HospitalInspections.org

Based on observation, document review, and staff interviews, the Governing Body failed to:

1. Ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant.

Refer to Tag A0144


2. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed.

3. Ensure Nursing Services developed and implemented an approved written nurse staffing plan or methodology that determined appropriate staffing levels based on patient acuity, staff competencies, and staff training on 1 (3 West) of 1 Behavioral Health Units observed.

Refer to Tag A0392


4. Ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of available nursing staff on 1 (3 West) of 1 Behavioral Health Units observed.

Refer to Tag A0397

Based on observation, document review, and staff interviews, the facility failed to ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant.

The deficient practices were identified under the Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144

Based on observation, document review, and interview, Nursing Services failed to:

1. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed.

2. Develop and implement a nurse staffing plan or have a methodology to determine appropriate staffing levels based on patient acuity, staff competencies, and staff training.

Refer to Tag A0392


3. Ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of the available nursing staff for 1 (3 West) of 1 Behavioral Health Units observed.

Refer to Tag A0397


The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observation, document review, and staff interviews, the facility failed to ensure all patients received care in a safe, ligature-resistant environment on 1 (3 West) of 1 Behavioral Health Units observed. Specifically, the facility failed to identify that the shower heads in 10 (Rooms #302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) of 10 patient rooms observed were not ligature resistant.


The deficient practices were identified and were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


On 10/02/2025 at 11:38 AM, Patient #1 was found hanging by a sheet affixed to the shower head in Room #302 on the 3 West Behavioral Health Unit. Staff removed the ligature and lowered Patient #1 to the floor. A Code-Blue (an emergency code that signals a life-threatening medical situation) was initiated. An Ambu-bag (a handheld device used to assist a patient with their breathing by squeezing air into their lungs) was used for ventilation, and Cardiopulmonary Resuscitation (CPR) was initiated. Patient #1 had a Return of Spontaneous Circulation (ROSC-the resumption of a sustained heartbeat and breathing). Patient #1 was then transferred to the emergency department.

A review of Nursing documentation by RN Staff #4 (10/02/2025 at 12:26 PM) and RN Staff #7 (10/02/2025 at 12:30 PM) described the patient kneeling in the shower with a flat sheet fashioned into a noose and attached to the shower head, confirming that the fixture served as a ligature point.


The deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients with suicidal ideations at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings:

A tour was conducted of the Behavioral Health Unit, 3 West, on 10/07/2025 at 10:00 AM with Chief Executive Officer (CEO) Staff #1, Chief Nursing Officer (CNO) Staff #2, and Assistant Chief Nursing Officer (ACNO) Staff #23. The following observations were made.

The 3 West Unit was divided into two separate units, the Externalizing and Internalizing sides. Patient Rooms #302-306 were on the externalizing side of the unit. The Externalizing side houses patients who express distress outwardly through behaviors such as agitation, aggression, or defiance, and who require closer observation to ensure the safety of themselves and others. Each patient room had a private restroom that included a toilet, a hand-washing sink, and a shower.

Patient #1 was assigned to Room #302. Room #302 was the last room in the hallway, farthest from the nursing station and closest to the entrance/exit locked doors for 3 West. An observation of Room #302 showed a fixed metal shower head protruding 3.5 inches from the wall, 66.5 inches above the floor, with no slope to prevent ligature attachment. A second tour on 10/07/2025, after 3:00 PM, with CNO Staff #2, RN Staff #16, and ACNO Staff #23 confirmed the same fixed metal shower head in all ten patient rooms.

A medical record review was conducted on 10/07/2025 at 10:50 AM with CNO Staff #2 and Registered Nurse (RN) Staff #20. The record review showed Patient #1 was a 38-year-old male admitted involuntarily on 9/26/2025 for paranoid delusions, depression, and suicidal ideation.

A review of the Psychiatric Evaluation dated 9/28/2025 at 8:16 AM by Resident Physician #26 revealed that Patient #1 was suicidal with a plan to hang himself upon admission. He was placed on standard monitoring with every (Q) 15-minute safety checks. (The Q 15-minute check is a documented observation of the patient's location and behavior).


