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.

UT HEALTH EAST TEXAS JACKSONVILLE HOSPITAL 501 S RAGSDALE JACKSONVILLE, TX 75766 June 28, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview the facility:
A. Failed to notify the law enforcement officers, patient's attending physician and patient's husband prior to allowing the patient to leave the hospital Against Medical Advice. The patient had been deemed a threat to herself and others by the local law enforcement officers. The patient was allowed to leave the hospital unaccompanied after she had attempted to commit suicide by drug overdose. The attending physician was not notified. The patient's family was not notified of the patient's leaving the hospital.

Refer to A0131

B. Failed to keep the patient safe from herself. The patient was allowed to leave the facility after she had attempted to commit suicide by drug overdose. The staff failed to notify law enforcement officers of the patient intent to leave the hospital. The staff informed the surveyor that at the time the patient left the hospital, she was unsteady on her feet and there was fear of the patient falling. The staff failed to recognize that the patient was still a threat to herself even though the patient had no regards or concerns of ripping out the IV. The staff admitted to giving the patient the remainder of the drug (Xanax) she used in her suicide attempt.

Refer to tag A0144

C. The facility and staff failed to provide services necessary for the patient's medical and mental illness resulting in the patient's death.

Refer to tag A0145

It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of the likelihood of harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on chart review and interviews, the facility failed to notify the patient's representative of 1 of 6 (#6) suicidal patients reviewed, of the change in the patient's condition and allowed the patient to leave the hospital unaccompanied even though the patient was deemed to be a threat to herself and others.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of the likelihood of harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility

An interview was held with staff #5 on 6/27/2013 at 10:30 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and 9.

Staff #5 confirmed that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stating that she need to leave the hospital. The patient repeatedly said that they are going to take my children from me. Staff #7 stated staff #5 was in the room and attempted to calm the patient. The patient reached for the IV (intravenous catheter) and attempted to pull it out. Staff #7 reached and covered the IV and told the patient of the damage and injury that could be done by ripping out the IV. The patient told the staff to remove the IV or she will take it out herself. At the demand of the patient, staff #7 removed the IV.

Staff #5 confirmed that the patient had signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in the attempt to kill self, be returned. Staff #5 confirmed that the medications were returned to the patient.

Staff #5 stated she escorted the patient was escorted off the property unaccompanied by any responsible adult. Staff #5 followed up by saying that "the patient was very unsteady and there was fear the patient may fall and injure themself. That is why I walked the patient to the edge of the property and the patient walked off in the direction of the Whataburger restaurant".

Staff #5 was asked about notification of law enforcement officers, attending physician or patient's family. Staff #5 confirmed no thought was given to notifying law enforcement officers. Staff #5 denied knowing that there was a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" in place to detain the patient. Staff #5 confirmed that the attending physician was not notified of the patient's demand to leave the hospital or when the patient eventually left the hospital. Staff #5 was asked if the facility had provided education for caring for the mentally ill patient. Staff #5 stated, "no". Staff #5 was prompted by staff #1, that staff #5 had attended education for the care of the mentally that was provided by a local State hospital that cared for the mentally ill patient. Staff #5 replied, "yes, I remember that. Yes the hospital has provided education".

An interview was held with staff #7 on 6/27/2013 at 09:50 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and 9.

Staff #7 was the primary nurse caring for patient #6. Staff #7 revealed that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stated that she need to leave the hospital. The patient repeatedly said that they are going to take my children from me. Staff #7 stated that staff #5 was in the room and attempted to calm the patient. The patient reached for the IV (intravenous catheter) and was attempted to pull it out. Staff #7 reached over and covered the IV and told the patient of the damage and injury that could be done by ripping out the IV. The patient told Staff #7 to remove the IV or she will take it out herself. At the demand of the patient, staff #7 removed the IV.

Staff #7 stated that the patient had signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in the attempt to kill self, be returned. Staff #7 revealed the medications were returned to the patient.

Staff #7 stated the patient was escorted off the property by staff #5 and allowed to leave unaccompanied by a responsible adult. Staff #7 was asked about notification of law enforcement officers, attending physician or patient's family. Staff #7 revealed no thought was given to notifying law enforcement. Staff #7 followed up by saying that the patient would have been gone by the time the law enforcement officers responded.

Staff #7 denies knowing that there was a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" in place to detain the patient. Staff #7 was asked, you would not question if a detention warrant was not in place for a patient attempting suicide? Staff #7 stated, "No".

