HospitalInspections.org

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Based on observation, staff interviews, and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights as evidenced by the facility's failure to ensure that an adolescent female patient was free from physical abuse by a staff member.
Refer to A-0145.

Additionally, the facility failed to ensure that patients were provided with a safe environment. More specifically, the facility failed to ensure:

A. Three doors with self-closing hardware closed properly. This failure had the potential to expose 12 suicidal patients on the Sunrise Unit to multiple tie-off ligature points in two conference rooms (rooms 416 and 417). Inside these two rooms were numerous ligature risks including electrical and computer cords. There was a desk with drawer handles that could be used as tie-off points. Both rooms had drop ceilings with removable ceiling tiles. The desk and a table could be used to reach the drop ceiling, allowing patients access to ligature risk points in the space above the drop ceiling such as electrical wiring and plumbing that could be used to hang oneself. Additionally, this failure had the potential to expose 18 suicidal patients on the Maples Unit to multiple tie-off ligature points found on the massive locking system on the seclusion room door (room 715). Refer to A-0144.

B. Seclusion room 418 was safe. A segment of the FRP trim in the seclusion room had been bent outward, creating a very sharp edge that could be used for self-mutilation (scratching or cutting self). Refer to A-0144.

C. Seclusion rooms were free of items that could be used as weapons. An ottoman that could be used as a weapon was found in two seclusion suites (418 and 718). The ottoman in seclusion suite 418 had been used as a weapon less than a week earlier by a patient in an attempt to assault a staff member. Refer to A-0144.

D. Cabinets and drawers were locked and/or the locking mechanisms were not compromised. On all five units, various cabinets and drawers were either unlocked or the locks were broken giving patients access to plastic markers with conical tips, plastic wrap, and removable heavy wooden shelves. This exposure exposed 54 suicidal patients and/or 15 assaultive patients to items that could be used to harm self or others. Refer to A-0144.

E. Items that could be used for strangulation or suffocation were out of reach of the patients. Rubber gloves and plastic sleeves to Styrofoam cups were unattended and within the reach of 20 suicidal patients. Refer to A-0144.

F. A commercial trash can was always monitored. A 45-gallon black round commercial trash can on wheels was left unattended in the hallway by a housekeeper when she entered a group room to collect trash, allowing the door to close behind her. The receptacle was lined with a large plastic bag and an unused plastic bag was draped over the edge of the container. There were two spray bottles of cleaning chemicals hung on the edge of the container. The receptacle was over three quarters full of trash. There were 7 suicidal patients and 1 assaultive patient that had potential access to these items. Refer to A-0144.

G. Housekeepers were properly trained on housekeeping duties and equipment. A housekeeper didn't know the cleaning cart locked. Refer to A-0144.

H. Heat and air units were free of dust and debris. A random check of the heat and air units in the 18 patient bedrooms on the Sunrise and Willows units showed a very substantial accumulation of dust and debris. Exposure to dust can have adverse health outcomes, such as respiratory problems, asthma, and allergic reactions. Refer to A-0144.

I. An environmental risk assessment with mitigation strategies had been completed. The one and one-half page facility wide Lifepoint Risk Assessment, initiated by Staff F (EOC Director), did not encapsulate the entire facility. For example, it did not include all ligature risks (seclusion room door lock, computer cords), unattended items such as housekeeping carts that contain hazardous items (mops, brooms, cleaning agents, etc.), or unsafe items brought by visitors to patients in locked units). Additionally, the assessment did not outline environmental risk assessment strategies. Refer to A-0144.

J. Some form of identification was worn by all employees working with patients. Two employees, providing direct patient care, were not wearing any form of identification. Refer to A-0144.

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Based on observation, staff interviews, and record review, the facility failed to ensure that patients received care in a setting - a setting that protected emotional and physical health and safety of behavioral health patients. Namely, the facility failed to ensure that:

A. Three doors with self-closing hardware closed properly.
This failure had the potential to expose 30 suicidal patients to multiple ligature risks.

B. The seclusion room was free of sharp features that could be used to scratch or cut self.
The FRP (Fiberglass Reinforced Panels) trim in the seclusion room (room 418) had been bent outward, creating a very sharp edge that could be used for self-mutilation (scratching or cutting).

C. Two seclusion rooms had been cleared of objects that could be used as weapons to harm others.
An ottoman that could be used as a weapon was found in 2 of 5 seclusion rooms (418 and 718).