A review of the nursing notes was as follows:

9/26/2025 at 6:31 PM by RN Staff #4:
" ...Patient received on unit at 1750 in the care of (Physician #15's name) as involuntary patient ...
Reason for admission: PT ANXIOUS AND SCARED.
Patient reports depression 7/10, anxiety 10/10, and reports agitation on admission.
Patient CSSRS score on admission is MODERATE.
Orders for observation: Q 15 minutes. Patient lives ALONE IN VEHICLE
Patient report support system: PARENT AND FAMILY.
Patients denies alcohol use or use of street drugs.
Will continue to monitor and offer a safe environment ...".

10/01/2025 at 6:34 AM by RN Staff #27:
"Patient approached nurse station agitation and paranoid reporting he is being poisoned and needs 911 called and he needs to go to the ER, responding poorly to verbal redirection and education, patient with raised voice and agitated, allowed vital signs, elevated BP possibly d/t agitation 160/106. Dr. (Physician #28) notified and awaiting response".

10/01/2025 at 12:38 PM by RN Staff #4:
"Patient #1 has requested for voluntary discharge at 12:19 PM".


10/01/2025 at 1:51 PM by RN Staff #4:
"Patient withdrew the request. Moving to the externalizing side for increasing psychotic agitation".


10/02/2025 at 12:27 AM by RN Staff #29:
"Pt isolated to room for most of the shift. Upon approach for shift assessment, patient appeared upset and requested to be left alone. He was paranoid and delusional, refusing to answer assessment questions. Around midnight, patient approached nurse reporting he was "red all over" and experiencing "warmness," pointing to his arms and face. Patient stated, "Nurse is blind if they cannot see the redness." On assessment, no redness or warmth to touch was noted. Vitals were obtained as requested (see flow sheet). During further assessment for delusions, itching, or other symptoms, patients became increasingly upset, stating that nurse was angry. Assessment was terminated due to patient escalation".


10/02/2025 at 11:01 AM by RN Staff #4:
"Pt noted to be coming out of peers restroom. Treatment team notified".


10/02/2025 at 11:18 AM by RN Staff #4:
"Pt placed on CLOSE OBSERVATION d/t intrusive behaviors, entering others rooms, leading to vulnerability due to risk of harm from others When outside room".


10/02/2025 at 12:26 PM by RN Staff #4:
"At approximately 1138 staff alerted this nurse that pt was hanging in shower. This nurse ran to assist pt. Pt found with PNA, nurses got pt down from ligature and assessed pt. Pt was pale and bluish with pulse. Nurse called for Code, life threatening emergency and crash cart. Med nurse called overhead. Ambu bag applied by this RN, Given a few breaths, rechecked for pulse, no pulse found. Compressions initiated by 2nd RN. Assistance arrived from code team. Crash cart present during code. This nurse removed self from pt side to allow response team room to work. Nurse stayed to assist. Patient moved to hallway and lifted to stretcher. Patient did have a pulse prior to leaving unit".


10/02/2025 at 12:30 PM by RN Staff #7
"This RN in nurses' station completing a separate task, and on phone with House Supervisor to request assistance when PNA staff approached the nurses' station and reported that a patient was found hanging in the shower. Charge RN immediately proceeded to the patient's room. This RN informed the House Supervisor that a code was being called and immediately went to assist CRN. Patient was found in the shower, kneeling, with a flat sheet fashioned into a noose around the neck, attached to the shower head. Patient appeared cyanotic. Ligature was removed from the shower head, and the patient was safely lowered to the ground by Charge RN and this RN. A faint carotid pulse was palpable; no spontaneous respirations were observed. Crash cart and code were called. Ambu bag requested and ventilation initiated. Patient lost pulse; chest compressions were initiated immediately. Code team arrived shortly thereafter. This RN was relieved from compressions and remained present to assist as needed throughout the code. ROSC achieved prior to patient leaving unit".



A review of Resident Physician #11's progress note dated 10/01/2025 at 8:00 AM was as follows:

"Comments: Interval events were reviewed - pt became acutely paranoid early this morning and claimed he was poisoned. There is a notable change in mental status today compared to our previous interviews. The patient is paranoid and says there is a chemical in his body increasing his internal temperature. Plan to start risperidone for psychosis. Update: Pt requested voluntary discharge shortly after the morning meeting. He withdrew the request but was verbally aggressive and threatening when I spoke with him. He said he needed to leave to meet God.
The patient said someone was standing next to me who I could not see. He is exhibiting numerous signs of psychosis. The current symptoms are driving problematic behaviors. Recommend pursuit of involuntary treatment if the patient requests voluntary discharge again."


