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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, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals.

Findings included:

The facility's Governing Body failed to ensure:

1.) Patients' Rights,were protected and promoted in accordance with the facility's policies and procedures; core staffing grid; and in accordance with State law for 15 of 21 patients reviewed (Patient ' s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 with patient rights violations.

Specifically, the facility's Governing Body failed to ensure:

A.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, "meth," [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ' s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the "meth" to other adolescents in the unit.

The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with "contraband," a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ' s safety search was completed on 4/4/25.

The facility ' s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And,

B.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ' s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot." Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ' s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ' s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And,

C.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit.

The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found.

D.) staff documented an incident report according to the facility ' s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury.

This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs.

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. The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights. Refer to deficiencies; A0144, A 0160, and 0167 for evidence of specific findings.

2.) Adequate numbers of nursing personnel, other supportive staff to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients; and in accordance with the facility's current staffing grid.

Specifically, the facility utilizes a core staffing grid to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census.

Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity.

A.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients.

B.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit.

The facility's failure to provide adequate numbers of nursing personnel resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility.

As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death.

Refer to deficiencies; A0392, A0395, and A1704 for evidence of specific findings.

The cumulative effects of these deficient practices and that the Hospital's Conditions of Participation were not met for Patient Rights, Nursing Services, and Special Staff Requirements For Psychiatric Hospitals; resulted in facility's inability to meet the Condition of Participation for Governing Body.

Based on observation of facility video surveillance, review of facility's policies and procedures, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility's policies and procedures; core staffing grid; and in accordance with State law for 15 of 21 patients reviewed (Patient ' s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 with patient rights violations.

Specifically, the facility failed to ensure:

1.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, "meth," [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ' s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the "meth" to other adolescents in the unit.

The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with "contraband," a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ' s safety search was completed on 4/4/25.

The facility ' s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And,

2.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ' s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot." Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ' s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ' s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And,

3.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit.

The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found.

4.) staff documented an incident report according to the facility ' s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury.

This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs.

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.

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

Refer to deficiencies; A0144, A 0160, and 0167 for evidence of specific findings.

Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to supervise and evaluate the nursing care of each patient in accordance with the facility's policies and procedures and current staffing grid.

Specifically, the facility utilizes a core staffing grid to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census.

1.) On 4/3/25 and 4/6/25 the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity.

Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients.

On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid and failed to ensure the immediate availability of an RN assignment for each unit.

2.) On 4/6/25, RN staff failed to ensure implementation and evaluation of the emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility's policy and procedures during a group incident that occurred in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot."

Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion by RN #13 without monitoring or documentation. Patient's #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility's HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The facility's failure to provide adequate numbers of nursing personnel resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility.

As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.23 Nursing Services, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death.

Refer to deficiencies; A0392 and A0395 for evidence of specific findings.

Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other supportive staff to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients; and in accordance with the facility's current staffing grid.

Specifically, the facility utilizes a core staffing grid to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census.

Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity.

1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients.

2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit.

The facility's failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility.

As a result, the facility was not able to meet the requirements for the Condition of Participation, CFR 482.62: Special Staff Requirements, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and potential death.

Refer to Tag A1704 for specific evidence.

Based on observation of video review, records review and interviews, the facility failed to ensure patients received care in a safe setting for 15 of 21 patients reviewed (Patient ' s #1, Patient #2, Patient #3, Patient #4, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #17, Patient #21 and Patient #21 .

Specifically, the facility failed to ensure:

1.) staff followed the contraband safety search policy for patients being admitted to the facility. On 3/19/25, 16-year-old Patient #1 had a medical change in condition and was transferred to the emergency department of another acute care hospital. It was determined Patient #1 ingested an illegal drug, "meth," [methamphetamine] that another 14-year-old, Patient (#2) brought into the facility ' s adolescent unit (A) on 3/17/25. Further documentation indicated Patient #2 also provided the "meth" to other adolescents in the unit.

The facility failed to ensure this serious event was thoroughly investigated, corrective action was immediately implemented, and appropriate monitoring was completed which resulted in; Patient #3, 16 years old was found with "contraband," a cell phone, in the same adolescent unit (A) on 4/16/25. Patient #3 ' s safety search was completed on 4/4/25.

The facility ' s systemic failure resulted in an identified Immediate Jeopardy when all patients in the facility were placed at risk for potential serious injury, significant harm, or potential death if illegal drugs, ligature items, dangerous items and/or weapons are brought into the units. And,

2.) staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ' s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot." Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient ' s #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ' s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight. And,

3.) adequate staffing during psychiatric behavioral codes (Code Green) and other emergencies; including an RN present at all times in the unit.

The failure to maintain adequate staffing during an emergency behavioral code resulted in Patients #17, #20 and #21 eloping from the facility and Patient #21 has not been found.

4.) staff documented an incident report according to the facility ' s policy for Patient #4 who was involved in a physical altercation with another patient on the adolescent unit (A) on 6/1/2024; and was not appropriately assessed and monitored following the incident until the following day after complaints of facial pain and injury.

This failure places patients at risk of undetected injury, delay of care, and unmet clinical needs.

Findings included:

1.) A.) Review of complaint Intake TX00538159 dated 3/28/25 indicated Patient #1, a 16-year-old female, placed at the facility between 3/16/25 and 3/24/25 was provided and took "meth" [methamphetamine] given by Patient #2, who brought in the meth hidden in her bra. Patient #1 snorted the "meth;" that looked like a rock. Patient #1 had a seizure due to the meth and was taken to the hospital. Patient #1 tested positive for methamphetamine. Facility staff never reported the incident to Child Protective Services (CPS), Patient #1 ' s legally managing conservator. CPS immediately took custody of Patient #1.

Review of the facility ' s Incident Report dated 03/19/2025 at 09:15 AM for Patient #1 in Unit-A revealed the following, in part: Patient experiencing what appeared to be relentless panic attacks. Vitals taken and Blood Pressure (BP) was 137/97 [elevated] and pulse was 97, with the patient ' s eyes rolling back. Patient would stop behavior when asked to allow for staff to take vitals. Physician ordered patient to receive Ativan Intermuscular(IM) and send to hospital for further evaluation. Upon further investigation it was discovered patient had possibly ingested meth that was brought in by another patient. Patient returned medically cleared with no acute findings noted. Able to continue treatment.

There was no further documentation available upon multiple requests regarding an investigation of how Patient #1 obtained the meth and whether other patients on the unit had also been provided meth.

Review of Patient #1 ' s record titled, Return Assessment and Recommendations dated 03/19/2025 at 12:52 PM, indicated Patient #1 was sent to an acute care hospital on 03/19/25 due to having panic attacks, staring relentlessly and eyes rolled back in her head. Patient #1 returned to the facility at 2:49 PM with lab findings indicating she was positive for meth and benzo [benzodiazepine].