D. Various cabinets and drawers on all five units were locked or the locks were not compromised.
This failure had the potential to expose 54 suicidal patients and 15 assaultive patients to multiple items found in the cabinets and drawers that could be used for self-harm or to harm others.

E. Items that could be used for suffocation and strangulation (rubber gloves and plastic sleeves) were out of reach of suicidal patients.
This failure had the potential to expose 29 suicidal patients and 10 assaultive patients to these items.

F. A 45-gallon black round commercial trash can on wheels filled with trash, bottles of chemicals, and plastic bags was always monitored on the Cedars Unit, an adult unit. This failure potentially placed 8 suicidal patients at risk.

G. 1 of 1 housekeepers (Staff I) was properly trained on the safety features of the commercial housekeeping cart.

H. The heat and air units in the patients' bedrooms were dust-free. This failure had the potential to expose 23 patients to compromised ventilation.

I. A comprehensive assessment of environmental risk strategies had been completed.

J. Staff were provided with an identification badge while performing patient care.


Findings were:

A. Three doors with self-closing hardware did not close properly.

Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm."

Review of policy 15562536, Suicide Prevention Program Guidelines, last approved 4/2024, showed: "Unit Safety ... Group rooms and unoccupied office doors are locked."

Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed: "Risk Reduction Feature - Doors on patient units: Hardware safe and doors are self-closing and self-latching."

Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 12 patients on the Sunrise Unit (Patients #15 through #26) and 18 patients on the Maples Unit (Patients #32 through #49) on suicide precautions.

During a tour of the adolescent units on 5/20/2025, 10:00am - 10:45am, it was observed that the self-closing hardware on the doors of two conference rooms (rooms 416 and 417) located adjacent to the commons area on the Sunrise Unit did not work properly. The lock latch did not fall into the strike plate after the door was manually opened and released. There was a desk and a table in each room, along with two computer screens, a keyboard, a surge protector, and numerous electrical and computer cords. The desks had two metal bar drawer handles. Both rooms had drop ceilings with removable ceiling tiles. Further observation on the Maples Unit at 12:15pm showed that the self-closing hardware on seclusion room door (room 715) did not work properly. The lock latch did not fall into the strike plate after the door was manually opened and released. The seclusion room door had a massive locking system with numerous tie-off points a patient could use for hanging oneself.

In an interview with Staff B (Compliance) and Staff F (EOC - Environment of Care Director) during the tour, they both stated that the doors to the two conference rooms and the seclusion room should have automatically closed. Staff B stated that the table and desk in the conference rooms could provide the necessary height for a patient to reach the drop ceiling. Staff F (EOC) stated that in the space above the drop ceiling houses electrical wires and possibly plumbing. Staff B stated that these items could provide tie-off points, thus becoming ligature risks for hanging oneself. She also stated the draw handles on the desks provided tie-off points and that the electrical and computer cords could be used to hang oneself. The computer screens and keyboards could be used as weapons.


B. The seclusion room FRP trim had sharp edges that could be used to scratch or cut self.

Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm."

During a tour of the adolescent units on 5/20/2025, 10:00am - 10:45am, it was observed that 4 feet by 8 feet sheets of FRP paneling had been vertically applied to the walls of the seclusion room (room 418). A thin FRP trim ran horizontally around the room where the two panels butted together. A 2-3-inch stretch of the trim had been bent outward, exposing a very sharp edge.

In an interview with Staff B (Compliance) and Staff F (EOC) during the tour, Staff F (EOC) was aware of this issue, adding that a patient had damaged the trim by trying to pull it off. Staff B (Compliance) stated that a patient could harm self with the area of the trim that had been compromised.


C. Two seclusion rooms had not been cleared an ottoman that could be used as weapons to harm others.

Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm."

During a tour of the Sunrise Unit on 5/20/2025, 10:00am - 10:45am, and the Maples Unit, 12:15pm - 1:30pm, an ottoman was observed in the anteroom / seclusion room suite.

In an interview with Staff B (Compliance) and Staff C (Chief Nursing Officer - CNO) during the tour, they both stated that the ottoman in the seclusion suite 418 had been used as a weapon less than a week earlier by Patient #1, a 17-year-old adolescent female, toward a staff member. They also stated the ottomans were not supposed to be in this area.

In an interview with Staff H (Unit RN) on the Sunrise Unit on 5/20/2025 at 10:35am she stated that the ottoman "should never have been in the seclusion area."

