #2's record, including physician order's, Staff #15 confirmed there were not any orders to "sleep out" from her assigned room, stating sometimes the patient's "want to sleep out, they're more comfortable."

Further interview with RN #15 stated that patients would "sleep out if sexually inappropriate; for both female and male or if they self-harm, that way we can watch them."

Observations on 8/20/25 at 3:42 PM in Unit-A revealed Patient #2 was sleeping/resting in her assigned bedroom (906) where two other patients were also resting. MHW (mental health worker) #12 was sitting outside of Patient #2's room in the hallway.

Interview with MHW #12 on 8/20/25 at 3:45 PM stated Patient #2 "likes to sleep out, feels safer; to prevent self-harm." MHW #12 was asked if there were any concerns regarding Patient #2's bed; having to sleep on a mattress on the floor, and she responded, that Patient #2 feels like she will "self-harm at night and knows we are watching her" when she sleeps out.

Patients who require additional monitoring should be assigned staff to monitor them in their room. Patients who require additional privacy due to unique personal situations such as a patient transitioning, should be assigned a private room. Requiring patients to sleep in public areas because of unique needs contribute to a loss of respect and dignity and can negatively impact their emotional well-being. It could also impact the emotional well-being of other patients who witness what they perceive as the lack of care for patients with unique personal situations or need additional attention due to medical or mental health conditions.

D) On 8-20-25, the list of incident reports for May, June, July, and August were reviewed along with the quality reporting.

Quality reporting for June's incidents was as follows:

"Risk Report: The following is a summary of the Risk Report for June 2025. There was a total of 483 incidents reported for the month. The majority were physical confrontation/aggression (248) and treatment issues / AMA (against medical advice) discharges (120). There was a total of 32 boundary violations which is below the target of 38. There was a total of 207 restraint, seclusions, and emergency medications (74 restraints, 34 seclusions, & 99 emergency medications). The majority of R/S (restraints/seclusions) occurred on Sunday on first shift. DRM (director of risk management) reviewed the R/S trends by unit with (Unit B) having the most. Observation rounds at 93% in June.

Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting."

Interview was conducted with Staff #2, Staff #3, and Staff #14 on 8-20-25 at 10:00 AM. Staff #3 confirmed that the number of incidents of aggression were being tracked for total numbers such as "The majority of R/S occurred on Sunday on first shift. DRM reviewed the R/S trends by unit with (Unit B) having the most." However, incidents were not analyzed for patterns or possible causes for possible process improvement interventions. Staff #2 confirmed that there was no process improvement teams or formal process improvement projects currently focused on tracking, trending, analyzing and developing possible solutions to reduce the number of patient aggression incidents.

Other than reviewing cameras for analysis of injuries and discussion with leadership after the fact, no initiatives to prevent patient aggression incidents were developed and implemented. The lack of an effective process to develop programs aimed at preventing and/or reducing incidents places all patients and staff at risk of harm.

E) Complaint TX00549972 alleged that on 07/15/2025 (date of discharge) complainant noticed bruising on the Patient #6's arms. Complainant stated she observed bruises that looked like fingerprints. Patient #6 told complainant the nurse (name unknown) kept pushing her fingers into her and squeezing her. Complainant stated Patient #6 had gray bruises on left and right arms. The complainant sent pictures of the bruising to mental health therapist #17.

The medical record of Patient #6 was reviewed with the following findings. Seclusion/Restraint/Emergency Orders revealed Patient #6 was restrained on the following dates/times: 06/29/2025 at 10:55, 06/29/2025 at 19:20, 07/04/2025 at 10:59, 07/09/2025 at 20:35, 07/11/2025 at 20:06 and 07/12/2025 at 15:59 with the skin assessments showing no bruises noted on these dates.

Therapist #17 was interviewed on 08/20/2025 at 3:00PM regarding complaint TX00549972. She confirmed she was the primary therapist for Patient #6 during her admission to the facility. She confirmed that Patient #6's guardian had contacted her by phone on 07/15/2025 stating Patient #6 came home with multiple bruising on her arm. The guardian had attached three pictures of the upper arm bruising. When asked if she related these concerns of the guardian to anyone, Therapist #17 said she had been taught during her orientation that once a patient is discharged, the facility has no responsibility towards the patient. She stated that in retrospect, it would have been appropriate to contact the patient advocate regarding the guardian's concerns.

The Reporting Abuse, Neglect and Exploitation Policy and Procedure, effective November 2010 and last revised July 2025 was reviewed with the following pertinent to this complaint: Procedure for internal reporting: When an allegation is made to a therapist or the therapist becomes aware of such, he/she notifies the Nursing Supervisor/Director of Nursing and Program Manager.