Review of the facility ' s Incident Report dated 03/19/25 at 09:15 AM for Patient #2 in Unit-A revealed the following, in part: Another peer [Patient #1] was having what appeared to be a panic attack or seizure like activity. When questioned about the source of the change in condition, Patient #1 reported she had ingested a substance given to her by Patient #2. Patient #2 endorsed having brought in ' meth" hidden inside of her bra. Staff reporting [specific staff unknown] they thoroughly searched Patient #2 ' s belongings and are not sure how the substance would have made it onto the unit. Thorough room and safety search completed. No additional contraband found. There was no further documentation indicating whether Patient #2 had given meth to other patients on the unit. The Director of Risk Management (DRM) Staff #3 and the Unit Nurse Manager/Staff #5 signed this incident report on 3/24/25 without any further documentation, investigation, or corrective action noted.

Review of Patient #2 ' s Nursing Admission Assessment, dated 03/17/2025 at 2:40 PM revealed Patient #2 was a 14-year-old female, that admitted to using "a lot" of amphetamine and marijuana yesterday, (03/16/2025). Further review of the Nursing Admission Assessment documented the skin assessment and search conducted at 3:47 PM by RN #6 and RN #7.

Review of Patient #2 ' s Physician ' s MOT Order and Preliminary Plan, dated 03/17/2025 at 6:32 PM revealed she was admitted with the preliminary psychiatric impression of: Amphetamine (or other stimulant use disorder). Admit Patient to Inpatient Program: Substance Use Rehabilitation.

Review of Patient #2 ' s Daily Nursing Progress Note, dated 03/19/2025 at 09:00 PM revealed, "Patient irritable and demanded her clothes after being placed on scrubs. Patient had admitted to smuggling methamphetamines into the unit using it and giving/sharing with peers."

Review of Patient #2 ' s Discharge Summary dated 03/31/2015 at 11:44 AM, documented Patient #2 "managed to sneak in methamphetamines from the streets. The patient was sharing drugs with other girls on the unit. Safety searches were conducted, and she turned over the illicit drugs."

Interview on 03/31/2025 at 11:00AM with the Director of Performance Improvement (DPI) revealed there was no further documentation regarding the incident of Patient #2 giving Patient #1 meth. She further indicated that all nurses and mental health technicians will be retrained on the following dates: April 8, 9, 10 and 12 on how to conduct admission "searches".

Interview with the Director of Risk Management (DRM) on 3/31/25 at 11:00 AM stated he was on vacation when the incident regarding Patient #1 and Patient #2 was reported. He stated that when he is on vacation, the incident investigations are the responsibility of the unit nurse managers.

As of 04/19/2025, the facility did not provide further documentation of an investigation or evidence whether other patients in the unit may have also ingested the meth brought in by Patient #2.

Interview on 4/3/25 at 3:15 PM with RN #12 from the intake/admissions unit stated they complete an initial safety search before taking the patients to their assigned unit. RN #12 stated the initial search process included having the patients empty out their pockets and then use the metal detector, security wand around them to check for any concealed contraband/weapons before escorting them to the unit. RN #12 stated they basically completed a limited overall visible search, and after the patient arrives to their assigned unit, the assigned unit staff will complete a "head to toe" search for any contraband.

Interview on 4/3/25 at 3:52 PM with the facility ' s Director of Risk Management (DRM) stated he continues to follow up with staff regarding safety searches in accordance with the facility ' s policy and procedure for searches. The DRM stated Patient #2 was interviewed and admitted she snuck "meth" into the unit, inside of her bra. The DRM was asked if any other Patient ' s admitted to Unit -A were interviewed to determine if they were provided meth from Patient #2 as reported, and he responded that he did not because he was on vacation/leave when this incident was reported and, the Unit Director/Staff #5 or the CNO would have been responsible to conduct the investigation.

Further interview on 4/18/25 at 2:25 with the DRM stated the facility did not currently have a CNO and the current Unit Director/Staff #5 was also on leave when the incident was reported on 3/19/25 for Patient #1 and Patient #2. The DRM confirmed this incident was classified as a Level III serious event which would require reporting to the Assistant Corporate Risk Manager according to the facility's policy. The DRM confirmed there were not any further interviews obtained from other patients.

Interview on 4/28/25 at 2:50 PM with RN #7 who assisted Patient #2 with her safety search on 3/17/25. RN #7 stated she did not remember Patient #2 ' s safety search specifically, but the process for searches was to check for a bra with a wire and if they have a bra with a wire, they have to remove the bra and provide them with a sports bra. RN #7 stated the patients have to remove their shirt, and "shake out their bra all the way around while maintaining their privacy at the same time." RN #7 stated the patients only remove their bra if they have a wire, otherwise they pull out away from their body, all the way around. The surveyor asked RN #7 if she was aware that many bras have an opening in them where the padding can be placed in and out, and she responded that her supervisor recently told her that. RN #7 was asked if the patients remove their underwear during the safety searches and she responded, no; they have the patients "stretch out the waist band, and make sure nothing falls out." RN #7 stated the patients are given a towel after they remove their top and then their bottom clothing. She said they do not have them totally remove all their clothing. RN #7 stated that patient safety searches are supposed to be done immediately when the patient arrives to the unit from admissions; however, that does not always occur if they are "short staffed, or a crisis is going on; which happens lots of times. You can ' t always do the searches right when they come to the unit."

Review of Policy and Procedure titled "Searches", last revised September 2024 revealed the following, in part:

3. Full body searches and process for skin assessment:
Full body searches require removal of clothes with a full visual inspection of the patient ' s body, including the inspection of clothing and property carried by the patient. Full body searches are conducted on all patient admissions during the initial nursing assessment that takes place on the unit. Will be conducted by two staff members; one being a Registered Nurse. Full body searches occur only in the examination room. Any patient requiring a full body search is in full observation of staff prior to this search, to prevent the patient from removing hidden items and storing them in the facility.

6. Certain contraband items such as weapons, illegal drugs, matches, etc., will be confiscated. In all cases where contraband is found, the individual performing the search will report in writing, the action taken, patient response, results and any special events will be documented in the chart, to include progress or nursing notes. This Incident Report will be routed daily to the Risk Manager.

Review of Performance Improvement Monitor Monthly Summary for January, February and March 2025 revealed the following: 24 incidents of security/contraband during these three months. Upcoming Improvement Strategies: In our ongoing commitment to enhancing patient safety and quality of care, we are focused on strengthening improvement strategies through staff education and improved processes. The facility has noted several high-risk contraband incidents in the 1st quarter of 2025. In response to this trend during the 2nd quarter the facility will be introducing additional training for all direct care staff on the safety search and environment of care observation rounds. A focus will be placed on thoroughly inspecting the patient ' s person as well as any personal belongings that may accompany them.

