The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on record review, observations, staff interviews and the hospital's policy and procedure, the facility failed to ensure a safe patient environment in the emergency room (ER) for patients, family members and staff. This deficient practice allowed the patient to inflict a fatal gunshot to her head. The findings are:

A. Review of the three male Sheriff deputies' narrative report dated 01/24/13 revealed the following:
1. The reports did not indicate that the patient's perineum was pat searched.
2. Two of three guns in the house were found: a .38 revolver and a shotgun in the case. A black case for a Ruger 9mm semiauto handgun was found on top of the bed with a loaded magazine, but that gun was not found in the house.
3. The scene was cleared by the deputies without finding the Ruger handgun for Emergency Medical Services (EMS).
4. The Sheriff deputies followed the EMS ambulance to the hospital and stayed with the patient until the hospital security officer arrived.

B. On 02/01/13 at 9:00 am, during telephonic interview, the ER nurse stated, "[Patient's name] came in with EMS. [Patient's name] was sitting in bed. There were 3 police officers outside her door. I went in and spoke with her. She said that she was not suicidal and that her mother made up the story because she [her mother] wanted her kids. [Patient's name] disrobed and asked if she could keep on her sports bra. I told her I had to look inside of it. Same with her underwear. Her waist band looked like a thong in the back. She had one hand on her gown and put it in front of her. I thought she pushed it down for modesty reasons. I patted it in the front but didn't put my hands underneath her body. She was sitting at this time. We usually let patients like [Patient's name] leave their underwear on. I was never shown how to pat someone down. I was feeling for anything sticking out. When I was finished, I opened the door to her room. The police officers were gone. I logged all of her belongings. She fluctuated between being calm and agitated. She kept saying that she wasn't suicidal..."

C. On 02/01/13 at 10:30 am, during interview, the hospital Security Guard, assigned to the patient one-on-one, stated the following: "I was sitting where the ward clerk is. I could see into the room. [Patient's name] was crying off and on. She asked to use the phone to call her husband but her request was denied. At one time she was cursing her mom. I took her to the restroom, stood outside, and held the door handle down. I walked her back to the room. She was walking normally. I sat down by the ward clerk's desk. I heard her say rather loudly, 'Tell my husband...' I then looked up and saw a gun pointed in my direction. I got up and started to walk to the room, I saw her chamber a round. She put the gun to her head and pulled the trigger. She had the weapon in her hand...I have no idea where she could have hidden the gun."
1. On 02/01/13 at 11:00, during a tour of the ER with the hospital Security Guard, Chief Nursing Officer (CNO), the Director of ER and the hospital attorney, the surveyors observed where the Security Guard was sitting in relation to the patient in room #3. The CNO stated the distance between the guard and the patient was 25 feet.

D. Review of the hospital's policy and procedure titled "Behavioral Health Order Set: Patients that are Suicidal/Homicidal or Threatening to hurt themselves or others" approved on 11/14/12, revealed the following: "Initiate 1-1 observation for suicidal/homicidal patients or patients that may be a harm to themselves or others - Security guard preferred."