Failure to report and investigate all allegations of abuse and neglect create an unsafe environment where potential abuse and neglect could continue unchecked.

Based on review and interviews the facility failed to ensure the hospital was measuring, analyzing, and tracking adverse patient events, developed performance improvement activities to implement preventive actions and mechanisms, and failed to ensure clear expectations were established and followed by the medical staff to ensure data is collected for measurement and assessment of processes and outcome.

A review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and monthly summary for May, June and July 2025 revealed there was only data provided.

The monthly summary provided for June 2025 revealed incident reports were broken out into "Incident Categories" such as AMA, change in condition, patient injured no classification, non-suicidal self-injurious behavior, and suicide behavior. Each category had just a percentage number.

The monthly summary for June 2025 revealed incidents were broken out into number of incidents for the following issues.
a. Medication issues-5
b. Slips/falls-20
c. Treatment/AMA issues-120
d. Sexual Allegations-9
e. Elopement/AWOL-3
f. Aggression-248
g. Property-8
h. Security/Contraband-24
i. Boundary Violations-32
j. Miscellaneous-7
k. Complaint-6

Total of 483 incidents for June.

Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting." (DRM-Director of Risk Management).

An interview was conducted with Staff #2, Staff #3, and Staff #14 on 8-20-25 at 10:00 AM. Staff #3 confirmed that the number of incidents of aggression were being tracked for total numbers such as "The majority of R/S occurred on Sunday on first shift. DRM reviewed the R/S trends by unit with (Unit B) having the most." However, incidents were not analyzed for patterns or possible causes for possible process improvement interventions. Staff #2 confirmed that there were no process improvement teams, or formal process improvement projects currently focused on tracking, trending, analyzing and developing possible solutions to reduce the number of patient aggression incidents.

Review of the Annual Review Performance Improvement Program and the Quality Assurance &Performance Improvement (QAPI) plan revealed staff #3 signed and approved the plans and policy on 3-26-25 for Governing Board (GB) approval. Staff #3 confirmed that she was just the performance Improvement (PI) manager but did not do PI projects. Staff #3 stated that she trained to collect data. Staff #3 confirmed that she was the only QAPI person in her department, but that Risk also participated in collected data.

A review of the QAPI Plan stated, " ...12. ORGANIZATION DEPARTMENT & SERVICES
All departments, services and clinical programs participate in the QAPI program. Performance metrics are established to set priorities for measurement and improvement. Objective, measurable criteria reflect expected levels of achievement against which performance can be assessed, using appropriate statistical quality control techniques and tools. Data is collected for measurement and assessment of processes and outcomes, particularly those high risk/ low volume and problem prone processes, based upon a comprehensive set of performance measures. The findings are analyzed to identify significant variances and/or opportunities to improve patient outcomes.

A methodical data analysis approach is conducted that includes an evaluation of data and results over time to identify levels of performance, patterns, trends, and variation. Data are compared to external sources and benchmarks when available. Once patterns are defined, the data are evaluated at a more granular level using stratification, for example by unit, day of week, time of day etc.

Reports of measurement and assessment activities are prepared and presented to the Performance Improvement Committee by the department/service director. Reports include specific actions and follow-up necessary to prevent and/or correct identified variances and improves patient care. QAPI findings are reviewed and discussed in meetings of the respective departments and clinical programs at regular meetings. Each department, service and program maintain minutes of meetings with performance management reviewed as a standing agenda item."

The director of each department, service and program is responsible for leading QAPI activities within the individual department, including effective implementation of improvement effort and process changes.

Employees are empowered through training, support and delegation of authority to take appropriate actions to improve performance within their respective departments. If the problem or required action involves another department or service, the Performance Improvement Committee is notified for further action."


21863

Based on review and interviews the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program was followed according to the QAPI plan to conduct improvement projects with measurable progress and monitoring, failed to follow their own abatement plan from 4/18/25 to monitor and analyze incidents and contraband to ensure patient safety, and report the information to the Governing Board (GB) to ensure compliance.

A review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and monthly summary for May, June, and July 2025 revealed there was only data provided.

The monthly summary provided for June 2025 revealed incident reports were broken out into "Incident Categories" such as AMA (Against Medical Advice), change in condition, patient injured no classification, non-suicidal self-injurious behavior, and suicide behavior. Each category had just a percentage number.

The monthly summary for June 2025 revealed incidents were broken out into number of incidents for the following issues.
a. Medication issues-5
b. Slips/falls-20
c. Treatment/AMA issues-120
d. Sexual Allegations-9
e. Elopement/AWOL-3
f. Aggression-248
g. Property-8
h. Security/Contraband-24
i. Boundary Violations-32
j. Miscellaneous-7
k. Complaint-6

Total of 483 incidents for June.