A review of Resident Physician #11's progress note dated 10/02/2025 at 8:00 AM was as follows:

"Pt continues to exhibit signs of psychosis and has been engaged in intrusive/paranoid behaviors such as entering other patient rooms to take showers. Nursing reports describe paranoid behaviors and other delusional complaints. He told staff he spit out risperidone yesterday morning but asked for an additional dose yesterday afternoon and appeared to take it without issue. Pt denied SI during the resident assessment this morning and he has not engaged in any self-harming or suicidal behaviors in the hospital. Plan to titrate risperidone for psychosis/mood and upgrade obs to close-obs when out of his room for intrusive/impulsive behaviors".


Physician #11 entered an electronic order on 10/02/2025 at 11:05 AM that read, "Maintain visual contact (Close Observations). The order was modified by Physician #11 on 10/02/2025 at 1124 AM to read, "Close observations while outside of the room".


On 10/08/2025 at 1:22 PM, a review of the recorded camera footage dated 10/02/2025 at 11:00 AM to 11:51 AM on the Externalizing Patient side of 3 West was conducted with CNO Staff #2, RN Staff #3, RN Staff #16, and ACNO Staff #23. The review of footage was as follows:

11:00 AM-PNA Staff #5 was seen at the nurses' station.
11:00:45-PNA Staff #5 and PNA#6 were in the seen in the hallway.
11:03:24-PNA Staff #5 and PNA Staff#6 were no longer visible in the hallway of the patient rooms.
11:05:22-Case Manager (CM) Staff #24 entered Patient #1's room (room #302).
11:06:50-CM Staff #24 exited Patient #1's room.
11:07:21-PNA Staff #6 walked down the hallway and stopped short of Patient #1's room.
11:08:15-Patient #1 exited room #302 and walked down the hall to the nurses' station.
11:08:40-Patient #1 returned to room #302 and closed the door. PNA Staff #6 followed Patient #1 back down the hall to room #302, but Staff #6 did not open the door and enter the room.
11:10:42-Patient #1 exited room #302 and returned to the nurse's station.
11:11:27-Patient #1, PNA Staff #5, and PNA#6 were standing in the hallway by the nurses' station.
11:11:37-Patient #1 returned to room 302 and closed the door to the room.
11:33:57-CM Staff #24 opened the closed door and entered Patient #1's room.
11:34:22-CM Staff #24 exited Patient #1's room and was seen talking to PNA Staff #6 outside Patient #1's room.
11:34:34-CM Staff #24 reentered patient #1's room.
11:34:44-PNA Staff #6 stood at the doorway of room #302 and looked inside Patient #1's room.
11:34:48-PNA Staff #6 opened the doors and looked in room #303 and #304.
11:34:49-CM Staff #24 exited Patient #1's room.
11:35:30-PNA Staff #6 was seen outside the nurses' station.
11:36:14-PNA Staff #6 was seen standing outside the nurses' station, looking at his Rover (a rover is a handheld electronic device used for documentation).
11:38:05-PNA Staff #5 and PNA Staff #6 were standing in the hallway near room #302, Patient #1's room.
11:38:40-PNA Staff #5 entered Patient #1's room.
11:39:30-PNA Staff #6 entered Patient #1's room.
11:39:44-PNA Staff #5 was seen exiting room #302 and running to the nurses' station. PNA Staff #6 was seen standing in the hallway outside room #302.
11:39:46-PNA Staff #5 was seen hitting on the glass at the nurses' station (to get the attention of the nurses in the closed and locked nurses' station),
11:39:49-RN Staff #4, RN Staff #7, and RN Staff #8 ran down the hallway to Patient #1's room.
11:40:04-RN Staff #8 ran back to the nurses' station and called an emergency code.
11:40:51- PNA Staff #5 was seen taking the emergency cart to room #302, Patient #1's room.
11:41:00-Family practice physicians and the house supervisor arrived on the unit.
11:41:47-Physician #15 and Residents arrive on the unit.
11:41:51-Physician #25 arrived on the unit. RN Staff #4, RN Staff #7, and RN Staff #8 were still engaged in the emergency code.
11:51:30-Patient #1 was taken to the emergency Department (ED) by stretcher.


