Cedar Crest Hospital & RTC

Risk level: Medium High : 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

The operation had 8 children for 1 staff member at the time and day of the incident.

Risk level: Medium High : 748.2463(3) - Emergency Behavior Intervention-Never used as a means to get a child to comply

A child in care was restrained for a non-emergency situation.

Risk level: Medium High : 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

A caregiver pushed a child in care.

Risk level: Medium High : 748.2551(a) - EBI Implementation-Must be an appropriate response to the behavior demonstrated, and de-escalation must have failed

A caregiver failed to de-escalate a situation which resulted in an unnecessary restraint of a child in care.

Risk level: High : 748.2551(b) - EBI Implementation-The caregiver must act to protect the child's safety

A child in care was inappropriately restrained. The restraint resulted in the child being injured.

Risk level: Medium : 748.311(6) - Serious Incident Documentation-Includes nature of the incident

Review of the Serious Incident Report found the second fall was not included. The child that witness the incident and the staff that were involved were not documented on the incident Report.

Risk level: Medium High : 748.1101(b)(4)(A)(v) - Children's rights- To be free from being subjected to remarks that belittle or ridicule the child or the child's family

A caregiver made belittling and antagonistic comments to a child in care, as well as used profane language. These actions further escalated the child's behavior.

Risk level: Medium High : 748.2307(8) - Other Prohibited Punishments-humiliating, shaming, ridiculing, rejecting, or yelling at a child

Through child and staff interviews it was determined that several staff and children have heard another staff yell at a child, blaming the child for an incident between two other children and tell the child they were not a good friend for allowing the incident to occur. The same staff was also heard calling a child "disgusting" and shaming a child about their weight.

Risk level: High : 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

During the walkthrough of the operation, a youth was seen in the common area on the phone with no supervision, auditory or visual. A staff member admitted to allowing the youth a phone call, but later forgetting the youth was still on the phone or providing any level of supervision. This youth was on observation every 15 minutes due to youth's high-risk behaviors, the youth reported being on the phone and alone for longer than 15 minutes.

Risk level: Medium High : 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

During the walk through of the operation all 3 units were observed, there were more than five children being cared for by one staff member in several units. It was stated in interviews that staff members were aware of the 1 to 5 ratio but couldn't account for what youth they were responsible for while on duty.

Risk level: Medium High : 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks

Staff did not demonstrate prudent judgment when they grabbed a child, who was being non-compliant, by the ear in an attempt to make the child move to a different area.

Risk level: Medium : 748.311(5) - Serious Incident Documentation-Includes names or other means of identifying witnesses to the incident, if any

While reviewing the serious incident reports it was found that child witnesses were not documented.

Risk level: Medium : 748.1501(a)(1) - Dental care-Children in care must receive dental care initially according to the requirements in 748.1225

Two of two child files did not have documentation of a dental exam being performed in accordance with 728.1225. Neither of the files had documentation of a dental exam being performed within the last year prior to being admitted to the operation.

Risk level: High : 748.2001(b) - Administration of Medication-Must obtain written, signed, & dated consent for a new psychotropic medication

A child's parent refused consent for the operation to administer Lithium to their child. A nurse administered one dose of Lithium to the child after the refusal.

Risk level: Medium High : 748.863(a)(3) - Caregiver for child-care or prog. svcs only must have 8 hours EBI training, 4 before counted in ratio, rest in 90 days; 16hrs for treatment svcs

A caregiver did not have 16 hours of preservice EBI training within 90 days of being hired.

Risk level: High : 745.635(2) - AP Background check determination - If ineligible then you must immediately remove subject from operation and confirm to CBCU receipt of notice letter

A staff member was determined by the background check unit to be ineligible to be at the operation on 1/9/25. The staff worked on 1/11/25.

Risk level: High : 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity

Caregivers were not aware or accountable of children's ongoing activity when a child was able to go into another child's room and have inappropriate contact. Staff was reported to be on their phone when this occurred.

Risk level: Medium High : 748.2551(b)(2) - EBI Implementation-The caregiver must consider the permitted types of emergency behavior intervention

A caregiver did not use permitted type of emergency behavior intervention when they held a child against a wall, with the child's back against the wall and then when they held a child down on a bed with the child's head hanging over the bed. While the child was being held on the bed, it was observed that the caregiver's hand was near or on the child's neck.

Risk level: Low : 748.1341(a) - Initial Service Plan-Must give the child's parent(s) at least two weeks advance notice of the meeting

Three of three child files did not have documentation that parents were notified of service plan meeting at least two weeks before the meeting. Two files had documentation that had incorrect dates while the other file had no documentation at all.

Risk level: High : 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation

A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.

Risk level: Medium High : 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child

On 8/14/24 children and staff witnessed an incident where there were concerns that a staff physically assaulted a child in care. This was not reported to Licensing until 8/20/24.

Risk level: High : 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting

Through interviews it was determined that a staff member threatened corporal punishment to a child if a child behaved the way they did again.

Risk level: Medium High : 748.2307(9) - Other Prohibited Punishments-subjecting a child to abusive or profane language

Through multiple interviews of staff and children it was determined that staff have been heard using profane and abusive language towards children.

Risk level: Medium High : 748.1003(a) - Child/caregiver ratio-Caregiver may care for 5 children if any require tx svcs, 8 children if not; children under 5 yrs old count as 2 children

Six children and three staff who were interviewed report on 7/7/24 three children were placed on 1:1 observation and the rest of the unit was out of ratio.

Risk level: High : 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being

A child in care was left unsupervised in a hallway by themselves. The child accessed a hospital gown and used the strings to tie around their neck. After the child was placed on 1:1 observation, the staff assigned to the child responded to incident involving another child and brought the child on 1:1 to the other child's room and was not providing 1:1 observation.