"Action: The facility has noted several incidents of aggression which new DRM is focused on camera review and thorough analysis of each inpatient injury to include incidents of EBI (Emergency Behavioral Interventions). All level 3 & 4 incidents are discussed with CEO and DRM as well with the leadership team in daily flash meeting." (DRM-Director of Risk Management)

An interview was conducted with Staff #3, on 8-20-25. Staff #3 revealed that she was PI (performance improvement) and not quality. Staff #3 stated that she did not do any of the analysis or monitoring that each department should handle that. Staff #3 asked who else worked in the QAPI department and she stated she was the only PI manager, and that RISK also works on patient safety and data. Staff #3 was asked about the 438 incidents and who was analyzing and monitoring that data? Staff #3 stated they bring those issues to the "keep me safe" work group.

A review of the "Annual Review of Performance Improvement Program 2024" revealed the "Keep Me Safe-LRTC work group that focuses on decreasing restrictive interventions such as restraints, seclusions, and emergency medications. This group meets to analyze data for trends, discuss trainings, and actions to reduce the use of restraints and seclusions. Nursing leadership acquired this initiative from the clinical team this year. Also in 2024, LRTC received training in Trauma Informed Care which was incorporated into the Keep Me Safe efforts."

Staff #3 confirmed that she did not keep up with that information and that nursing had some PI projects. Staff #3 confirmed that she did not have any information to share with the surveyor concerning "Keep me safe" other than what was in the annual review. Staff #3 stated that she was trained to collect data and was never trained to do the PI process with analysis, PI teams, planning, and monitoring. Staff #3 was asked about the complaint survey that resulted in an Immediate Jeopardy. The facility provided an abatement plan on 4/18/25 that stated the facility would follow the policy and procedure for contraband and searches.

The facility would ensure to mitigate risk and ensure patient safety immediately, the facility conducted a unit search and safety sweep of the children and adolescent unit the contraband was detected on, Brazos unit. The facility implemented the process of the weekend RN supervisors assuming responsibility for all patient skin assessments and safety searches. The RN Educator trained the weekend RN supervisors on how to properly conduct skin assessment and safety searches as outlined in the facility's search policy, PC-49. This process was immediately implemented.
The facility will continue to review all incidents and conduct thorough and timely investigations. All investigations will be shared with the CEO for review and approval when closing the investigation.

MONITORING:
Monitoring will be conducted by the RN leadership at LRTC on a daily basis by auditing all new admits medical records to ensure proper completion of the skin assessment and safety searches. Nursing leaders will spot check three assessments in real time each day for the next 30 days to ensure the new process is being accurately implemented and followed. All findings are corrected immediately to include staff retraining and disciplinary action as indicated.

Aggregated data is reported daily in flash leadership meeting and to the Performance Improvement Committee and Medical Executive Committee monthly and to the Governing Board quarterly."

Staff #3 confirmed that the abatement plan was changed, and the patient's contraband and skin searches went back to the charge nurse responsibility when the patient was taken to the unit. Staff #3 confirmed that these issues are discussed in the daily flash meetings but there was no written evidence that this process was being monitored or tracked for patient safety through the PI process.

An interview was conducted with Staff #5 on 8/20/25 concerning the monitoring and auditing for of the abatement plan for the three assessments in real time each day, what analysis was completed on the data and any monitoring for the abatement plan. Staff #5 stated that they discussed these issues in Flash meetings and that she was monitoring the plan. Staff #5 was asked to provide the information, and any tools, or processes put in place. Staff #5 was unable to provide any information upon multiple request.

A review of the 8/14/25 Board of Trustees Meeting Minutes revealed the following.

"C. CMS action Plan Compliance Review

The facility received an IJ in April with 100-page state and federal action plans focusing on staffing and not investigating serious incidents. Great strides are being made to fix the staffing issue that were identified. Efforts continue to identify and address the investigation and serious incidents.,. We are expecting a return visit sometime by September."

Staff #3 and #5 was asked what are the "strides" to fix the staffing issues and how was that information utilized and analyzed in the QAPI process? Staff #3 and #5 were unable to provide the surveyor on PI process for staffing issues per request. Staff #3 stated that she did not have that information.

Based on review, observations and interviews the facility failed to ensure that a Registered Nurse (RN) was always available and supervision was provided for patient care units A, B, C, D, E, F, G, and H.