An interview with CNO Staff #2 on 10/07/2025, after 10:30 AM, confirmed that Case Manager Staff #24 exited Room #302 at 11:34:22 AM and told PNA Staff #6 the patient was not in the room. Q15-minute documentation showed PNA Staff #6 documented "resting in room" at 11:35 AM. The recorded video footage showed he was at the nurses' station and could not see Patient #1. CNO Staff #2 confirmed that PNA Staff #6 did not visually observe Patient #1 "resting in his room" at 11:35 AM as documented. The camera footage confirmed PNA Staff #6 was at the nurse's station on 10/02/2025 at 11:35 AM and could not see into Patient #1's room.

Further review of the recorded camera footage revealed that from 11:11 AM to 11:38 AM, no staff member had visually observed Patient #1 for 27 minutes.


An interview was conducted with CEO Staff #1 and Facilities Director Staff #13 on 10/08/2025 at 9:30 AM. During the interview, Staff #13 provided documentation for the shower head model installed in 10 of 10 patient rooms on 3 West, identified as the Act-O-Matic Showerhead AC-450 manufactured by the Sloan Valve Company. Staff #13 confirmed that the shower heads installed in all patient rooms on 3 West were the same model. When asked if the product was ligature-resistant, Staff #13 stated the manufacturer's product specifications indicated only that the shower head was for institutional use and did not specify that it was ligature-resistant.

A cross-reference to the same product number on the Grainger.com website confirmed that the Act-O-Matic Showerhead AC-450 is NOT ligature-resistant. Staff #13 verified that there was no documentation available to demonstrate that the shower heads installed on the 3 West Behavioral Health Unit were ligature-resistant.
An interview conducted with CEO Staff #1, CNO Staff #2, and Quality Director Staff #3 on 10/08/2025 after 2:00 PM confirmed that the facility had failed to identify that the shower heads in patient rooms (#302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) on 3 West were not ligature-resistant, which posed a substantial risk to patient safety.


An interview conducted with CEO Staff #1, CNO Staff #2, and Quality Director Staff #3 on 10/08/2025 after 2:00 PM confirmed that the facility had failed to identify that the shower heads in patient rooms (#302, 303, 304, 305, 306, 312, 313, 314, 315, and 316) on 3 West were not ligature-resistant, which posed a substantial risk to patient safety.




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An observation tour of the Internalizing side of the Behavioral Health Unit, 3 West, was conducted on 10/07/2025, after 3:00 PM, with CNO Staff #2, RN #16, and ACNO Staff #23. The Internalizing side of 3 West houses patients who direct distress inward, rather than outward, showing depression, anxiety, or suicidal thoughts, and require close monitoring for self-harm. During the tour, PNA Staff #21 explained that Q15-minute checks were documented on the Rover electronic device and that the information was synced to the patient's medical record.

While observing the unit, a patient entered Room #312 and closed the door; staff confirmed patients were allowed to shut their doors while inside. An interview was conducted with Staff #3 and RN Staff #23 on 10/08/2025 after 1:00 PM. RN Staff #23 and Staff #3 were asked if patients were allowed in their rooms with the doors closed. Staff #3 stated, "We do not lock the patient rooms on the unit. Patients can go in and out of their rooms whenever they want to. We rely on close observation or 1:1 orders as deemed necessary for closer monitoring. TVs were removed from the rooms to discourage them from staying in their rooms". Staff #3 and RN Staff #23 were asked if the hospital had a policy regarding when patients were allowed to stay in their rooms with the doors closed. After multiple requests, no policy was provided for review.

A review of the incident log for October 2025 was conducted with Quality Director Staff #3 on 10/02/2025 at 3:13 PM. The incident report was documented as follows;

"This RN in nurses' station completing a separate task, and on phone with House Supervisor to request assistance when PNA staff approached the nurses station and reported that a patient was found hanging in the shower. Charge RN immediately proceeded to the patient's room. This RN informed the House Supervisor that a code was being called and immediately went to assist CRN.

Patient was found in the shower, kneeling, with a flat sheet fashioned into a noose around the neck, attached to the shower head. Patient appeared cyanotic. Ligature was removed from the shower head, and the patient was safely lowered to the ground by Charge RN and this RN. A faint carotid pulse was palpable; no spontaneous respirations were observed.