B.) Review of Patient #3 ' s Intake Assessment dated 4/4/25 at 08:28 AM revealed Patient #3 was a 16-year-old female with endorsed chronic episodic suicidality with a plan.

Review of Patient #3 ' s initial Nursing Admission Assessment dated 4/4/25 documented the skin assessment and search was completed at 09:52 AM by RN #8 and Staff #9 on Unit-A. RN #8 documented patient guarded for safety search. Took lots of redirection to cooperate. Patient had padding in pants and bra. Required redirections to remove, along with other contraband.

Review of the facility ' s Incident Report dated 4/16/25 at 4:00 PM for Patient #3 on Unit-A documented, Patient was reported by other patients to have a phone on her. The physician ordered a room search and safety search. Patient extremely guarded and hesitant during search. No contraband found. Approximately 15 minutes later, the patient handed over the phone to peer, who turned it into the Mental Health Worker.

Review of the Educational Inservice provided "April 2025" for Unit-A, Unit-B, and Unit-C all child/adolescent units, revealed education and reinforcement provided for the importance of safety searches, ensure staff understand the policy and procedures, and demonstrate the correct method. There was no evidence that RN #8 had been provided re-education regarding the safety search policy and procedures.

Interview with RN #8 on 4/17/25 at 3:00 PM in Unit-A indicated the initial skin assessments and safety searches were completed for the patient upon admission to the unit with 2 staff present and, the patients were to "take all clothes off." RN #8 indicated they have them remove their bottom clothing first, and then their top clothing. They will have the patient go around their underwear band and shake them. RN #8 confirmed that the underwear is not removed all the way off from the patient. RN #8 said they check their bras for wires and give another bra if their bra has wires. They use a screen or sheet to allow the patient privacy during this process. They will ask the patient if there is anything in their pockets or socks. They will have them remove their shoes and check their hair or buns for anything hidden inside. RN #8 confirmed they do not have the patients remove their top and bottoms at the same time, and do not have them remove their undergarments unless the bra has a wire. RN #8 was asked if she received any retraining on the safety searches after the incident with Patient #1 that occurred on 3/19/25 on this unit, and she replied, "No," she had not.

Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated the following: This was her first inpatient psychiatric admission for treatment, and she was able to sneak a cell phone into the unit by putting it in her bra, stating "I ' m sneaky." Patient #3 stated she had the phone almost two weeks, was letting other girls use it, and then another patient "rat me out." Patient #3 said that during her initial search on the unit, RN #8 did not have her take off her underwear or bra; they just had her "stretch out her waist band" and "pull out her bra" as she demonstrated this process. Patient #3 said she initially kept giving the staff conducting the search "push back" stating she didn ' t want to and stalled. She was able to move the phone from her pants to her bra during the search and kept pushing back as a distraction to allow her to get away with sneaking the phone in. Patient #3 said she had the cell phone in her bra when she pulled it away from her skin and holding the cell phone at the same time. She further stated that girls bring in contraband all the time and reported a week ago she heard someone brought in a "razor blade." Patient #3 said the girls report they bring contraband between the soles of their shoes. Patient #3 said the staff need to make sure patients remove their shoes and undergarments; and that staff inspect their undergarments thoroughly. Patient #3 said that girls report bringing in contraband in the pockets of their bras that usually hold the padding and if you do not thoroughly inspect and take out the padding, the staff will miss items.

In an interview on 4/17/25 at 5:15 PM with the DPI confirmed that RN #7 who assisted with Patient #2 ' s safety search and RN #8 who conducted Patient #3 ' s safety search had not received re training on the safety search policy and procedures; further stating "they are sitting on [interim assistant DON/Staff #4's] desk to be completed."

2.) Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other.

Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the "Riot" that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ' s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was "ongoing" and they continue to review the video.

Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part;

Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient's color and respirations minimally.

Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room.

Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation:

Seclusion/Restraint/Emergency Medication Order to include:

reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian.

Post Intervention, Nursing Summary and Notifications include:

face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours.

Debriefing.

Patient #7:

Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM.

Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation.

Further review of Patient #7 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #8:

Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM.

Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression.

Further review of Patient #8 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #9:

Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM.

Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation.

Further review of Patient #9 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #10

Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM.

Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression.

Further review of Patient #10 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #11:

Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025.

Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation.

Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation.

Further review of Patient #11 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #12:

Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM.
Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI indication: agitation.

Further review of Patient #12 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ' s record.

Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion.

Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the "riot" incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now "deleted," the system only keeps for "21 days." The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO.

Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 "did not see it as seclusion" when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the "door was not locked." However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning.

Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the "riot."

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the "state findings." The counseling included the DRM missing incidents in the facility's internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff #5 ) and that the nursing department was in the process of restructuring.

Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the "riot" incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then "people spit in the water" and then Patient #7 threw the cup. Patient #19 "hopped" the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but "they held [Patient #16] back. We all got the booty juice [emergency IM medications]." She said later Patient #19 ' s parents were yelling at the door, but Patient #19 was the one who "swung first" and then her and Patient #21 were like, "oh no, she pulled out our hair." Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter "got booty juice." Patient #17 said the staff were attempting to hold Patient #19 and she "snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses." Patient #21 and Patient #19 were being held by staff. She said they were "short staff" with only 3 MHW ' s and wer were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was "shoving, some punching, some were bleeding;" mostly from Patient #19. Patient #17 said they "calmed us down, and then we got booty juice." Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair.

Review of Patient #17 ' s record revealed there was not any documentation of a physical restraint on 4/6/25.

Review of the facility ' s core staffing grid used to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census revealed the adolescent unit-A staffing for 4/6/25 failed to ensure the minimum staffing requirements were m

Based on review of medical records, policy, and interview, the facility failed to ensure chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) for behavioral emergencies were identified and monitored as a restraint for 6 of 11 Patient ' s reviewed (Patient's #7, #8, #9, #10, #11, and #12) in the adolescent unit -A that were administered emergency medications on 4/6/25 following an incident labeled as a "riot."

Failure to identify and monitor emergency medications used as restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility which posed significant risks to patient safety.

Findings included:

Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other.

Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the "Riot" that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ' s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff (RN #13). The door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was "ongoing" and they continue to review the video.

Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part;

Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient's color and respirations minimally.

Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation:

Seclusion/Restraint/Emergency Medication Order to include:

reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian.

Post Intervention, Nursing Summary and Notifications include:

face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours.

Debriefing.

Patient #7:

Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM.

Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation.

Further review of Patient #7 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #8:

Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM.

Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression.

Further review of Patient #8 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #9:

Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM.

Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation.

Further review of Patient #9 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #10

Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM.

Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression.

Further review of Patient #10 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #11:

Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025.

Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation.

Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation.

Further review of Patient #11 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #12:

Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM.

Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI indication: agitation.

Further review of Patient #12 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ' s record.

Interview on 4/18/25 at 4:20 PM stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot on 4/6/25. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion.

Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the "riot" incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now "deleted," the system only keeps for "21 days." The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO.

Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the "riot."

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the "state findings." The counseling included the DRM missing incidents in the facility's internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff #5) and that the nursing department was in the process of restructuring.

Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the "riot" incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then "people spit in the water" and then Patient #7 threw the cup. Patient #19 "hopped" the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but "they held [Patient #16] back. We all got the booty juice [emergency IM medications]." She said later Patient #19 ' s parents were yelling at the door, but Patient #19 was the one who "swung first" and then her and Patient #21 were like, "oh no, she pulled out our hair." Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter "got booty juice." Patient #17 said the staff were attempting to hold Patient #19 and she "snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses." Patient #21 and Patient #19 were being held by staff. She said they were "short staff" with only 3 MHW ' s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was "shoving, some punching, some were bleeding;" mostly from Patient #19. Patient #17 said they "calmed us down, and then we got booty juice." Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair.

Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure staff implemented emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility ' s policy during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot."

Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion without monitoring or documentation. Patient's #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility ' s HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The failure to document restraint episodes, seclusion, and provide monitoring after the administration of emergency medications posed significant risks to patient health and safety; and resulted in the inability to provide appropriate oversight.

Findings included:

Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other.

Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the "Riot" that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ' s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was "ongoing" and they continue to review the video.

Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part;

Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient's color and respirations minimally.

Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room.

Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation:

Seclusion/Restraint/Emergency Medication Order to include:

reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian.

Post Intervention, Nursing Summary and Notifications include:

face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours.

Debriefing.

Patient #7:

Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM.

Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation.

Further review of Patient #7 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #8:

Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM.

Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression.

Further review of Patient #8 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #9:

Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM.

Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation.

Further review of Patient #9 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #10

Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM.

Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression.

Further review of Patient #10 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #11:

Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025.

Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation.

Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation.

Further review of Patient #11 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #12:

Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM.

Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI indication: agitation.

Further review of Patient #12 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ' s record.

Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion.

Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the "riot" incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now "deleted," the system only keeps for "21 days." The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO.

Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 "did not see it as seclusion" when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the "door was not locked." However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning.

Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the "riot."

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the "state findings." The counseling included the DRM missing incidents in the facility's internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. The CEO stated that another DON has been named (Staff # 5) and that the nursing department was in the process of restructuring.

Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the "riot" incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then "people spit in the water" and then Patient #7 threw the cup. Patient #19 "hopped" the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but "they held [Patient #16] back. We all got the booty juice [emergency IM medications]." She said later Patient #19 ' s parents were yelling at the door, but Patient #19 was the one who "swung first" and then her and Patient #21 were like, "oh no, she pulled out our hair." Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter "got booty juice." Patient #17 said the staff were attempting to hold Patient #19 and she "snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses." Patient #21 and Patient #19 were being held by staff. She said they were "short staff" with only 3 MHW ' s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was "shoving, some punching, some were bleeding;" mostly from Patient #19. Patient #17 said they "calmed us down, and then we got booty juice." Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair.

Review of Patient #17 ' s record revealed there was not any documentation of a physical restraint on 4/6/25.

Based on observation, interviews, and document review, the facility failed to ensure that actions aimed at performance improvement were adequately implemented and monitored to sustain improvements as required under the hospital's QAPI program.

Specifically, following the death of a patient in seclusion on 3/3/2025, the facility conducted a root cause analysis and developed a corrective action plan; however, the facility failed to ensure that the action steps were fully executed and monitored for effectiveness.

Staff continued to inaccurately document patient monitoring during seclusion or failed to document physical hold restraints, and the governing body failed to oversee whether the action plan was followed, including verifying the accuracy of documentation, ensuring documentation is completed for patients in restraint and seclusion, and reviewing available video footage for compliance. This failure placed other patients at risk for harm due to unaddressed systemic issues and noncompliance with safety interventions intended to prevent reoccurrence of serious adverse events.

Findings included:

Review of Intake Information, TX00536658, received 3/10/25 indicated on 3/3/2025, Patient #5 was taken from Unit-C to Unit-D; due to a behavioral event. He was injected with medications, possibly sedative. Patient #5 was placed in the seclusion room in an effort to allow the medication to work. No one checked on Patient #5 for about 55 to 60 minutes, until staff found him unresponsive and bleeding from his mouth. Patient #5 expired. Patient #5 was "not aggressive, only annoying." The facility was not in ratio as there were four staff for 25 patients. There is supposed to be one staff for every five patients. Patient #5 was a 44-year-old Hispanic male with mild IDD (Intellectual and Developmental Disability), with no signs of physical problems. Patient #5 never presented a threat to himself or others.

Review of the facility incident report dated 03/03/2025 at 3:30 PM, documented Patient #5 "out of control, 27." Patient at nursing station voicing delusional though process. Attempted to remove from nurse station. Patient continued delusional behavior in day area, running around. Attempted to remove from stimuli, where patient pushed staff. Then escorted to seclusion. Patient noted lying down in seclusion room.

Review of the facility incident report dated 03/03/2025 at 6:25 PM, revealed Patient #5 died while he was sleeping in seclusion. Patient #5 ' s Incident report was reviewed by interim assistant CNO/Staff #4 on 03/04/2025 at 8:30 AM and the Director of Risk Management (DRM)/Staff #3 on 03/04/2025 at 08:30 AM with the following comments: On 03/03/2025 at 6:28 PM, staff enter the unlocked seclusion room where patient is laying down. After entering and calling the patient ' s name, he is unresponsive to the verbal cue. Staff then retrieve the nurse who entered the seclusion room, turns the patient onto his back and attempts to arouse him via verbal cues and a sternal rub with no response. Code blue called and CPR initiated at 6:31 PM. Code blue bag arrives, and AED is put in place. Patient #5 remains unresponsive, and CPR is continued. Fire Department arrives at 6:42 PM and takes over CPR. Fire Department ceases CPR and calls time of death at 7:03 PM.

Review of facility form HV-114 Restraint/Seclusion/Emergency Meds Acute Care Revised 07/2023, for Patient #5 dated 03/03/2025 revealed but was not limited to the following: Patient was in seclusion from 3:40 PM to 4:20 PM. Patient was listed as laying on mattress sleeping at 3:45 PM. Post Intervention, Face to Face Evaluation was completed by registered nurse at 4:57 PM with continued need for restraint/seclusion checked as, no.

Review of Physician Preadmission Evaluation Review and Admitting orders, dated 03/02/2025 at 6:54 PM revealed Patient #5 was admitted with an observation level of every five minutes (q5).