A tour was conducted on 8/19/25 at 11:30am on units A with staff #7. An observation of the unit revealed the unit was locked and required the staff to use a badge for entry and exit. The unit contained a central nurse's station that included access to the medication room. A locked door adjacent to the nurse's station led to a hallway with four whiteboards with patient information and photographs. The hallway also provided access to a seclusion room through a second door and to an exit door, which was locked.

While standing in the nurse's station the surveyor observed a locked double door separating the day rooms. Unit A had an A and B hallways separated by locked double doors. The A and B hallways included a small day area with a hallway to patient rooms. Hallway A had 15 men and hallway B had 9 women. Staff #7 confirmed the doors were locked and the men were separated from the women due to inappropriate behaviors making it separate units.

Unit A had one Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN),1 Mental Health Technician (MHT), and 1 Mental Health Technician (MHT) on a 1:1. The staff were having to get to each side of the unit through the nurse's station due to the locked doors separating the unit. If the nurse was sitting on one side of the nurse's station, she could only view one hallway. When the RN had an issue on hallway A, she was unable to see or hear what was happening on hallway B. There was no staff assigned for both hallways of unit A.

An interview with Staff # 9 LVN and Staff #8 RN was conducted on 8/19/25 in the afternoon. Staff # 8 and 9 confirmed that the unit doors were always locked to separate the patients, but they were staffed for only one unit. Staff #9 stated that this was a high acuity level unit and took violent patients. Staff #8 confirmed that the milieu was often very hectic, and patients had not only hurt other patients but the staff as well. Staff #9 reported that the staffing pattern frequently consisted of only female staff, which placed them at risk of being overpowered by physically stronger male patients. Staff #9 stated that more than often the staff consist of only women and can become overpowered by strong men. Staff #9 stated about three weeks ago she was injured by a patient. Staff #9 was thrown to the ground, and she hit her head. Staff #8 and #9 stated that when they call codes (due to violent behaviors) "sometimes only one person shows up." Staff #8 and #9 confirmed they are short staffed, feel vulnerable and unsafe, and unable to complete all their duties within the 12-hour shift. Staff #8 and #9 stated that they have a walkie talkie at the nurse's desk to call for help, but they do not take it with them. If they are injured or trapped "we just yell out for help." Staff #9 passes the patient medications and requires RN supervision. Staff #8 stated that she was responsible for all patient's, staff, patient assessments, all admissions and discharges to the unit and any other problems as they arise including monitoring patients in restraint and seclusion. Staff #8 was asked if she was able to get any help with admissions or when the unit was full. Staff #8 and #9 confirmed they were told that they could not refuse any admissions and to make it work. Staff #8 stated that she stays 3-4 hours over her shift to finish paperwork on many occasions. Staff #8 was asked about acuity and how the RN was able to determine when the staffing should be increased or decreased. Staff #8 and 9 confirmed there were no acuity levels other than a 1:1 (one staff member within arm's length of a patient.) Staff #8 confirmed that if a patient was ordered to be on a 1:1 then they would come up with an extra MHT, but it did not increase the RN. Staff #8 confirmed "A" unit would receive very high acuity patients and many individuals with Intellectual and Developmental Disabilities (IDD) causing high risk incidents.
Staff #8 and #9 was asked who covered when they went on breaks? Staff #8 and #9 stated that they were not allowed breaks. When they needed bathroom breaks, they would just have to leave the unit. Staff #8 confirmed that if she needed to go to the bathroom, she had to leave the unit unattended, leaving the LVN and MHT unsupervised and void of an RN. Staff #8 confirmed the house supervisor did not cover for breaks. Staff #8 and #9 stated they were not allowed lunch breaks. The staff have to snack or eat at the nurse's station when they can. Staff #8 confirmed that when an admission came to the unit that had not been searched for contraband, it was RN's responsibility to go through the locked doors behind the nurse's station to search the patient. This action would take sometimes 15-25 minutes leaving the unit without an RN. Staff #9's timecard was pulled and from 7/13/25 through 8/19/25 staff #9 had not clocked out for any breaks. Staff #8 and #9 were asked if they had ever been informed of the Nurse Staffing Committee and if they were invited or voted for the committee. Staff #8 and #9 stated they had never heard of that and were not involved in nurse staffing. Staff #8 and #9 stated they did not feel comfortable with calling safe harbor. Staff #9 stated that another nurse had recently "called" safe harbor and then she was fired.
(In Texas, Safe Harbor is a legal process that protects nurses from employer retaliation, discipline, or termination and from Board discipline if they, in good faith, refuse to accept an assignment they believe would result in a violation of the Texas Nursing Practice Act (NPA) or Board rules, or harm a patient. The process requires the nurse to first discuss their concerns with their supervisor and, if unresolved, submit a quick request form, followed by a more detailed form to their facility's peer review committee, which evaluates the situation and determines appropriate actions.)