Staff #7 confirmed that the attending physician was not notified until patient rounds were made at approximately 1:00 PM of that day. Staff #7 followed by stating that "the physician's never make the patients stay."If I would have called him, he would have said to let the patient sign an AMA form and let the patient leave." When asked about notifying the patient's family, Staff #7 responded that the patient didn't want them notified. Staff #7 was asked if staff #7 had knowledge that the patient had killed herself after being allowed to leave the hospital. Staff #7 replied "yes." Staff #7 stated that "It was unfortunate the patient killed herself but if someone makes up their mind to kill themselves there is not much you can do to stop it. The patient was very agitated and aggressive. I had another patient on a ventilator that needed my attention and she wanted to leave the hospital and it was the patient's right".

In a combined interview with staff #1, #2 and #9 on 6/27/2013 at 11:30 AM in the Administrative Conference Room, all confirmed staff #5 and #7 failed to provide care to address the patient's psychiatric condition and failed to take measures to keep the patient safe. All confirmed that the staff failed to notify the attending physician, law enforcement officers or the patient's family of the change in the patient's condition, (increased agitation, aggressiveness towards herself and staff, demands to leave the hospital).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, the facility failed to take measures to address the psychiatric condition of 1 of 6 (#6) suicidal patients reviewed. The staff failure lead to the patient's patient's death upon discharge. The patient died of a self-inflicted gunshot wound on the day she left the hospital.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of the likelihood of harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility.

A review of the medical record for patient #6 revealed that the patient arrived at the facility's emergency room on [DATE] at 22:02 (10:02 PM), by ambulance, after taking an overdose (suicide attempt) of Xanax, (a drug commonly used and FDA approved for the medical treatment of panic disorder, and anxiety disorders).


The medical record showed that patient #6 was escorted by law enforcement officers. The law enforcement officers escorting the patient had filled out the document titled, "Law Enforcement Officer Application for Detention of Person as Mentally Ill (Section 26 Mental Health Code" and the officer had provided this document to the facility. The document revealed, "Name of patient: #6. 1. I hereby state my belief that the above named person evidences mental illness with substantial risk of serious harm to himself or others, and that there is therefore imminent risk of harm if this person is not immediately restrained. 2. This opinion is based upon specific recent behavior, overt acts, attempts or threats observed by me or reliable reported to me (to be clarified below). These are described in detail as follows: "Subject intestinally ingested approx. 40-48 Alprazolam (Xanax). Subject advised officers that she wanted to hurt herself. Patient #6 advised officers and nurse that she wished to kill herself." 3. There not being sufficient time to obtain a warrant and for reasons described above, I make application for immediate detention of: patient #6 as provided in Chapter3, Section 26 of the Texas Mental Health Code of Laws."


Due to the lack of documentation in Electronic Medical Record, the exact time of the
patient's transfer to ICU was unavailable. The Electronic Medical Record indicated that the patient was transferred from the Emergency Department to the Intensive Care Unit (ICU) between the hours of 1:05 AM and 2:00 AM.


At 1:03 PM on 6/24/2013, staff #7 documented, "patient very agitated, saying that "they" are going to take her kids away, pulling off telemetry stickers and O2 sensor and reaching for IV site. Staff #5 and I at bedside, attempting to calm patient agreed to wait until AMA paperwork prepared. Patient calmer once she was assured that she was going to be able to leave. Patient denied having thoughts of suicide or of harming herself."


This entry was not labeled as or indicated by the nurse as being a late entry but in fact was a late entry made by staff #7. The entry was made after the patient was allowed to leave the facility at 7:40 AM on 6/24/2013.

A review of the document contained in the medical record, dated 6/24/2013, timed 7:40 AM and titled "Discharge of Patient from Hospital Against Medical Advice" revealed, "This is to certify that patient #6, a patient in ETMC Jacksonville is leaving or being taken from this institution. I hereby acknowledge that this action to be against the advice of the attending physician(s) and/or hospital authorities. I have been informed of the possible/probable dangers to my health that may result from leaving the hospital at this time, including but not limited to: (nurse entered) further thoughts of harming self/others, fall, death. Patient demands that meds be given back to her, states that "they will not kill her." This document was signed by patient #6 and witnessed by staff #5 and #7.


The patient's medical record contained no evidence of notification to law enforcement officers of patient #6 leaving the hospital.


There was no evidence of notification of the attending physician.


There was no evidence of notification of the patient's family of the patient leaving the hospital.