Crash cart and code were called. Ambu bag requested and ventilation initiated. Patient lost pulse, chest compressions were initiated immediately. Code team arrived shortly thereafter. This RN was relieved from compressions and remained present to assist as needed throughout the code. ROSC achieved prior to patient leaving unit".

An interview was conducted with the Quality Director, Staff #3, on 10/08/2025 after 10:00 AM. Staff #3 confirmed that a Root Cause Analysis (RCA) had been initiated but was not complete.

Staff #3 was asked if the hospital conducted a ligature risk assessment on the behavioral health units. Staff #3 confirmed that environment of care rounds for ligature risks were performed once a year and typically during the fourth quarter. A review of the document titled "Mental Health Environment of Care Checklist" dated October 2024 confirmed the showerheads on the Behavioral Health Unit, 3 West, were not identified as a ligature risk.

During an interview on 10/08/2025, Staff #3 acknowledged documentation errors were identified during the incident review. Staff #3 confirmed that PNA Staff #5 documented that Patient #1 was awake in the shower at 11:38 AM. This was the same time that Patient #1 was found hanging. Staff #3 stated that during an interview with PNA Staff #5, PNA Staff #5 confirmed the documentation and stated that the Rover (a handheld electronic device used to record patient safety checks) contained preset options for the patient's location and behaviors, and "awake in shower" was the closest available choice. Video footage confirmed that PNA Staff #5 immediately went to the nurses' station without delay and alerted the nurses. This was consistent with the timeline seen in the video.

An interview was conducted with Staff #3 and RN Staff #23 on 10/08/2025 after 1:00 PM. Staff #3 confirmed Patient #1 had been on a 1:1 (constant monitoring) for high suicide precautions in the Emergency Department, but observation levels were downgraded to Q 15-minute checks, and suicide precautions were lowered to a moderate level when Patient #1 was transferred to 3 West because the unit was considered ligature-free.

Based on observation, document review, and interview, Nursing Services failed to:

1. Identify that a locked door that separated patients by acuity created two distinct patient care units that required an adequate number of Registered Nurses (RN) and Psychiatric Nursing Assistants (PNA) to provide safe nursing care on a locked psychiatric unit for 1 (3 West) of 1 Behavioral Health Units observed.

2. Develop and implement a nurse staffing plan or have a methodology to determine appropriate staffing levels based on patient acuity, staff competencies, and staff training.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings:

An observation tour was conducted on the Behavioral Health Unit, 3 West, on October 7, 2025, at 10:20 AM, with Chief Executive Officer (CEO) Staff #1 and Chief Nursing Officer (CNO) Staff #2.

The Behavioral Health Unit had two entry doors onto the unit. There was one central nursing station. The nurses' station had locking doors located on each side of the station, accessible only with a key. The front of the nursing station was shielded by non-breakable glass to prevent patients from reaching into the nurses' station and removing items from the desk. This single unit was divided by a locking door accessible by badge only, which separated patients by acuity. Rooms #302, 303, 304, 305, and 306 were private rooms located on one side of the locked door. These rooms were used for more aggressive patients and were referred to as the "Externalizing Side". Externalizing patients expressed their emotions outward and were more aggressive. These patients required closer and more frequent observations. Rooms #312, 313, 314, 315, and 316 were double occupancy rooms located on the opposite side of the locked door. These rooms were used for less aggressive patients and referred to as the "Internalizing Side". Internalizing patients' directed distress inward, rather than outward, showing depression, anxiety, or suicidal thoughts, and required close monitoring for self-harm.

Inside the nurses' station was a large monitor with multiple camera views of the unit. On 10/07/2025, after 10:00 AM, RN Staff #8 confirmed that there was not always someone in the nurses' station to monitor the video cameras and that no staff were ever assigned specifically for this task.

CNO Staff #2 confirmed that the wall construction and locking door in the middle of the unit were completed about a year ago. The physicians wanted the ability to separate the more aggressive patients from the others. CNO Staff #2 confirmed that all patients on 3 West were still considered acute psychiatric patients, and the unit was considered 1 unit; therefore, it was not staffed as two separate units. CNO Staff #2 was asked if the hospital had a nurse staffing plan that included the Behavioral Health Unit. CNO Staff #2 confirmed the hospital did not have a written nurse staffing plan.