A tour was conducted of unit D on 8/19/25 in the afternoon hours with Staff #7. Staff #7 stated that unit C was closed but unit D was open. A tour of the units revealed unit C and D were identical to A and B. 15 adolescents were on unit D with locked doors between hallways A and B. Staff # 16 confirmed that unit D was staffed with one RN, LVN and MHT for both A&B hallways. Staff #16 was asked if she ever had to leave the locked unit unattended. Staff #16 stated that she had patients that were taken over to the closed unit (C) for programing by the therapist. She stated that the patients would stay over there all day, sometimes until bedtime but the LVN or MHT would go over leaving her unit short. However, Staff # 16 confirmed that were times she would have to go over to the other locked unit to check on the patients, leaving the unit without an RN. Staff #16 confirmed that she was not relieved for any bathroom or meal breaks. Staff #16 confirmed that she was not aware of any nurse staffing committee and has never been asked to participate. Staff #16 confirmed that she did not know who the Director of Nursing Services was and had never met her. Staff #16 confirmed that she was not aware of any acuity levels that would constitute staffing up or down. Staff #16 confirmed she did not feel comfortable calling Safe Harbor and was afraid of possible retaliation.

A tour was conducted of unit B on 8/20/25 in the afternoon hours. Unit B had locked doors between hallways A and B. Staff # 13 stated that she was the only RN and was responsible for both locked units. Staff # 13 stated she could not see down both hallways at once and felt the unit was not a safe place. Staff #13 confirmed that she did not get any breaks and was told to eat on the unit without a lunch break. She confirmed that she had to leave the unit unattended to go to the bathroom or assist with a code. Staff #13 stated communication was poor and was not aware of any nurse staffing committee.

According to the policy and procedure Acute Acuity, Critical Factors and Appropriate Staffing Levels stated, "Procedures:
1. The Chief Nursing Officer is responsible for developing a core staffing plan for each patient care unit based upon the population served. The staffing will include Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHWs).
2. In the development of the core staffing plan the CNO shall consider the following:
a. Each residential unit will have the minimum number of staff per state of Texas requirements.
b. Each patient care unit will always have a minimum of one RN. If only one RN is scheduled to a unit for a shift, relief coverage for the RN will be planned and documented.
c. A minimum of two staff will be assigned to all units, one of which will be an RN on each shift.
d. The patient/resident specific population and special needs, the staff mix, and competencies required to provide safe, quality patient care.
3. The staffing plan for each unit establishes the minimal staffing levels for that unit (core staffing). Special needs of patients/residents related to both their medical and psychiatric care are always primary factors. Additional consideration is given to:
a. General number and types of patient/resident precautions
b. Medical monitoring, such as vital sign frequency, blood glucose monitoring, ECT, and detox protocols.
d. Admission/discharge patterns
e. Medications administration numbers (routine and/or PRN)
f. Mix of more than one age group of patients, such as children and adolescents
g. The physical design of the environment
h. Staff competencies
j. Age and emotional, behavioral, and developmental functioning of the individuals served.
4. Multiple factors influence the functioning of a patient care/residential unit, and the CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels include, but are not limited to:
a. Overall acuity on unit based on formal scoring or nursing assessment of unit activities and patient population.
b. New admissions increasing unit acuity.
c. Patients/residents placed on increased levels of monitoring, to include 1 to 1 observation.
d. Number of patients/residents requiring assistance with personal care
e. High risk conditions such as aggressive and/or violent patients/residents toward self and/or others
f. Multiple patients on detox protocols
g. Patients/residents who have required multiple restraints and/or seclusions to maintain safety to self or others.
h. Scheduled special procedures/tests out of facility with transport/escort required.
I. Skill level of employees
J. Patient/resident activity, including school and visiting hours.
k. Scheduled in-services and training
l. Newly hired staff completing shadow shifts.
m. Environment of care issues or concerns
n. Admission of patients to fulfill facility responsibilities under EMT ALA standards.
5. Determining the appropriate staffing mix is the responsibility of the CNO/delegates
6. Daily Nursing Shift Report, scheduled admissions and discharges, daily 1: 1 report, and 24-hour Administrative Reports shall be reviewed each shift by the Nursing Directors and/or Nursing Supervisor to adjust the numbers and mix of staff on each unit, with direct oversight by the Chief Nursing Officer.
7. The Daily Nursing Shift Report serves as a communication tool for nursing leadership and facilitates adequate staffing levels based on unit acuity and intensity of patient care needs.
8. The CEO and Human Resources Director conduct weekly reviews of staffing vacancies to ensure on going compliance with RN staffing requirements.
9. The CNO/delegate, RN Directors, Staffing Coordinators, and RN Supervisors meet every weekday to discuss current staffing levels in the Safety Review Huddle.
10. All staffing nonc01w2liance is discussed with leadership in daily flash meetings.
11. The CNO/delegate is authorized to increase the staffing level on any unit based on the assessment of the nursing care needs and acuity of the patients/residents and the capabilities/qualifications of the staff assigned to the unit.
12. The CNO/delegate must be kept informed of any changes in the acuity level on the units ...."