In an interview with Staff G (Patient Care Assistant - PCA) on 5/20/2025 at 10:15am, she stated the ottoman can be in the seclusion room if the patient is in the Quiet Room, "but not if [the patient is] locked in seclusion." She also stated that the ottoman should not have been in this area with Patient #1, an acknowledged "killing machine like my dad."


D. Various cabinets and drawers on all five units were not locked or the locks were not compromised.

Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm."

Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed:
" 7 suicidal patients on the Cedars Unit (Patients #8 through #14),
" 12 suicidal patients on the Sunrise Unit (Patients #15 through #26),
" 5 suicidal patients on the Willows Unit (Patients #27 through #31),
" 18 suicidal patients on the Maples Unit (Patients #32 through #49), and
" 12 suicidal patients on the Meadows Unit (Patients #50 through #61).
Additionally, this failure had the potential to provide 15 patients throughout the facility on assaultive precautions (Patients #16, 28, 30, 31, 40, 42, 59, 62, 63, 64, 65, 66, 67, 68, and #69) with the means to harm other.

During a tour of the five inpatient units on 5/20/2025, 10:00am - 12:30pm, it was observed that numerous cabinets and drawers throughout the facility were either unlocked or the locks were broken giving patients access to numerous items that could be used for self-harm or as weapons. Items included plastic markers with conical tips, plastic wrap, and removable heavy wooden shelves.

In an interview with Staff B (Compliance) she stated that the plastic markers with conical tips and the wooden shelves could be used as a weapon or to self-harm. She also stated that the plastic wrap could be used to suffocate oneself.


E. Items that could be used for suffocation and strangulation (rubber gloves and plastic sleeves) were out of reach of suicidal patients.

Review of policy 17833451, Patient Bill of Rights, last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a ... humane environment in which you are protected from harm."

Review of the Review of policy 15562536, Suicide Prevention Program Guidelines, last approved 4/2024, showed: "No plastic wrap on linens in patient areas."
Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed that rubber gloves or sleeves found on Styrofoam cups were not addressed.

Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed: "Nurse Stations ... The nurse stations are monitored 24/7 by a staff member. Patients will not have access to the nurse station."

Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed:
" 12 suicidal patients (Patients #15 through #26) and 2 assaultive patients (Patient #16 and Patient #63) on the Sunrise Unit,
" 5 suicidal patients (Patients #27 through #31) and 4 assaultive patients (Patients #28, 30, 31, and Patient #64) on the Willows Unit, and
" 12 suicidal patients (Patients #50 through #61) and 4 assaultive patients (Patient #59, 67, 68, and Patient #69) on the Meadows Unit.

During a tour of the five inpatient units on 5/20/2025, 10:00am - 12:30pm, the Nurse's Station on the Sunrise Unit was observed. The workstation faced out onto the common areas. Two nurses were seated at the station. Behind them against the wall on a ledge was two unattended boxes of rubber gloves. They were within reach of patients. A plastic sleeve of Styrofoam cups was observed on the Willows Unit and the Meadows Unit. On the Meadows Unit, bath clothes wrapped in plastic wrap were stored in one of the unlocked cabinets adjacent to the common area.

In an interview with Staff B (Compliance) she stated that the rubber gloves were within reach of patients, adding that the gloves should have been stored in a more secure place. She also stated the plastic sleeves and plastic wrap should not have been accessible to patients on the unit.


F. 45-gallon black round commercial trash can on wheels unattended.

Observation of Staff I (Housekeeper) on 5/20/2025 at 11:25am on the Cedars Unit showed Staff I had left the trash receptacle unattended in the hallway. She was observed in a group room performing duties. The group room had a self-closing door that closed and locked behind her when she entered the room. The receptacle was lined with a large black plastic bag. An unused large black plastic bag was draped over the edge of the container. There were two spray bottles of cleaning chemicals hung on the edge of the container. The receptacle was over three quarters full of trash.

Review of the Cedars Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 7 patients (Patients #8 through #14 and Patient #62) on Suicide Precautions and 1 patient (Patient #62) on Assaultive Precautions.

During an interview with Staff I on 5/20/2025 at 11:20am, Staff C (CNO) translated into Spanish the questions posed by the surveyor. According to Staff C, Staff I did not know that the trash receptacle needed continuous monitored while on the units.


G. Housekeepers was not properly trained on the safety features of the commercial housekeeping cart.

In an interview with Staff I on 5/21/2025 at 9:55am, Staff C (CNO) translated into Spanish the questions posed by the surveyor. According to Staff C, Staff I did not know that housekeeping cart had a lock, a safety feature.