A review of the "UT Health Tyler North Campus 3 West Acute Behavior Health Minimum Staff Matrix" was as follows:

"3 West Acute Behavior Health
7a-7p, 2RN's & 4 PNA's
7p-7a, 2RN's & 4 PNA's
If additional staff is needed based on acuity, clinical judgement, or shortages, the following steps should be followed:
Monday through Friday 8am to 5pm:

1. Escalate needs to the House Supervisor who will assist with calling on-call or off-duty staff. If no one is available or additional resources are still needed, move to Step 2.
2. Access Float Pool. If no one is available or additional resources are still needed, move to Step 3.
3. ACNO will evaluate staffing throughout the facility and float any additional resources to the 3 west. If
no one is available or additional resources are still needed, move to Step 4.
4. ACNO will notify the Administrator on Call (AOC). If no resources are identified, move to Step 5.
5. Notify the Chief Nursing Officer (CNO). The CNO will work with the AOC and house supervisor to limit admissions and close beds as necessary.

Monday through Thursday 5pm to 8am and Friday 5pm through Monday at 8am:

1. Escalate needs to the house supervisor who will assist with calling on-call or off-duty staff. The house
supervisor will evaluate staffing throughout the facility and float any additional resources to the
emergency department. If no one is available or additional resources are still needed, move to Step 2.
2. Access Float Pool. If no one is available or additional resources are still needed, move to Step 3.
3. House supervisor will contact the Administrator on Call (AOC). If no resources are identified, move to
Step 4.
4. Administrator on Call will notify the Chief Nursing Officer (CNO). The CNO will work with the AOC and house supervisor to limit admissions and close beds as necessary.


An interview was conducted with the Interim Director, RN Staff #16, on 10/08/2025 after 9:00 AM. RN Staff #16 stated that the minimal staffing matrix had not been revised after the unit was divided into two sides by the locked door. Also, RN Staff #16 confirmed that the staffing matrix was used for the entire unit and that the unit had never been staffed as two separate units.


Further review revealed there was no approval date, effective date, review date, policy number, or who approved the staffing matrix on the document. After multiple requests for this information, none was provided for review.

A review of the staffing assignment sheets dated September 26 through October 2, 2025, for the Behavioral Health Unit, 3 West, was conducted on October 8, 2025, with RN Staff #16. The staffing assignment sheets were separated into AM Staff and PM Staff. The AM Shift was 7:00 AM-7:00 PM, and the PM Shift was 7:00 PM-7:00 AM. The review was as follows:

"September 26, 2025
AM-Patient Census-13, 1 Charge Nurse and 1 Medication Nurse, 1 Unit Clerk, 5 Psychiatric Nurse Assistants (PNAs)
PM-Patient Census 11, 2 RN's, 4 PNAs

September 27, 2025
AM-Patient Census 13, 2 RN's, 5 PNAs
PM-Patient Census 13, 2 RN's, 5 PNAs

September 28, 2025
AM-Patient Census (Not documented) 2 RN's 4 PNAs
PM-Patient Census 13, 2 RN's, 5 PNAs

September 29, 2025
AM-Patient Census 13, 2 RN's, 4 PNAs
PM-Patient Census 12, 2 RN's, 4 PNAs

September 30, 2025
AM-Patient Census 12, 2 RN's, 5 PNAs, 1 Unit Clerk
PM-Patient Census 12, 2 RN's, 4 PNAs & 1 PNA on orientation

October 1, 2025
AM-Patient Census 12, 2 RN's, 4 PNAs
PM-Patient Census 12, 2 RN's, 4 PNAs

October 2, 2025
AM-Patient Census 12, 2 RN's, 4 PNAs, & 1 PNA on orientation
PM-Patient Census 11, 2 RN's, 4 PNAs".

During an interview with RN Staff #16 on 10/08/2025 after 9:00 AM, it was confirmed that the Behavioral Health Unit, 3 West, was only staffed as one unit. RN Staff #16 confirmed that the staffing assignment sheets did not reveal patients' names or room assignments. The surveyor was unable to determine whether adequate nursing staff and other personnel were available for appropriate and safe patient care based on the patient's acuity and the staff's competencies and training.