An interview was conducted with Staff # 5 on 8/20/25. Staff #5 stated that she was the interim Director of Nurses for the last 4 months. Staff #5 stated that she had previous experience in staffing and had worked in leadership in the past. Staff #5 was asked why the facility was staffing two separate locked units with only one set of staff? Staff #5 stated she did not realize that the locked doors between the unit would require two sets of staff. Staff #5 confirmed that she was staffing for only one unit instead of two and was staffing to the minimum staffing grid. Staff #5 confirmed that she had no evidence to show that the RN was being covered when she/he left the unit for a bathroom break or to search a new patient admission for contraband. Staff #5 confirmed that patient units A-H were staffed all the same.

Based on review, observations and interviews the facility failed to ensure safe staffing levels were provided for patient care units A, B, C, D, E, F, G, and H.

A tour was conducted on 8/19/25 at 11:30am on units A with staff #7. An observation of the unit revealed the unit was locked and required the staff to use a badge for entry and exit. The unit contained a central nurse's station that included access to the medication room. A locked door adjacent to the nurse's station led to a hallway with four whiteboards with patient information and photographs. The hallway also provided access to a seclusion room through a second door and to an exit door, which was locked.

While standing in the nurse's station the surveyor observed a locked double door separating the day rooms. Unit A had an A and B hallways separated by locked double doors. The A and B hallways included a small day area with a hallway to patient rooms. Hallway A had 15 men and hallway B had 9 women. Staff #7 confirmed the doors were locked and the men were separated from the women due to inappropriate behaviors making it separate units.
Unit A had one Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN),1 Mental Health Technician (MHT), and 1 Mental Health Technician (MHT) on a 1:1. The staff were having to get to each side of the unit through the nurse's station due to the locked doors separating the unit. If the nurse was sitting on one side of the nurse's station, she could only view one hallway. When the RN had an issue on hallway A, she was unable to see or hear what was happening on hallway B. There was no staff assigned for both hallways of unit A.

An interview with Staff # 9 LVN and Staff #8 RN was conducted on 8/19/25 in the afternoon. Staff #8 and 9 confirmed that the unit doors were always locked to separate the patients, but they were staffed for only one unit. Staff #9 stated that this was a high acuity level unit and took violent patients. Staff #8 confirmed that the milieu was often very hectic, and patients had not only hurt other patients but the staff as well. Staff #9 stated that more than often the staff consist of only women and can become overpowered by strong men. Staff #9 stated about three weeks ago she was injured by a patient. Staff #9 was thrown to the ground when she hit her head. Staff #8 and #9 stated that when they call codes (due to violent behaviors) "sometimes only one person shows up." Staff #8 and #9 confirmed they are short staffed, feel vulnerable and unsafe, and unable to complete all their duties within the 12-hour shift. Staff #8 and #9 stated that they have a walkie talkie at the nurse's desk to call for help, but they do not take it with them. If they are injured or trapped "we just yell out for help." Staff # 9 passes the patient medications and requires RN supervision. Staff #8 stated that she was responsible for all patients, staff, patient assessments, all admissions and discharges to the unit, and any other problems as they arise including monitoring patients in restraint and seclusion. Staff #8 was asked if she was able to get any help with admissions or when the unit was full. Staff #8 and #9 confirmed they were told that they could not refuse any admissions and to make it work. Staff #8 stated that she stays 3-4 hours over her shift to finish paperwork on many occasions. Staff #8 was asked about acuity and how the RN was able to determine when the staffing should be increased or decreased. Staff #8 and 9 confirmed there were no acuity levels other than a 1:1 (one staff member within arm's length of a patient.) Staff #8 confirmed that if a patient was ordered to be on a 1:1 then they would come up with an extra MHT, but it did not increase the RN. Staff #8 confirmed "A" unit would receive very high acuity patients and many individuals with Intellectual and Developmental Disabilities (IDD) causing high risk incidents. Staff #8 stated that she was unable to properly assess the patients when needed or supervise the milieu due to high acuity, and admissions.