Observation of the housekeeping cart on 5/21/2025 at 9:55am showed that the housekeeper did not know how to lock the top of the cart when instructed to do so by Staff C (CNO).

Further interview with Staff C (CNO) on 5/21/2025 at 9:55am, she stated that the housekeeping cart needed to be locked when on the unit.


H. The heat and air units in the patients' bedrooms were not dust-free.

Review of "Guidelines for Environmental Infection Control in Health-Care Facilities," prepared by L. Sehulster, Ph.D. and R. Chinn, MD, June 6, 2003, showed the following recommendation: "Ensure that heating, ventilation, air conditioning (HVAC) filters are properly ... maintained to prevent ... dust overloads." Additionally, The Joint Commission standards for dust in hospitals focus on ensuring proper ventilation, maintenance of HVAC systems, and preventing dust accumulation to minimize the risk of infection.

Review of policy 17833451, "Patient Bill of Rights," last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to a clean ... environment in which you are protected from harm."

Review of the policy 17332679, "General Cleaning Policy," last approved 3/2025, showed: "Monthly: Vertical surfaces, corners, vents, grates, etc., should be cleaned using a vacuum cleaner with crevice tool and upholstery brush attachments."

Review of the Unit Census dated 5/20/2025 provided by Staff B (Compliance) and Staff C (CNO) showed 15 patients (Patients #15 through 26, 63, 70, and #71) were on the Sunrise Unit and 8 patients (Patients #27 through 31, 64, 72, and #73) were on the Willows Unit.

Random checks of the heat and air units in the 18 patient bedrooms during the tour of the Sunrise and Willows units on 5/20/2025, 10:00am - 12:30am, showed a very substantial accumulation of dust and debris. This had the potential to affect patients on the Sunrise and Willows Units.

In an interview with Staff L (RN - Infection Control Coordinator - ICC) on 5/21/2025 at 11:21am, she stated the dust should not have been in the heat and air units. She also stated General Cleaning Policy states that all vents and grates are to be cleaned with a vacuum cleaner monthly.


I. Comprehensive assessment of environmental risk strategies.

Review of the Lifepoint Risk Assessment, initiated by the EOC Director, created 1/27/25, revised 4/8/25, showed:
The drop ceilings throughout the facility had not been assessed with mitigation strategies. (See item A.)
There was no reference to the FRP trim in the seclusion room (room 418). (See item B.)
The cabinets and drawers adjacent to the common areas on the five behavioral health units were not included in the assessment with mitigation strategies. (See item D.)
Unsupervised access to rubber gloves and plastic sleeves for Styrofoam cups were not included in the assessment with mitigation strategies. (See item E.)
The trash receptacles and commercial cleaning carts were not included in the assessment with mitigation strategies. (See item F and G.)

In an interview with Staff F (EOC) on 5/21/2025 at 10:30am, he stated the environmental issues found the previous day during the tour on the facility needed to be on the Lifepoint Risk Assessment to minimize environmental risks. Staff F and Staff B (Compliance) stated that a team would be created to develop a more comprehensive environmental risk assessment. They also stated that based on the risk assessment findings, education and training would be needed.


J. Staff were not wearing an identification badge while performing patient care.

Review of policy 15183000, "Identification Badges, Keys, Personal Safety Devices, last approved 3/2024, showed: "Identification badges are to be worn at all times while on work premises and while conducting facility business. Badges will state the employee's name, position, and/or department. The identification badge should be attached to the outermost garment and should be worn at all times while on duty. The employee's picture and name should be visible at all times ... Human Resources has the responsibility of ensuring that orienting employees have been issued a badge. Damaged and lost badges will be replaced by Human Resources."

Observation of Staff G (PCA) on 5/20/2025 at 10:15am showed that she was not wearing any type of identification. In an interview with Staff G, she stated she was providing direct patient care. She also stated her badge had "cracked" the previous day and she had not had it replaced. She had not identified an alternative method of staff identification.

Observation of Staff K (PCA) on 5/21/2025 at 9:55am showed that he was not wearing any type of identification. In an interview with Staff K, he stated he was providing direct patient care. He also stated he was a new employee and had not had a badge for two weeks. He had not identified an alternative method of staff identification.

In an interview with Staff C (CNO) on 5/21/2025 at 10:00am, she stated all staff were required to wear an identification badge.