Interview with Director of Performance Improvement (DPI) on 04/17/2025 at 11:26 AM revealed the facility terminated employment for all staff who were on duty on the unit (D) where the Patient #5 ' s death occurred, including two registered nurses, one licensed vocational nurse and two mental health workers. The DPI stated a root cause analysis (RCA) was completed with recommended terminations due to misleading or falsifying documentation, and failure to follow policies and procedures. Action plans were implemented to address the issues identified in the RCA.

Review of the RCA completed 4/8/2025 found in part, for Patient #5;

-continuous observation when the patient was locked in the seclusion room did not occur per policy and procedure.
- there was a 23-minute gap between the patient observation rounds.
-observation rounds were documented without staff actually visualizing the patient.
-the Q5-minute observations ordered upon admission in accordance with the physician orders were not being followed.
-there were discrepancies in the documentation versus what was observed in the camera review.
-no vital signs were obtained during the entire event timeline.

Review of the plan of correction/action plan revealed the following, in part: Action Plan #2: Daily observation reports will be reviewed and distributed to the respective nursing director for review and to complete follow up action for all late rounds greater than 20 minutes effective 04/01/2025.

Action #3: Evening supervisor will conduct at minimum two in person rounds on all patient care units auditing all observation tablets for rounding compliance and forced errors effective 04/01/25.

Action #5: All events of restraints and seclusion will be reviewed by the Director of Risk Management and respective unit nursing director for compliance. Completion Date: 03/19/2025.

Review of Seclusion/Restraint/Emergency Medication Order dated 04/04/2025 at 10:20 AM for Patient #13 revealed he was placed in seclusion from 10:29 AM to 10:41 AM. Review of his Patient Observation Sheet for 04/04/2025 for this time (10:29-10:41 AM), revealed documentation Patient #13 was in the "day room," as opposed to the "seclusion room".

Review of Seclusion/Restraint/Emergency Medication Order dated 04/06/2025 at 12:33 PM for Patient #14 revealed she was placed in seclusion from 12:33 PM to 12:40 PM. Review of Patient #14 ' s Observation Sheet for 04/06/2025 for this time (12:33 -12:40 PM) revealed documentation she was in the "day room" as opposed to the "seclusion room."

Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other.

Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the "Riot" that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ' s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff (RN #13). The door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was "ongoing" and they continue to review the video.

Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion. The DPI stated the DPM is supposed to include his monitoring, recommendations, or action plans on the incident reports review.

Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 "did not see it as seclusion" when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the "door was not locked." However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning.

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the "state findings." The counseling included the DRM missing incidents in the facility's internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents.

Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients, and in accordance with the facility's current staffing grid.

Specifically, the facility utilizes a core staffing grid to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census.

Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity.

1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients.

2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit.

The facility's failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placing patients at risk for harm, delayed care, and inadequate supervision.

Findings included:

1.) Observation on 4/3/2025 at 2:30 PM on Unit A (the adolescent female unit) with the interim Assistant- Director of Nurses (A-DON)/Staff#4 present revealed the following: RN #10 was in charge, there was a medication nurse (RN instead of LVN), and 3 MHW's assigned to the unit. There were 28 patients total on the unit, 27 assigned and 1 "programming from another unit". There had been 2 admissions since 7:00 AM and RN #10 was working on the daily nursing assessments. The surveyor attempted an interview with RN #10 at the nurses' station but was continuously interrupted by patients with requests, phone calls from parents and providers, staff reporting lab results, staff asking for guidance, and staff coming and going.

Review of the unit Core staffing grid for Unit A, revealed there must be 4 MHW's for a census of 25 patients. The staffing grid did not account for patient census exceeding 25.

During an interview conducted on 4/3/25 at 2:35 PM with the assigned RN #10 stated:
There were 28 patients on the unit today. The census is 27 and there is another patient programming on the unit. RN #10 said he is responsible for completing a nursing assessment on all 27 patients during his 12-hour shift.

2.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit A: 29 patients; staffed with 1 RN, 1 LVN, and 3 MHW's. The staffing grid requires 4 MHW's. This is a female adolescent unit.
o Unit C: 16 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit E: 15 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit G: 20 patients; no MHW's staffed. The staffing grid requires 2 MHW's.
o Unit H: 22 patients; staffed with 2 MHW's. The staffing grid requires 3 MHW's.
o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit J: 13 patients; no LVN provided/staffed. The staffing grid requires 1 LVN.
o Unit K: 17 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit L: 19 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.

This equates to at least 11 staff this shift not provided affecting 10 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels.

B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit D: 22 patients; staffed with 2 MHW's. The staffing grid requires an additional MHW for 8 hours (0.75 MHW).
o Unit E: 15 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW).
o Unit F: 15 patients; no LVN provided/staffed. The staffing grid requires 1 LVN.
o Unit G: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW).
o Unit I: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW).
o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit K: 17 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW).
o Unit M: 13 patients; no RN. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12.

This equates to at least 7 staff this shift not provided affecting 8 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels.

An interview was conducted with Patient #3 on 4/17/25 at 3:15 PM in Unit-A's group room and stated that most of the time she is unable to go to the cafeteria to eat her meals because there is not enough staff available to escort the patients. Patient #3 reported that there must be at least one staff member available to accompany every seven patients to the cafeteria, and staffing is frequently insufficient to meet this requirement. Patient #3 further stated that staff frequently say they are "short-staffed," and staffing shortage often results in patients being unable to go to the cafeteria for meals or participate in outdoor activities. Patient #3 expressed that she feels the staff are not compassionate and lack empathy, further contributing to her dissatisfaction with the care provided at times. Patient #3 said that on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. She said they mix the13 and 17-year-old girls together, and they should be kept separate.

An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A. The patient reported that on April 6, 2025, there was a "riot" on Unit A. Patient #17 stated that the unit was "short-staffed" on the day of the incident. During the riot, Patient #17 stated she was "restrained" and administered an emergency injection, referred to by the patient as "booty juice." Patient #17 also disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded, leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned.

Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN "floor nurse."

This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff.

In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff.

There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN's with direct care roles in accordance with Texas State Law requirements.

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility's CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring.

Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel to ensure the immediate availability of a registered nurse (RN) assigned on each unit to supervise and evaluate the nursing care of each patient; and in accordance with the facility's policies and procedures, and current staffing grid.

Specifically, on 4/6/25:

1.) There were 4 of 14 units reviewed (F, I, J, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid to ensure the immediate availability of an RN for each unit, and

2.) RN staff failed to ensure implementation and evaluation of the emergency interventions including physical restraint, seclusion, and administration of emergency medications according to the facility's policy and procedures during a group incident that occurred on 4/6/25 in the adolescent unit (A) where several patients were engaged in physical fighting and property destruction; labeled as a "riot."

