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Based on reviews, observations, and interviews, the facility failed to ensure that nursing was following the policy and procedure for Code Blue, and the Registered Nurses failed to ensure that completed patient medical assessments and reassessments were performed for 4 of 4(patient #7, # 9, 15, and #16) patients.

FINDINGS:
A review of the patient #7's chart revealed she was a 47-year-old female on a voluntary admission. She was given a diagnosis of psychosis but was oriented x 3 and could understand her rights upon admission.

A review of her Intake form dated 10/16/25 at 15:39 stated, "Pt is a 47-year-old female. Pt is a voluntary walk-in accompanied by her case worker. Pt is highly psychotic and aggressive. Pt made threats to staff to physically assault them. Pt goes on tangents and speech is ineligible (sic) and rapid. Pt's case worker reports that pt wanders off out of residence, impulsively buys junk food, has not slept in 5 days, and cries uncontrollably, stating that she is being repeatedly raped by a Dallas police officer every time she goes to sleep. Pt is observed to be responding to internal stimuli. Pt denies current SI. Pt's CSRSS is moderate suicide risk due to history. Pt's DASA score is 7 due to verbal threats, unwilling to follow directions, sensitive to perceived provocation, and negative attitudes. Requesting inpatient services due to the patient being a danger to others."

A review of the physician's history and physical dated 10/17/25 revealed,
Patient #7 was seen for her Physical and History on 10/17/25 at 1615. Patient was oriented to person and place. All systems were marked as normal except for musculoskeletal, stating that the patient had 2+ edema in both lower legs. Recommendation for a low-sodium diet and elevate extremities. "The patient had stopped taking her medications 7 days ago."

The physician wrote an order to elevate the bilateral legs on a pillow when in bed on 10/17/25. A review of the nurses' notes on 10/17/25 for the 7am to 7pm shift and the 7pm to 7am shift revealed there was no documentation on the patients' systems ( neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and integumentary) or edema. There was no documentation concerning leg elevation or pain.

A physician order was written on 10/18/25 to start HCTZ (blood pressure and diuretic) 12.5 mg po daily. A review of the nurse's notes dated 10/18/25 and 10/19/25 revealed there was no documentation on the patient's edema, new medication and effectiveness, or of the TED hose.

A review of the physician orders revealed to move the patient to a blocked room for Sexual Acting Out (SAO) precautions. The nurse had written on 10/19/25 that the patient continued to take her clothes off, was found masturbating in the seclusion room, and needed redirection. Patient was also placed on a q 5-minute observation. A review of the nurse's note dated 10/20/25 revealed there was no documentation concerning the edema in the patient's legs, whether she had elevated legs with TED hose, or if medication was effective. There was no documentation of a systems review.

A review of the nurse's notes dated 10/20/25 revealed that there was no documentation concerning the patient's edema and at 0630, the patient had refused to put on her TED hose, but was signed by the nurse taking them off at 2100. There was no documentation when the hose was applied.

A review of the nurse's notes dated 10/21/25-10/22/25 revealed there was no documentation on the patient's edema, systems, or medication effectiveness. A review of the Master Treatment Plan revealed there was no written plan on the patient's new medication regimen for HCTZ, edema, or the TED hose.

A review of the nurse's note on 10/24/25 at 250am revealed the "patient was found with mucous coming out of her nose and on the pillow. The nurse went into the patient's room and changed her position. Mucous was cleared, and the vital signs were 100/68, HR 66, Resp 16, and O2 sat 95%. No further change in condition. At 220am the nurse stated that there was a change in condition, and MHT (Mental Health Technician) informed the nurse. "Patient gasping for air. Pulse faint at this time. B/P 60/40, Hr 45, resp 6, O2 sat at 68%.
222am responding cart available, no pulse and no B/P noted.
223 Code blue initiated. Patient pulseless. CPR started at 110 bpm, O2 was initiated, and suction performed. Skin warm, more mucous coming out. Patient jumped up and relapses.
226- 911 called
240- EMS arrived and took over the resuscitation.
310- Paramedics stopped CPR. Dr. Kern Brotell pronounced the patient dead ..." (patient was pronounced by phone.)"

A review of the Code Blue policy and procedure stated, " PROCEDURE
1. Establish the nature of the emergency and initiate "Code Blue" using the overhead paging system. At least one staff member, the one with the most clinical experience, should remain with the patient at all times until assistance arrives.

2. Initiate First Aid, as appropriate or begin basic cardiac life support.

3. Admit RN, supervisor and/or designee brings Emergency Cart to the scene.

The most senior RN or medical staff member will assume responsibility for the code and will determine if 911 should be activated. If the code leader is not a physician and a physician arrives on the scene, the lead position should be assumed by the physician.