A phone interview was conducted on 6/27/2013 at approximately 3:30 PM with the patient's attending physician #4. The interview confirmed that there was no notification made to the physician that the patient wanted to leave the hospital or had left the hospital. The physician confirmed that there was no assessment made on the patient to determine the mental or physical status prior to the patient's leaving the hospital. The physician was notified of the patient being allowed to leave by the staff #5 and #7 when the physician arrived at the hospital to make rounds on 6/24/2013 at approximately 1:00 PM. During the interview on 6/27/2013, the physician was asked why the patient was allowed to leave with a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" document in place. The physician denies being made aware of this document.


An interview was held with staff #7 on 6/27/2013 at 09:50 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and #9.


Staff #7 was the primary nurse caring for patient #6. Staff #7 stated that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stating that she need to leave the hospital. The patient repeatedly said" they are going to take my children from me." Staff #7 stated that staff #5 was in the room and attempted to calm the patient. The patient reached for the IV (intravenous catheter) and attempted to pull it out. Staff #7 reached over and covered the IV and told the patient of the damage and injury that could be done by ripping out the IV. The patient told Staff #7 to remove the IV or she will take it out herself. At the demand of the patient, staff #7 removed the IV.


Staff #7 stated that the patient had signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in her attempt to kill herself, be returned. Staff #7 revealed the medications were returned to the patient.


Staff #7 stated that the patient was escorted off the property by staff #5 and allowed to leave the hospital unaccompanied by a responsible adult. Staff #7 was asked about notification of law enforcement officers, attending physician or patient's family. Staff #7 revealed no thought was given to notifying law enforcement officers. Staff #7 followed up by saying that the patient would have been gone by the time the law enforcment officer responded. Staff #7 denies knowing that there was a Law Enforcement Officer Application for Detention of Person as Mentally Ill in place to detain the patient. Staff #7 was asked, you would not question if a detention warrant was not in place for a patient attempting suicide? Staff #7 stated, "No".


Staff #7 confirmed that the attending physician was not notified until the physician arrived at the hospital to make patient rounds at approximately 1:00 PM. Staff #7 stated that the "physician's never made the patients stay. If I would have called him, he would have said to let the patient sign an AMA form and let the patient leave." When asked about notifying the patient's family, Staff #7 stated that the patient didn't want them notified. Staff #7 was asked if staff #7 had knowledge that the patient had killed herself after being allowed to leave the hospital. Staff #7 replied "yes". Staff #7 further stated that "it was unfortunate the patient killed self but if someone makes up their mind to kill themselves there is not much you can do to stop it. The patient was very agitated and aggressive. I had another patient on a ventilator that needed my attention and patient #6 wanted to leave the hospital and it was the patient's right."


An interview was held with staff #5 on 6/27/2013 at 10:30 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and #9. Staff #5 confirmed that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stated that shee need to leave the hospital. The patient repeatedly said "they are going to take my children from me."


Staff #5 confirmed that the patient had signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in her attempt to kill herself, be returned. Staff #5 confirmed the medications were returned to the patient.


Staff #5 stated that she escorted the patient escorted off the property and allowed to leave the hospital unaccompanied by a responsible adult. Staff #5 followed up by saying that "the patient was very unsteady and there was fear the patient may fall and injure herself. That is why I walked the patient to the edge of the property and the patient walked off in the direction of the Whataburger restaurant."


Staff #5 was asked about notification of law enforcement officers, attending physician or patient's family. Staff #5 confirmed no thought was given to notifying law enforcement officers. Staff #5 denied knowing that there was a Law Enforcement Officer Application for Detention of Person as Mentally Ill in place to detain the patient.


Staff #5 confirmed that the attending physician was not notified of the patient's demand to leave th hospital or at the time of the patient left the hospital. Staff #5 was asked if the facility had provided education for caring for the mentally ill patient. Staff #5 stated, "no". Staff #5 was prompted by staff #1, that staff #5 had attended education for the care of the mentally that was provided by a local State hospital that cared for the mentally ill patient. Staff #5 replied, "yes I remember that. Yes the hospital has provided education."