Staff #8 and #9 were asked who covered when they went on breaks. Staff #8 and #9 stated that they were not allowed breaks. When they needed bathroom breaks, they would just have to leave the unit. Staff #8 confirmed that if she needed to go to the bathroom, she had to leave the unit unattended, leaving the LVN and MHT unsupervised and void of an RN. Staff #8 confirmed the house supervisor did not cover for breaks. Staff #8 and #9 stated they were not allowed lunch breaks. The staff must snack or eat at the nurse's station when they can. Staff #8 confirmed that when an admission came to the unit they had not been searched for contraband and it was RN's responsibility to go through the locked doors behind the nurse's station to search the patient. This action would take sometimes 15-25 minutes leaving the unit without an RN. Staff #9's timecard was pulled and from 7/13/25 through 8/19/25 staff #9 had not clocked out for any breaks.

A tour was conducted of unit D on 8/19/25 in the afternoon hours with Staff #7. Staff #7 stated that unit C was closed but unit D was open. A tour of the units revealed unit C and D were identical to A and B. 15 adolescents were on unit D with locked doors between hallways A and B. Staff #16 confirmed that unit D was staffed with one RN, LVN and MHT for both A&B locked hallways. Staff #16 was asked if she ever had to leave the locked unit unattended. Staff #16 stated that she had patients that were taken over to the closed unit (C) for programming by the therapist. She stated that the patients would stay over there all day, sometimes until bedtime, but the LVN or MHT would go over leaving her unit short. However, Staff #16 confirmed that there were times she would have to go over to the other locked unit to check on the patients, leaving the unit without an RN. Staff #16 confirmed that she was not relieved for any bathroom or meal breaks and would have to leave the unit unattended.

A tour was conducted of unit B on 8/20/25 in the afternoon hours. Unit B had locked doors between hallways A and B. Staff #13 stated that she was the only RN and was responsible for both locked units. Staff #13 stated she could not see down both hallways at once and felt the unit was not a safe place. Staff #13 confirmed that she did not get any breaks and was told to eat on the unit without a lunch break, confirmed that she had to leave the unit unattended to go to the bathroom, or assist with a code.

A review of the staffing schedule, grid, and the census sheets was conducted on 8/21/25. Staff #5 presented a staffing schedule called the "Staffing Analysis Tool" for each unit, from 6/29/25 through 8/23/25. The tool had the patient census and how many RN's, LVN's, and MHT's were working for three different shifts. There were no names of the staff, patients that were on precautions, or any patient acuity levels on this tool.

Staff #5 provided a staffing grid for each unit but had only two shifts on it. Days (7am-7pm) and nights (7pm-7am). Staff #5 was asked what hours and shifts do the staff work. Staff #5 confirmed the facility uses 2 shifts days and nights. The grid was unable to be followed due to the number of patients per unit. The patient census started at seven instead of one. The surveyor was unable to determine, if the unit had only 1 patient what staffing would be required. There was no acuity levels built into the grid, nor was there a complete tool to assist the scheduler in deciding on safe staffing levels.

According to the Patient Safety Precautions policy and procedure:
1. All patients who have been clinically identified as having a high risk for safety will be placed on appropriate precautions via an order from a licensed independent practitioner (LIP) to increase awareness of risk to self or others in the areas identified ...
a. Suicide
b. Assault
c. Homicide
d. Sexually acting out-victim
e. Sexually acting out-predator
f. Elopement
g. Medical
h. Falls
These precautions may require extra protective measures and should be identified to adjust scheduling as needed to ensure patient safety. There was no evidence these acuity levels were being factored into the staffing grid or schedule.
A review of the Unit Staffing Census Sheet for unit A and unit B revealed there was no documentation when the staff received breaks and who covered them for that break time. There was no information of when someone covered for another employee when they were late or needed to go home early, the patient's name that was on a 1:1 was written on the sheet but no information on what staff member was on the 1:1, when the 1:1 started, or when it was discontinued. Once a staff member takes on a 1:1 patient they are unable to assist with any other patients or duties. That staff member must be replaced, or the unit is now short staffed.

The surveyor was able to determine that units A-H were short at least 1 RN,1 LVN, and 1 MHT each shift. The surveyor was unable to determine if the one hallway had enough staff due to inability to determine patient acuities, times that patients were placed and removed from 1:1's, any medical needs, staff competencies, and if there were patients on the unit that required hands on care such as developmental delays, and/or behavioral outbursts. Staff #5 confirmed that patient units A-H were all staffed the same.