Several unidentified Patients were seen on video playback being physically held in restraint without any physical restraint documentation. Patient #12 was placed in seclusion by RN #13 without monitoring or documentation. Patient's #7, #8, #9, #10, #11, and #12 were administered chemical restraints (emergency behavioral medications) without evidence of monitoring or documentation of the facility's HV-114 form for Restraint/Seclusion/EmMeds in accordance with the policy. Patient #17 stated she was physically restrained on 4/6/25 during this event without restraint documentation.

The facility's failure to provide adequate numbers of nursing personnel and ensure nursing personnel supervised and evaluated patients care provided resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and resulted in inadequate nursing staff supervision during medical and behavioral emergencies that can result in patient harm, injury and potential death.

Findings included:

1.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN.

B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit M: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12.

An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded (including the RN), leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned.

Review of the incident report for Patient #20 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff member while nurse was responding to a code on neighboring unit and took the staff member's badge and key and eloped from the facility. Patient was then found and returned to facility to transfer out to another unit for further evaluation and treatment. Patient #20 struck staff several times in the face and took her access badge that was secured in a badge holder worn on her arm. A peer was holding staff by the hair and striking her in the face when she took the armband. The local PD was called to press charges on Patients. The local PD arrived, reviewed video, and determined an assault and robbery took place.

Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN "floor nurse."

This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff.

In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff.

There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. The This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN's with direct care roles in accordance with Texas State Law requirements.

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility's CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring.

2.) Interview with Patient #3 on 4/17/25 at 3:15 PM in Unit-A ' s group room stated on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other.

Observation of the playback video surveillance with the DRM on 4/18/25 at 3:45 PM using his laptop to review the video of the "Riot" that occurred on 4/6/25 revealed the following observations of the video: Two video angles were viewed. The doors had been shut in the common living area which had separated the unit into two sides. At 7:42 PM there were approximately 5 adolescent girls that surrounded 1-2 other girls at these doors which are by the nurses station. There were 2 girls observed repeatedly hitting at another one of the girl ' s head area with their fists. Further observations revealed several girls jumping over the nurses station and going around to the other side of the common living area to get at other girls on the other side. There also were girls jumping over into the nurses station, knocking down medical equipment and patient records. Multiple staff were seen holding several patients in physical hold restraints. One staff was seen grabbing and holding a patient by her ankle that was attempting to cross over the nurses station. At 7:43 PM Patient #12 was placed in seclusion by staff, (RN #13), the door was closed and a large chair placed in front of the seclusion door preventing egress. The patient remained in the seclusion until 7:51 PM (8 minutes) when the chair was removed and the door opened. During these 8 minutes, there was not a staff member observing this patient in seclusion. Overall, there were an approximate 10 unidentified adolescent girls involved in the altercation; however, these girls were not identified during the time of the video observation because the DRM stated the internal investigation was "ongoing" and they continue to review the video.

Review of facility policy and procedure entitled Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion, last reviewed March 2024, revealed the following, in part;

Emergency Medication is defined as a psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency to prevent imminent risk to self/others when other interventions are ineffective or inappropriate. The use of emergency medications will be documented in same manner as physical restraint and seclusion. The RN must assess the patient and the effectiveness of the emergency medication 15 minutes after administration of the medication. A second assessment will be completed after an additional 15 minutes for a total of 30 minutes after administration of the emergency medication. Vital signs will be obtained at each assessment, at the 15-minute and 30-minute patient assessment. If unable to obtain the vital signs, documented a description of the patient's color and respirations minimally.

Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room.

Review of facility form HV-114 Restraint/Seclusion/Emergency Medication Acute Care revised 07/23 revealed but was not limited to the following documentation:

Seclusion/Restraint/Emergency Medication Order to include:

reason for intervention, less restrictive interventions, any medical conditions/abuse issues that would impact the used of restraint/seclusion, nursing summary and notifications to include time medication given, RN assessment of patient and response to emergency medications completed within 15 minutes of medication administration including vital signs, RN assessment of patient and response to emergency medications completed within 30 minutes of medication administration including vital signs, RN assessment of patient and responses to emergency medications completed within 45 minutes of medication administration including vital signs, RN review of patient response to emergency medication and brief system assessment to be completed within 60 minutes of medication administration, notifications to parent/family/ guardian.

Post Intervention, Nursing Summary and Notifications include:

face to face evaluation (to be completed within 1 hour of initiation of intervention) and seclusion/restraint/emergency medication patient debriefing to be completed after intervention when patient has calmed but no later than 24 hours.

Debriefing.

Patient #7:

Review of Patient #7 Medication Administration Record (MAR) revealed she received Benadryl 50 mg Intramuscular (IM) and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:35 PM.

Review of final physician medication orders for 04/06/25 from 11:07 PM (start) to 11:32 PM (stop); revealed diphenhydramine injectable 50 mg/ml SOLN was prescribed by Physician-A with indication: agitation. Olanzapine intramuscular 10 mg PWDI at 11:07 PM (start) to 11:32 PM (stop) indication: agitation.

Further review of Patient #7 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #8:

Review of Patient #8 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for aggression on 04/06/2025 at 8:25 PM.

Review of final physician medication orders for 04/06/25 from 10:32 PM (start) to 11:59 PM (stop) revealed diphenhydramine infectable 50 mg/ml SOLN was prescribed by Physician A with indication: aggression.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:47 PM (start) to 11:30 PM (stop) indication: agitation/aggression.

Further review of Patient #8 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #9:

Review of Patient #9 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:50 PM.

Review of final physician medication orders for 04/06/2025 from 11:02 PM (start) to 11:26 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physican A with indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 11:02 PM (start) to 11:26 PM (stop) indication: agitation.

Further review of Patient #9 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #10

Review of Patient #10 MAR revealed she received Benadryl 50 mg IM for agitation and Zyprexa 10 mg for aggression on 04/06/2025 at 8:55 PM.

Review of final physician medication orders for 04/06/25 from 10:59 PM (start) to 11:23 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI on 04/06/25 from 10:59 PM (start) to 11:24 PM (stop) indication: aggression.

Further review of Patient #10 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #11:

Review of Patient #11 MAR revealed she received Zyprexa 10 mg IM at 8:55 PM and Benadryl 50 mg IM at 9:45 PM for agitation on 04/06/2025.

Review of final physician medication orders for 04/06/2025 from 08:55 PM (start) to 08:56 PM (stop) revealed Olanzapine intramuscular 10 mg PWDI prescribed by Physician A indication: agitation.

Diphenhydramine injectable 50 mg SOLN for 04/06/25 from 09:45 PM (start) to 09:46 PM (stop) indication: agitation.

Further review of Patient #11 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications.

