HospitalInspections.org

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Based on observation, interview, and record review, the facility failed to ensure that the emotional health and well-being of Patient #1 was protected. This failure resulted when Patient #1, a 12-year-old patient, who shared a "Jack and Jill" bathroom with Patient #2, a 20-year-old patient, was touched inappropriately by Patient #2.

Findings were:

Review of the facility's website, Nexus Health Systems, showed: "Inpatient pediatric specialty care for profound autism ... Nexus Children's Hospital - Houston provides ... structured, inpatient care for children ages 4 up to 18 with severe autism and other intellectual or developmental disabilities."
https://nexushealthsystems.com/locations/nexus-childrens-hospital-houston/

Review of policy "Abuse, Neglect & Exploitation" last revised 01.2025 showed, "Patients have a right to be free from abuse, neglect, and exploitation, and feel safe in their care setting."

Review of "Patient Rights and Responsibilities" showed, "Rights Related to Care ... Receive physical and emotional care in a safe setting, which includes environmental safety ... to the extent the facility can control that environment."

During a tour of the North Unit on 9.10.2025 at 10:22am, it was observed that the North Unit had 10 beds. CCO Staff B explained during the tour that the North unit programmed patients with very limited to no communication. It was observed that bedrooms 309 and 310 had a shared common bathroom. The bathroom had two separate entrances, one for each of the adjoining bedrooms, allowing the patients to use the facilities privately from their rooms. Each bedroom had a door to the hallway. Other "Jack & Jill" bathrooms on the North Unit were observed, and included bedrooms 303 - 304, 305 - 306, and 307 - 308. Bedrooms 301 and 302 were private bedrooms with private bathrooms.

Review of the Staff Assignment for 8.28.2025 showed that Patient #1 was assigned to bedroom 310 and Patient #2 was assigned to bedroom 309. (As noted above, bedrooms 309 and 310 were adjoining bedrooms with a shared common bathroom.)

Record review of the "Pre-Admission Evaluation" for Patient #1 by RN Staff T and LMSW Staff U dated 3.21.2025 showed an 11-year-old male. Admitting Diagnoses: Autism Spectrum Disorder, Intellectual Development Disorder, Full Incontinence of Feces, Fecal Smearing, Non-suicidal Self-Harm, Attention Deficit Hyperactivity Disorder, Cognitive Delays, Urinary Incontinence, Child in State Custody, and Wandering.

Record review of the "Pre-Admission Evaluation" for Patient #2 by MD Staff V dated 11.20.2023 showed an 18-year-old male with increasing agitation, dysregulation and impulsivity. Admitting Diagnoses: Autism Spectrum Disorder, Obsessive Compulsive Disorder, Tourette's, Intellectual Disability, Anxiety, Agitation, Disruptive Moo Dysregulation Disorder, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection, Seasonal Asthma, Expressive Language Delay, Chronic Vocal or Motor Tics, and Severe Elopement.

In an interview with Quality Director Staff K on 9.10.2025 at 12:09pm, she stated that Behavioral Manager Staff L reported on 8.27.2025 that she observed Patient #2 attempting to go into Patient #1's bedroom. Patient #2 ran from his bedroom through the adjoining bathroom into Patient #1's bedroom. Staff K further stated she saw Patient #2 "attempting to pull Patient #1's pants down."

In an interview with Quality Director Staff K on 9.10.2025 at 12:10pm, she stated that CNA (Certified Nursing Assistant) Staff M reported on 8.27.2025 that Patient #2 went into Patient #1's bedroom through the bathroom. "Earlier before this incident, Patient #1 had his shirt off and when asked what happened, he pointed at Patient #2." She also stated she saw Patient #2 "attempting to pull the pants [of Patient #1] down."

Review of a progress note in Patient #2's medical record by RN Staff P on 8.26.2025 at 7:30pm showed documentation that supports the above interview with CAN Staff M. RN Staff P further wrote, "Provided numerous redirections to prevent the patient [Patient #2] from entering the other patient's room [Patient #1] and from touching the other patient inappropriately." This information was also captured in an occurrence report completed by RN Staff P, dated 8.28.2025.

Review of progress note in Patient #2's medical record by RN Staff Q on 8.26.2025 at 10:40pm showed, "This nurse told the patient's mother what the day nurse told her in report about" Patient #2 taking off Patient #1's shirt, and trying to take off a Patient #1's pants while Patient #1 was "sitting on the toilet."

In an interview with Quality Director Staff K on 9.10.2025 at 12:15pm, she stated that NP (Nurse Practitioner) Staff O reported on 8.27.2025 that prior to the incident between Patient #1 and Patient #2 on 8.26.2025, she provided a safety plan for Patient #2 when he transferred to the North Unit. She went on to say that she recommended that Patient #2 NOT be placed in the bedroom that shared a bathroom with Patient #1 because Patient #2 "tends to pick on younger patients." Her recommendation was that Patient #2 be placed in a bedroom that did not have a shared bathroom. She concluded by saying that MD Staff H stated it was okay for Patient #1 and Patient #2 to be in bedrooms that shared a common bathroom.

Review of an occurrence report by Case Manager Staff R dated 8.27.2025 showed that NP Staff S notified Staff R of the documentation in Patient #2's chart of the incident between him and Patient #1. NP Staff S was concerned that this information was not documented in Patient #1's medical record. Case Manager Staff R wrote following the incident that she observed Patient #1 on the unit, in his bed asleep and would not get up when asked to ... [He] appeared to get upset" with staff attempting to wake him up. This was not Patient #1's "usual time to nap" nor was it "typical behavior." Patient #1's "behaviors have been escalating again over the last week or so including disrobing, "behavior that had almost gone away."
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