An interview was conducted with Staff #5 on 8/20/25. Staff #5 stated that she was the interim Director of Nurses for the last 4 months. Staff #5 stated that she had previous experience in staffing and had worked in leadership in the past. Staff #5 was asked why the facility was staffing two separate locked units with only one set of staff? Staff #5 stated she did not realize that the locked doors between the unit would require two sets of staff. Staff #5 confirmed that she was staffing for only one unit instead of two and was staffing to the minimum staffing grid. Staff #5 stated that she had flash meetings in the mornings with leadership to make sure that there is enough staff to cover the units. However, she was unable to provide what information she uses to make those decisions except for a staffing grid.
Staff #5 confirmed that she had no evidence to show that the RN was being covered when she/he left the unit for a bathroom break or to search a new patient admission for contraband. Staff #5 confirmed that she was aware the staff did not clock out for lunch. Staff #5 stated the staff were expected to eat with the patients. Staff #5 was asked if she thought it was productive and safe for the nurses to not get a break in a 12-hour shift. Staff #5 relayed "that the way it's been here." Staff #5 was asked about the bathroom breaks and was she aware the RN had to leave the unit unattended. Staff #5 confirmed that she was aware.

A review of the July Performance Improvement Committee notes revealed in June the facility had 483 incidents reported for the month. Physical confrontation/aggression 248, AMA/ discharges 120, 32 boundary violations, and 207 restraints in one month. Staff turn over was reported at 71%. The action to be taken stated, "HR closely tracks turnover and continues the staffing committee to decrease turnover and address staffing issues/concerns."

The facility was unable to provide any information in how the HR department tracks turnover and reports to the Nurse Staffing Committee. Staff #5 was asked if she had any Nurse staffing committee meeting minutes. Staff #5 was able to provide meeting minutes for 6/25/25 and 8/14/25.

According to the Nurse Staffing Committee policy and procedure stated,
"1. Laurel Ridge Treatment Center will establish a nurse staffing committee as a standing hospital committee.
A. The committee will be composed:
1) Members representative of the types of nursing services provided at Laurel Ridge Treatment Center.
2) 60% RN's who provide direct patient care at least 50% of their work time and are selected by their peers who also provide direct care during at least 50% of their work time; and
3) The Chief Nursing Officer
B. Participation on the Nurse Staffing committee by an employee as a committee member is part of the employee's work time and Laurel Ridge will compensate members for that time accordingly.
C. The committee shall meet at least quarterly.
D. The committee shall evaluate the effectiveness of the facility's Nurse Staffing Plan in relation to patient needs, nursing-sensitive quality indicators, nurse satisfaction measures collected by the system, and evidence-based nurse staffing standards.
E. The committee shall submit a semiannual report to the facility's Governing Board on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.
2. The Official nurse staffing plan shall use current standards and shall:
A. Set minimum staffing levels for patient care units that are based on multiple nurse and patient considerations and evidence-based safe nursing standards.
B. Includes a method for adjusting the staffing plan to meet patient needs, to include calling in or calling off staff based on the patient census, acuity and other hospital activities.
C. Includes a contingency plan when patient care needs unexpectedly exceed direct patient care and staff resources; and
3. Laurel Ridge Treatment Center prohibits the use of "mandatory overtime" per policy# NR-1.
4. The governing body of the facility must consider a nurse staffing plan based on input from the Nurse Staffing Committee."

The meeting for 6/25/25 was on multiple topics such as treatment plans, documentation, visitation protocols, and staffing. There was no true dedication for staffing only. Staff #5 stated that she just sent out an email to all nurses if they wanted to come. Staff #5 was asked if she followed the facilities policy and procedure for "60% RN's who provide direct patient care at least 50% of their work time and are selected by their peers who also provide direct care during at least 50% of their work time." Staff #5 stated she did not have an election or representatives selected by their peers. Staff #5 confirmed that the LVN's were not represented in the meetings. The attendees to the meeting did not meet the 60% direct patient care nurses. Staff #5 was unable to provide the surveyor with a semi-annual report to the Governing Board on nurse staffing, patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse service staffing plan and aggregated variations between the staffing plan and actual staffing. Staff #5 stated that the previous Director of Nursing may have done that, but she was not aware of where that information could be.

Staff #5 provided committee meeting minutes on 8/14/25. Only six people were in the meeting. All RN's. There was no LVN representation. The meeting was consistent with the June meeting including restraints, face to face, attendance policies, holding employees accountable for being on work on time. The meeting was not completely focused on staffing. Staff #5 stated it was just easier to have all of this done in one meeting. Again, staff #5 had no plan in how this information would get back to working staff and how the staff members could participate. The meeting minutes stated that the committee had decided to add another LVN to the grid for units I and J when the census rose above 26 patients. However, there was no other recommendations to ensure other units were staffed appropriatly in high patient risk area's.