Patient #12:

Review of Patient #12 MAR revealed she received Benadryl 50 mg IM and Zyprexa 10 mg IM for agitation on 04/06/2025 at 8:33 PM.

Review of final physician medication orders for 04/06/25 from 11:00 PM (start) to 11:24 PM (stop) revealed diphenhydramine injectable 50 mg/ml SOLN prescribed by Physician A indication: agitation.

Olanzapine intramuscular 10 mg PWDI indication: agitation.

Further review of Patient #12 ' s complete medical records did not reveal a form HV-114 for documenting the use of emergency medication administered on 4/6/25 and the RN assessment and response to the emergency medications administered according to the policy for emergency medications. There was not any documentation of seclusion for 4/6/25 at 7:43 PM on an HV-114 form or within the patient ' s record.

Interview on 4/18/25 at 4:20 PM with the DPI stated that when patients are in seclusion, there has to be continuous observation of the patient. The DPI stated there was no evidence of an incident report or seclusion documentation for Patient #12 that was observed on video dated 4/6/25 in seclusion from 7:43 PM to 7:51 PM and a door in front of the seclusion door. The DPI further confirmed there was no evidence completed by the DRM of video monitoring or documentation review completed for Patient #13 that was placed in Seclusion on 4/4/25, and Patient #14 placed in seclusion on 4/6/25. The DPI confirmed there were no incident reports or restraint documentation for any patients being physically restrained during this incident/riot. The DPI further confirmed the DRM had not been ensuring the Action Plan #5 was being completed for all events of restraints and seclusion.

Interview on 5/2/25 at 9:40 AM with DPI was asked about the documentation from DRM for the video observed from the "riot" incident on 4/6/25 in the adolescent unit (A) and she stated there was not any specific documentation from the video and the video is now "deleted," the system only keeps for "21 days." The DPI stated the DRM was at the facility over the weekend to review the video to determine who the patient was that was placed in seclusion. The DPI was asked if the video was saved/secured and she stated that it was not saved, it was not available and in addition; the emails had been deleted from the CEO.

Further interview on 5/2/25 at 11:30 AM with the DPI stated RN #13 "did not see it as seclusion" when she placed Patient #12 in the Seclusion room on 4/6/25 at 7:43 PM, because the "door was not locked." However, the DPI confirmed that the staff placed a door in front of the seclusion door where the patient could not exit. DPI indicated RN #13 received a written warning.

Interview on 5/2/25 at 2:25 PM with Patient #17 in the adolescent unit (A) stated the following regarding the "riot" incident on 4/6/25 in which she was involved: Patient #8 moved over to our side of the unit, and she was cussing at Patient #22. Patient #18 was at the nurses station counter when she and Patient #8 went and pulled her pants down. She said we were all running around and then "people spit in the water" and then Patient #7 threw the cup. Patient #19 "hopped" the nurses counter and started coming over to us and started swinging. Patient #19 was swinging and pulling out my hair. Patient #16 tried jumping over the nurses counter too, but "they held [Patient #16] back. We all got the booty juice [emergency IM medications]." She said later Patient #19 ' s parents were yelling at the door, but Patient #19 was the one who "swung first" and then her and Patient #21 were like, "oh no, she pulled out our hair." Patient #17 stated that she, Patient #16, Patient #18, and the girls who jumped over the counter "got booty juice." Patient #17 said the staff were attempting to hold Patient #19 and she "snagged a badge. They restrained us. I was restrained by a tech with purple and blonde hair with glasses." Patient #21 and Patient #19 were being held by staff. She said they were "short staff" with only 3 MHW ' s and we were able to get away because they were only holding our arms. Patient #18 was able to get back over here herself after she got the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was "shoving, some punching, some were bleeding;" mostly from Patient #19. Patient #17 said they "calmed us down, and then we got booty juice." Patient #17 said they would not let us call anyone, and no one checked us out afterwards, because she was hurt and missing hair.

Review of Patient #17 ' s record revealed there was not any documentation of a physical restraint on 4/6/25.

Interview on 05/02/2025 at 4:36 PM with the DPI indicated that all six Patients (#7, #8, #9, #10, #11, and #12) records were complete as reviewed and confirmed these patients did not have a completed HV-114 form for the administration of emergency medications that were administered on 4/6/25 in response to the "riot."

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) stated on 4/21/25 she provided the DRM with verbal counseling and coaching regarding missing incidents and due to the "state findings." The counseling included the DRM missing incidents in the facility's internal reporting process and not reporting Abuse and Neglect incidents of a child to police. The CEO further stated she is now involved in the daily incidents and ensuring the completion of the incidents are done and reviewing each of the incidents. Further interview with the CEO and DPI present, stated that another DON has been named (Staff # 5) and that the nursing department was in the process of restructuring. The CEO and DPI both confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility's CNO allowed this practice.

Based on observation, interviews, and document reviews, the facility failed to provide adequate numbers of nursing personnel, other personnel to provide care, and ensure the immediate availability of a registered nurse (RN) on each unit to meet the needs of the patients, and in accordance with the facility's current staffing grid.

Specifically, the facility utilizes a core staffing grid to allocate RN's, Licensed Vocational Nurses (LVN's), and Mental Health Workers (MHWs) per unit, based on patient census.

Review of unit staffing for 4/3/25 and 4/6/25 revealed the facility failed to ensure the minimum staffing requirements were met in accordance with patient census or acuity.

1.) Unit A: The staffing grid accounts for up to 25 patients; the number of licensed beds. On 4/3/25 and 4/6/25 the patient census exceeded 25 patients; there were not adequate assigned staffing levels for the patient census and staffing levels were not adjusted accordingly when the census exceeded 25 patients.

2.) On 4/6/25 there were 12 of 14 units reviewed (A, C, D, E, F, G, H, I, J, K, L, M) that did not meet the minimum staffing requirements in accordance with the facility's current Core Staffing Grid and failed to ensure the immediate availability of an RN for each unit.

The facility's failure to provide adequate numbers of staffing resulted in repeated failures to meet minimum care standards, placed staff and patients at risk for harm, delayed care, and inadequate staff supervision during behavioral emergencies that resulted in patient injuries and patients eloping from the facility.

Findings included:

1.) Observation on 4/3/2025 at 2:30 PM on Unit A (the adolescent female unit) with the interim Assistant- Director of Nurses (A-DON)/Staff#4 present revealed the following: RN #10 was in charge, there was a medication nurse (RN instead of LVN), and 3 MHW's assigned to the unit. There were 28 patients total on the unit, 27 assigned and 1 "programming from another unit". There had been 2 admissions since 7:00 AM and RN #10 was working on the daily nursing assessments. The surveyor attempted an interview with RN #10 at the nurses' station but was continuously interrupted by patients with requests, phone calls from parents and providers, staff reporting lab results, staff asking for guidance, and staff coming and going.