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Based on observation, interview, and record review, the facility failed to ensure that 1 of 1 patients, Patient #1, a 17- year-old adolescent was free from physical assault by Staff E, a Patient Care Assistant (PCA). Staff E did not follow the behavioral management training by disengaging and "punting" the intervention to another staff member when her personal feelings interfered with her ability to effectively respond to the patient. Additionally, other staff members did not intervene by encouraging Staff E to disengage and punt the intervention to them.

Findings were:

Review of policy 17833451, "Patient Bill of Rights," last approved 4/2025, showed: "Basic Rights for All Patients ... You have the right to be free from mistreatment, abuse, neglect, and exploitation."

Review of "Handle with Care Behavior Management System - Verbal Intervention Manual for Participants," copyright 2012, showed: "Be aware of your body language - nonverbal communication (facial expressions, hand gestures, pointing, etc.) reveals your true affect. If your own feelings about the client are interfering with your ability to do good work with him, recollect yourself or punt the intervention to someone else."

Review of Psychosocial Assessment by Staff S (LMSW) dated 5/9/2025 at 4:41pm, showed "unprovoked" anger, self-harm - cutting, and history of suicide attempt by overdose. She resided in a group home.

Review of Seclusion and Restraint documentation dated 5/15/2025 at 10:33am, showed that Patient #1 was given Haldol 5mg IM [antipsychotic given Intramuscularly], Ativan [used for anxiety] 2 mg IM, and Cogentin [counters side effects of antipsychotic] 1 mg IM by Staff R (RN) after the patient "threw things in the nurse's station and broke the exit doors" because she was "upset about discharge." The patient went to the seclusion room suite.

Review of video surveillance dated 5/15/2025 at 10:30am, showed Patient #1 and Staff E and Staff K, both PCA's, in the anteroom of seclusion suite 418. Though there was no audio, Staff E and Patient #1 were in what appeared to be a highly charged, emotional exchange. There were a lot of hand gestures made by Staff E. The patient picked up an ottoman and hurled it at Staff E. Staff K blocked the ottoman from hitting Staff E. The confrontation then moved to the hallway, just outside of the anteroom. More staff members arrived. Staff E continued to be engaged in an argument with the patient. Patient #1 quickly moved toward Staff E, striking Staff E. Immediately Staff E charged the patient and began hitting the patient with her fists, landing several blows to the patient's head. Other staff members intervened to protect the patient.

In an interview with Staff B (Compliance Director) on 5/20/2025 at 3:00pm during the review of the video surveillance, she stated Staff E (PCA) hit Patient #1 with a closed fist on 5/15/2025 at approximately 10:30am. She identified the following staff members as those that intervened to protect the patient from Staff E's punches: Staff J (HR), Staff K (PCA), Staff N (RN), Staff O (Patient Advocate), and Staff P (PCA). Staff E immediately went to the parking lot. Staff B (Compliance) was notified of the incident. Staff E was brought to Staff B's office to review the video. Staff E stated, 'I just lost it.' Staff E was sent home after relinquishing her keys and identification badge. She was terminated the following day. Staff B concluded by saying, "The police were called on behalf of the patient."

In an interview with Staff J (HR) on 5/20/2025 at 2:45pm, he stated that Staff E (PCA) had been "verbally inappropriate" with Patient #1.

Review of The State of Texas Fort Bend County police documentation (not dated or timed) showed that Staff M (Deputy) opened an investigation - Case #25-19375.

In an interview with Staff N (Nurse Supervisor) on 5/22/2025 at 9:34am, she stated Staff E should not have gotten into a power struggle with Patient #1.

Further interview with Staff B (Compliance Director) on 5/21/2025 at 1:30pm, she stated that Staff E (PCA) did not follow the Handle with Care behavioral management training. "She should have 'tapped out' and allowed another staff member to engage the patient. She also stated other staff members did not get Staff E to disengage and "tap out."

Review of the Employee Action Form showed "termination 5/16/2025." Staff E (PCA) "was struck by an adolescent patient and she [Staff E] responded by hitting the patient many times with her fists. Staff members had to restrain her [Staff E] from continuing the assault. Employee was suspended pending investigation immediately. This incident was reviewed and confirmed by camera footage. Due to this, they [sic] will be terminated."

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Based on observation, interview, and record review, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care of patients on an ongoing basis. More specifically, the facility failed to ensure that 1 of 1 patients (Patient #1), a 17-year-old female adolescent, was protected from physical assault by Staff E, a Patient Care Assistant (PCA). Staff E did not follow the behavioral management training by disengaging and "punting" the intervention to another staff member when her personal feelings interfered with her ability to effectively respond to the patient. Instead, Staff E hit Patient #1 repeatedly with her fists. Additionally, the registered nurse did not intervene by removing Staff E from the highly charged situation before it escalated to the point of a physical altercation between the PCA and the patient.