Confidential interviews were conducted on 10/07/2025 and 10/08/2025 with AM and PM Nursing and PNA Staff. The following was stated about staffing:


"The unit is always staffed as one unit and never two".

"We are responsible for all the patients regardless of what room they are in. We go to both sides of the unit to do assessments and give them medications".

"We relieve each other for lunch. There is no one else who comes to this unit to relieve us for a break or lunch. We know it leaves only one nurse on the unit, but that is the only choice that we have. The PNAs have to do the same thing".

"The doctors determine the acuity of the patients. The doctor had to approve when a patient was moved from one side to the other. Our census is never over 14, but the unit can be very unmanageable if the patient's behavior is hard to control. We can call the House Supervisor and ask for another nurse, but we most likely will not get one. Sometime in August or September, the night shift had only one nurse. The medication nurse came in sick and passed all the patient medications and then left. We were told there was no one to relieve or replace her, and no one could float to the unit because they were not trained. They will send another PNA before they send an extra nurse".

"The admissions nurse will bring a new admit and then leave. We still have to do the initial admissions assessment. We are responsible for all admissions, discharges, shift assessments, medications, emergency codes, answering the telephone, assisting the physicians and residents when needed on both sides of the locked door. Sometimes we are both on one side of the locked door, and all the patients on the other side are being cared for by the PNAs. It can be very overwhelming at times".

"All of us (PNAs) go back and forth to both sides of the unit and relieve each other for lunch. Sometimes there are just 4 of us, and when one person leaves for lunch then that just leaves one person on that side".



An interview was conducted with RN Staff #8 on 10/07/2025 after 12:30 PM. RN Staff was asked if she was the nurse caring for Patient #1 on 10/02/2025. RN Staff #8 confirmed that the nursing staff was not assigned to specific patients. RN Staff #8 was asked to tell the surveyor about the incident with Patient #1 on 10/02/2025. RN Staff #8 stated that the PNA came to the nursing station window and was hitting the window to get our attention, and told us that Patient #1 was hanging in the shower. We immediately got up and ran to the room. RN Staff #4 and #7 got the patient down, placed him on the floor outside his door, and I ran back to the nurses' station and called the code. RN Staff #8 was asked if a nurse was caring for the patients on the internalizing side of the unit. RN Staff #8 confirmed that only PNA Staff were on that side of the unit during the event with Patient #1.RN Staff #8 stated, "The PNA could have come to the other side of the locked door to get a nurse, but the hallway was full of physicians and residents, along with other staff, and it would have been hard for them to get to a nurse. We were all there with the patient. A review of the video camera footage dated 10/02/2025 from 11:00 AM through 11:51 AM confirmed there was no nurse available on the locked patient side of the unit.


An interview was conducted on 10/08/2025 with CNO Staff #2. During the interview, Staff #2 stated that the hospital did not have a written nurse staffing plan or an acuity tool to determine staffing needs based on patient acuity levels or staff training and competencies. CNO Staff #2 confirmed the UT Health Tyler North Campus 3 West Acute Behavior Health Minimum Staff Matrix gave directions on who to contact for additional staff, but did not have an acuity tool to determine when to ask for an adjustment in staffing. CNO Staff #2 stated, "We have talked about adding a nurse to the daily schedule because the PNAs do not have critical thinking skills, but we have not done that yet".

Based on observation, document review, and staff interviews, Nursing Services failed to ensure a Registered Nurse (RN) assigned nursing personnel to provide care to each patient in accordance with the individual needs of the patient and the specialized qualifications and competencies of the available nursing staff on 1 (3 West) of 1 Behavioral Health Units observed. .

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings:

An observation tour was conducted on the Behavioral Health Unit, 3 West, on October 7, 2025, at 10:20 AM, with Chief Executive Officer (CEO) Staff #1 and Chief Nursing Officer (CNO) Staff #2.

The Behavioral Health Unit had two entry doors onto the unit. There was one central nursing station. The nurses' station had locking doors located on each side of the station, accessible only with a key. The front of the nursing station was shielded by non-breakable glass to prevent patients from reaching into the nurses' station and removing items from the desk. This single unit was divided by a locking door accessible by badge only, which separated patients by acuity. Rooms 302, 303, 304, 305, and 306 were private rooms located on one side of the locked door. These rooms were used for more aggressive patients and were referred to as the "Externalizing Side". 312, 313, 314, 315, and 316 were double occupancy rooms located on the opposite side of the locked door. These rooms were used for less aggressive patients and referred to as the "Internalizing Side".