One staff member will be designated by the code leader to record the events on the Cardiopulmonary Resuscitation Flow Sheet.
One staff member remains at the desk to notify the provider to place, receive and record all incoming and outgoing calls regarding the emergency. MHT will clear all other patients and staff from the area.
BCLS (Basic Cardiac Life Support) is continued until:
a. Directed to stop by a medical provider or;
b. The paramedics arrive and take over the care of the patient.
When the situation has been resolved, the code leader will announce over the paging system "Code Blue all clear".
The code leader or designated unit RN should document in the medical record the events of the code. The RN will also complete the Code Blue Event Debriefing/Critique form.

The patient's provider should be notified as soon as appropriate.

The RN will notify the patient's family/guardian if the adolescent or if adult patient with Release of Information as soon as appropriate.

If patient is in Assessment and Referral area, admit RN will notify ER and give report to ER nurse. If patient is on the unit, unit RN will notify ER and give report to ER nurse. Patient will be transferred via ambulance to closest ER."

A review of patient #7's chart revealed that there was no Cardiopulmonary Resuscitation Flow Sheet or Code Blue Event Debriefing/Critique form found on the chart. A review of the house supervisor's note dated 10/24/25 stated that EMS had told the nursing staff that they were not allowed to take the patient to the ER unless they had obtained a pulse on the patient.

An interview was conducted with Staff #1 and #2 concerning the death and events of the death on 11/3/24 at 2:00pm. Staff #2 stated she had contacted the EMS station multiple times and had requested a run sheet with no results. Staff # 1 made a complaint to the EMS company and to the State of Texas. Staff #1 revealed an email that was sent to the DE Soto police department that the medical examiner (ME) had notified De Soto Police to initiate an investigation for failure to notify ME and transport. Staff #1 had also requested an autopsy report and revealed a form from the Southwestern Institute of Forensic Sciences at Dallas. The form stated the results of the autopsy were still pending. "Pending issues: Toxicology results."

Staff #1 and Staff #2 had started a Root Cause Analysis RCA) but were still in the investigation of the death. Staff #1 stated that she is aware that the staff need further training on Code Blue, and plans were in place to start training and perform drills. The facility had no code blue drills to provide for the surveyor.

UNIT 6
A tour of the facility was conducted on the morning of 11/4/25 with Staff #4. Staff #5 RN on Unit 6 was performing her nursing shift assessment with patient # 9. Staff #5 RN was sitting behind the nurse's desk, and the patient was standing on the other side. Staff #5 RN administered patient #9 her medications, asked about her sleep, if she had eaten breakfast, and if she was having any mental health issues. Staff # 5 RN thanked the patient, and she walked away from the desk.

Staff #5 RN called patient #15 to the desk and performed the same assessment as patient # 9. An interview was conducted with staff #5, RN, on 11/4/25 at 9:20 am. Staff #5 was asked if this was the procedure for nursing assessments for her patients. Staff #5 RN stated, "Yes. I have them come to the desk for their medications and ask them some questions, and chart on them." Staff #5 was asked when she would listen to their lung, heart, or gastrointestinal sounds. Staff #5 RN stated that if the patient was having any issues, like coughing.

A review of the Nursing assessment sheet revealed the patient should be assessed for pain, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and integumentary. The nurse had checked "systems were within normal limits," but never assessed or touched the patients concerning these systems.
A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope).

UNIT 8
A tour of the facility was conducted on the morning of 11/4/25 with Staff #4. Staff #7 RN performed a nursing assessment on patient # 16. The RN asked the patient questions concerning his mental health, but did not ask any questions about his pain, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, or integumentary. The nurse had checked "systems were within normal limits," but never assessed or touched the patients concerning these systems.

An interview was conducted with Staff #7 on 11/4/25 at 9:35 am concerning nursing assessment and how they are performed. Staff #7 stated that he assesses each patient the same and has them come to the desk to answer questions and administer medications.

A review of the policy and procedure, "ASSESSMENT AND RE-ASSESSMENT OF PATIENTS" stated, "o Reassessments are completed by the Registered Nurse on day and night shifts and documented on the Daily Nursing Assessment form (minimum of 2 times per calendar day). Registered Nurses will also complete at least one progress note per day, with a focus on problems identified in the Interdisciplinary Treatment plan. In addition, each patient is reassessed as necessary based on the patient's plan for care or change in their condition, including change in the patient's level of pain. Reassessments for pain are conducted as part of the routine nursing reassessments, minimum two times per day. Pain assessments are also conducted prior to and following the administration of pain medications
o Reassessments are also based on the patient's diagnosis; desire for care, treatment and services and response to previous care, treatment and services. In addition, the assessment and reassessment information include the patient's perception of the effectiveness of, and any side effects related to their medication."