Findings were:

Review of "Handle with Care Behavior Management System - Verbal Intervention Manual for Participants," copyright 2012, showed: "Be aware of your body language - nonverbal communication (facial expressions, hand gestures, pointing, etc.) reveals your true affect. If your own feelings about the client are interfering with your ability to do good work with him, recollect yourself or punt the intervention to someone else."

Review of Psychosocial Assessment by Staff S (LMSW) dated 5/9/2025 at 4:41pm, showed "unprovoked" anger, self-harm - cutting, and history of suicide attempt by overdose. She resided in a group home.

Review of Seclusion and Restraint documentation dated 5/15/2025 at 10:33am, showed that Patient #1 was given Haldol 5mg IM [antipsychotic given Intramuscularly], Ativan [used for anxiety] 2 mg IM, and Cogentin [counters side effects of antipsychotic] 1 mg IM by Staff R (RN) after the patient "threw things in the nurse's station and broke the exit doors" because she was "upset about discharge." The patient went to the seclusion room suite.

Review of video surveillance dated 5/15/2025 at 10:30am, showed Patient #1 and Staff E and Staff K, both PCA's, in the anteroom of seclusion suite 418. Though there was no audio, Staff E and Patient #1 were in what appeared to be a highly charged, emotional exchange. There were a lot of hand gestures made by Staff E. These three individuals were in the room arguing for several minutes. The patient picked up an ottoman and hurled it at Staff E. Staff K blocked the ottoman from hitting Staff E. The confrontation then moved to the hallway, just outside of the anteroom. More staff members arrived. Staff E continued to be engaged in an argument with the patient. Patient #1 quickly moved toward Staff E, striking Staff E. Immediately Staff E charged the patient and began hitting the patient with her fists, landing several blows to the patient's head. Other staff members intervened to protect the patient. The charge RNs for the unit (Staff T and Staff U) were not identified in the video.

In an interview with Staff B (Compliance Director) on 5/20/2025 at 3:00pm during the review of the video surveillance, she stated Staff E (PCA) hit Patient #1 with a closed fist on 5/15/2025 at approximately 10:30am. She identified the following staff members as those that intervened to protect the patient from Staff E's punches: Staff J (HR), Staff K (PCA), Staff N (RN), Staff O (Patient Advocate), and Staff P (PCA). Staff E immediately went to the parking lot. Staff B (Compliance) was notified of the incident. Staff E was brought to Staff B's office to review the video. Staff E stated, 'I just lost it.' Staff E was sent home after relinquishing her keys and identification badge. She was terminated the following day. Staff B concluded by saying, "The police were called on behalf of the patient."

In an interview with Staff J (HR) on 5/20/2025 at 2:45pm, he stated that Staff E (PCA) had been "verbally inappropriate" with Patient #1.

Review of The State of Texas Fort Bend County police documentation (not dated or timed) showed that Staff M (Deputy) opened an investigation - Case #25-19375.

Review of documentation of the meeting dated 5/15/2025 (not timed) with Staff E (PSA) showed that surveillance footage of the assault was viewed by Staff B (Compliance Director), Staff C (CNO), Staff J (HR Director), and Staff E.

In an interview with Staff C (CNO) on 5/21/2025 at 10:00am, she stated that Staff E (PCA) should have removed herself from the altercation with Patient #1. Evidence of a thorough investigation of the incident could not be provided.

In an interview with Staff N (RN) on 5/22/2025 at 9:34am, she stated Staff E should not have gotten into a power struggle with Patient #1, adding, "Don't have a power struggle. Let know before you lose it. It's okay. Let me switch out with you."

Further interview with Staff B (Compliance Director) on 5/21/2025 at 1:30pm, she stated that Staff E (PCA) did not follow the Handle with Care behavioral management training. "She should have 'tapped out' and allowed another staff member to engage the patient. She also stated other staff members did not get Staff E to disengage and "tap out."

Review of the Employee Action Form showed "termination 5/16/2025." Staff E (PCA) "was struck by an adolescent patient and she [Staff E] responded by hitting the patient many times with her fists. Staff members had to restrain her [Staff E] from continuing the assault. Employee was suspended pending investigation immediately. This incident was reviewed and confirmed by camera footage. Due to this, they [sic] will be terminated."