Inside the nurses' station, there was a large monitor with multiple camera views of the unit. On 10/07/2025, after 10:00 AM, RN Staff #8 confirmed that there was not always someone in the nurses' station to monitor the video cameras and that no staff were assigned specifically for this task.

A review of the staffing assignment sheets dated September 26 through October 2, 2025, for the Behavioral Health Unit, 3 West, was conducted on October 8, 2025, with RN Staff #16. The staffing assignment sheets were separated into AM Staff and PM Staff. The AM Shift was 7:00 AM-7:00 PM, and the PM Shift was 7:00 PM-7:00 AM. The staffing assignment sheets failed to identify specific nursing and PNA assignments.

The review was as follows:

September 26, 2025
AM-Patient Census-13, 1 Charge Nurse and 1 Medication Nurse, 1 Unit Clerk, 5 Psychiatric Nurse Assistants (PNAs)
PM-Patient Census 11, 2 RN's, 4 PNAs

September 27, 2025
AM-Patient Census 13, 2 RN's, 5 PNAs
PM-Patient Census 13, 2 RN's, 5 PNAs

September 28, 2025
AM-Patient Census (Not documented) 2 RN's 4 PNAs
PM-Patient Census 13, 2 RN's, 5 PNAs

September 29, 2025
AM-Patient Census 13, 2 RN's, 4 PNAs
PM-Patient Census 12, 2 RN's, 4 PNAs

September 30, 2025
AM-Patient Census 12, 2 RN's, 5 PNAs, 1 Unit Clerk
PM-Patient Census 12, 2 RN's, 4 PNAs & 1 PNA on orientation

October 1, 2025
AM-Patient Census 12, 2 RN's, 4 PNAs
PM-Patient Census 12, 2 RN's, 4 PNAs

October 2, 2025
AM-Patient Census 12, 2 RN's, 4 PNAs, & 1 PNA on orientation
PM-Patient Census 11, 2 RN's, 4 PNAs

An interview was conducted with RN Staff #16 on 10/08/2025 after 9:00 AM. RN Staff #16 was asked who made the staffing assignments for 3 West? RN Staff #16 confirmed that staffing was made by her and the House Supervisor. RN Staff #16 was asked if nurses and PNAs were assigned to specific patients. RN Staff #6 stated, "There are two RN's, but they are not assigned to specific patients". RN Staff #16 confirmed that the PNA staff were not assigned to specific patients. She stated, "The PNA tasks and responsibilities were rotated every two hours. Someone will do 15-minute checks for two hours and then rotate, and someone will be the float for 2 hours and then rotate that, but no specific patient assignments were made".

There was no way for the surveyor to determine which nurse or PNA had primary responsibility for which patient and which side of the unit or room number the patient was assigned to.

An interview was conducted with RN Staff #8 and RN Staff #14 on 10/07/2025 after 1:00 PM. RN Staff #8 and RN Staff #14 were asked if either of them made patient assignments for the nursing staff and PNAs. RN Staff #8 confirmed that patient assignments were not made for the nursing staff or the PNAs. Staff #14 stated, One of us is the Charge Nurse and the other is the Medication Nurse, but we are not assigned to specific patients. The medications nurse will give all the patients their medications, and the charge nurse gets all the shift assessments done, and then we just do what needs to be done. RN Staff #8 stated that the PNAs were not assigned certain patients either, unless they were monitoring a patient who was on a 1:1 or a close observation, and then they rotated that too.
An interview was conducted with PNA Staff #21 and PNA Staff #22 on 10/07/2025. PNA Staff #21 was asked if she was given patient assignments when she was on the schedule. PNA #21 replied that she was not given specific patients unless she was monitoring a close observation patient. PNA Staff #22 confirmed that an RN did not give them specific patient assignments, and it was not documented on the daily schedule.

On 10/08/2025, RN Staff #16 confirmed that the staff assignment sheets did not include patient care assignments for the RNs or the PNAs. RN Staff #16 further confirmed that patient names or room numbers were not documented on the staffing assignment sheets to correlate with the assigned nurse staff for the period of 9/26/2025 to 10/02/2025.