Review of the unit Core staffing grid for Unit A, revealed there must be 4 MHW's for a census of 25 patients. The staffing grid did not account for patient census exceeding 25.

During an interview conducted on 4/3/25 at 2:35 PM with the assigned RN #10 stated:
There were 28 patients on the unit today. The census is 27 and there is another patient programming on the unit. RN #10 said he is responsible for completing a nursing assessment on all 27 patients during his 12-hour shift.

2.) A.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 AM - 7:00 PM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit A: 29 patients; staffed with 1 RN, 1 LVN, and 3 MHW's. The staffing grid requires 4 MHW's. This is a female adolescent unit.
o Unit C: 16 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit E: 15 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit F: 15 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit G: 20 patients; no MHW's staffed. The staffing grid requires 2 MHW's.
o Unit H: 22 patients; staffed with 2 MHW's. The staffing grid requires 3 MHW's.
o Unit I: 20 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit J: 13 patients; no LVN provided/staffed. The staffing grid requires 1 LVN.
o Unit K: 17 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.
o Unit L: 19 patients; staffed with only 1 MHW. The staffing grid requires 2 MHW's.

This equates to at least 11 staff this shift not provided affecting 10 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels.

B.) Review of the Patient Census, Daily Staffing Report for 4/6/25 7:00 PM - 7:00 AM and corresponding Unit 2025 Core Staffing Grid revealed the following:

o Unit D: 22 patients; staffed with 2 MHW's. The staffing grid requires an additional MHW for 8 hours (0.75 MHW).
o Unit E: 15 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW).
o Unit F: 15 patients; no LVN provided/staffed. The staffing grid requires 1 LVN.
o Unit G: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW).
o Unit I: 20 patients; no LVN provided/staffed and staffed with only 1 MHW. The staffing grid requires 1 LVN and an additional MHW for 4 hours (0.25 MHW).
o Unit J: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN.
o Unit K: 17 patients; staffed with 1 MHW. The staffing grid requires an additional MHW for 4 hours (0.25 MHW).
o Unit M: 13 patients; no RN provided/staffed. The staffing grid requires 1 RN. This is a child unit with patients 5 years old to 12.

This equates to at least 7 staff this shift not provided affecting 8 units that were not adequately staffed according to the minimal staffing. There was no consideration taken for patient acuity or increased supervision levels.

An interview was conducted with Patient #3 on 4/17/25 at 3:15 PM in Unit-A's group room and stated that most of the time she is unable to go to the cafeteria to eat her meals because there is not enough staff available to escort the patients. Patient #3 reported that there must be at least one staff member available to accompany every seven patients to the cafeteria, and staffing is frequently insufficient to meet this requirement. Patient #3 further stated that staff frequently say they are "short-staffed," and staffing shortage often results in patients being unable to go to the cafeteria for meals or participate in outdoor activities. Patient #3 expressed that she feels the staff are not compassionate and lack empathy, further contributing to her dissatisfaction with the care provided at times. Patient #3 said that on her 2nd day there was a "riot and we were on lock down" because there were girls fighting, jumping over the nurses station to get at each other from one side to the other. She said they mix the13 and 17-year-old girls together, and they should be kept separate.

An interview was conducted with Patient #17 on 5/2/25 at 2:30 PM in Unit-A. The patient reported that on April 6, 2025, there was a "riot" on Unit A. Patient #17 stated that the unit was "short-staffed" on the day of the incident with only 3 MHW ' s and we were able to get away because they were only holding our arms. Patient #18 was able to get the door off the hinges. Some windows were busted out. Patient #17 said her head was throbbing from the amount of harm and hair pulling that Patient #19 did. Patient #17 said there was "shoving, some punching, some were bleeding;" mostly from Patient #19. During the "riot," Patient #17 stated she was "restrained" and administered an emergency injection, referred to by the patient as "booty juice."

Patient #17 also disclosed that on April 23, 2025, she and two other patients (#20 and #21) eloped from the facility. She explained that they had been planning it in advance. They waited until there was a code announced on the adjacent male adolescent unit (B), at which point most staff responded, leaving only one mental health worker behind on her unit (A). According to the patient, they jumped the remaining staff member, took her badge, and used it to exit the facility. Patient #17 stated she and Patient #20 were later apprehended by the local police department and returned, but that Patient #21 who also escaped has not been found or returned.

Review of the incident report for Patient #20 dated 4/23/25 at 8:20 PM indicated Patient and 2 other peers attacked staff member while nurse was responding to a code on neighboring unit and took the staff member's badge and key and eloped from the facility. Patient was then found and returned to facility to transfer out to another unit for further evaluation and treatment. Patient #20 struck staff several times in the face and took her access badge that was secured in a badge holder worn on her arm. A peer was holding staff by the hair and striking her in the face when she took the armband. The local PD was called to press charges on Patients. The local PD arrived, reviewed video, and determined an assault and robbery took place.

Interview on 5/2/25 at 4:15 PM with the DPI stated that when an emergency behavioral code (code green) is called on the overhead speaker, all available staff are to respond. There is not a specific code team or strategic plan each shift for specific staff to respond. The DPI stated the facility tried that in the past, and it did not work.

Review of the last Nursing Staff Committee (NSC) Meeting, dated 3/25/25 chaired by the interim Assistant Director of Nursing (A- DON)/Staff #4 revealed the members present included an RN House Supervisor, The RN educator, The RN infection control nurse, The child and adolescent RN unit director, and one LVN "floor nurse."

This was the first meeting under the new ADON(ACNO)/Staff #4. The new business discussion included the Nursing 12-hour shift template. Proposals to rotate shifts to address staff burnout-particularly for staff working 3/4 shifts in a two-week period. Strategies were discussed to rotate schedules and avoid 4 shifts consecutively. PRN pool management and part-time roles to support full-time staff.

In an interview with the new ADON(ACNO)/Staff #4 on 4/3/25 at 3:30 PM indicated he was recently placed as the interim assistant CNO (DON) of the facility and would be reviewing the staffing grid with other administrative staff.

There was not any documentation that discussed focusing on meeting minimal staffing ratios in relation to patient census, or a review of the actual staffing grid compliance. The This supports concerns that staffing shortages were not being formally evaluated or addressed in structured leadership meetings. The NSC did not include a composition of at least 60% of RN's with direct care roles in accordance with Texas State Law requirements.

Interview on 5/13/25 at 4:15 PM with the Chief Executive Officer (CEO) and the Director of Performance Improvement (DPI) revealed the CEO confirmed there was supposed to be an RN assigned to every unit for every shift. The DPI indicated the previous facility's CNO allowed this practice. The CEO stated that another DON has been named (Unit Director/Staff #5) and that the nursing department was in the process of restructuring.