In a combined interview with staff #1, #2 and #9 on 6/27/2013 at 11:30 AM in the Administrative Conference Room, all confirmed that staff #5 and #7 failed to provide care to address the patient's psychiatric condition and failed to take measures to keep the patient safe. All confirmed that the staff failed to notify the attending physician, law enforcement officers or the patient's family of the change in the patient's condition, (increased agitation, aggressiveness towards herself and staff, demands to leave the hospital).
VIOLATION: NURSING SERVICES Tag No: A0385
Based on documents review and interviews, the facility staff failed to perform ongoing assessments and take measures to address the psychiatric condition of 1of 6 (#6) suicidal patients reviewed which resulted in the patient being allowed to leave the hospital without a physician's medical or psychiatric evaluation of the patient. Patient #6 died of a self-inflicted gunshot wound on the day that she was discharged from the hospital.

Refer to tag A0395

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on documents review and interviews, the facility staff failed to perform ongoing assessments and take measures to address the psychiatric condition of 1of 6 (#6) suicidal patients reviewed which resulted in the patient being allowed to leave the hospital without a physician's medical or psychiatric evaluation of the patient. Patient #6 died of a self-inflicted gunshot wound on the day that she was discharged from the hospital.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility

A review of the medical record for patient #6 showed that the patient arrived at the hospital's emergency room on [DATE] at 22:02 (10:02 PM), by ambulance, after taking an overdose (suicide attempt) of Xanax, (a drug commonly used and FDA approved for the medical treatment of panic disorder, and anxiety disorders.)


The medical record showed that patient #6 was escorted by law enforcement officers to the hospital's emergency room for the medical evaluation and treatment of an intentional Xanax overdose.


The law enforcement officer who escorted the patient filled out the document titled, "Law Enforcement Officer Application for Detention of Person as Mentally Ill (Section 26 Mental Health Code"). The officer provided this document to the facility on arrival. The document revealed, "Name of proposed patient: #6. 1. I hereby state my belief that the above named person evidences mental illness with substantial risk of serious harm to himself or others, and that there is therefore imminent risk of harm if this person is not immediately restrained. 2. This opinion is based upon specific recent behavior, overt acts, attempts or threats observed by me or reliable reported to me (to be clarified below). These are described in detail as follows: "Subject intestinally ingested approx. 40-48 Alprazolam (Xanax). Subject advised officers that she wanted to hurt herself. Patient #6 advised officers and nurse that she wished to kill herself." 3. There not being sufficient time to obtain a warrant and for reasons described above, I make application for immediate detention of: patient #6 as provided in Chapter3, Section 26 of the Texas Mental Health Code of Laws."


The document titled, "ED Physician Notes" documented, "Chief Complaint: Suicidal Ideation, Clinical Impression/ Diagnosis: 1. Xanax Overdose, 2. Suicide Attempt".

The medical record contained the document dated 06/23/2013 and timed 22:26 (10:26PM) titled, "Assessment Report, ED Nursing Assessment and Care". The document revealed, Mode of Arrival Admission: Stretcher, Ambulance, Behavioral: Depression, Psychiatric Symptoms: Agitation, Alcohol Intoxication, Anger/Hostility, Anxiety, Suicidal Thoughts, Risk of Injuring Self or Others: Yes, Describe Unsafe: Overdosed on Xanax after having a fight with husband."

On review of the document titled "ED Medication Orders" revealed that the patient was treated with 50 gm of Activated Charcoal with Sorbitol at 22:31 (10:31 PM). (Activated charcoal works by binding with the poison in the stomach to decrease absorption of the poison into the body. Sorbitol works to help move the charcoal and poison out of the stomach and intestines more quickly)

The document tiled: Orders Report, Order Sub Type: Admission, dated 06/24/2013 at 1:02 AM revealed:
Admit to Medical/Surgical ICU Inpatient
Diagnosis- Xanax overdose, suicide attempt
All care transferred to Attending MD
Saline Lock
Diet, NPO
Ondansetron (Zofran) 4mg =2ml Intravenous, Q4H PRN nausea/ vomiting
Ketorolac (Toradol) 300mg = 1ml intravenous, Q6H PRN Moderate Pain (pain scale 5-7) for 5 days
Titrate O2 via Nasal Cannula for Sat > or equal to 92%
Vital signs every 2 hrs
Pulse Oximetry: Continuous


The Electronic Medical Record revealed that the patient was transferred from the Emergency Department to the Intensive Care Unit (ICU) at 2:00 AM.

Upon the review of the document titled, "Suicide Risk Evaluation (Risk indicators for suicide)" the patient was scored an 11 by the nurse. The scoring key indicates the patient was at low risk when the score is between 10 and13.

Upon the review of the document titled, "Special Precautions- Observation Rounds" the patient status was Level III requiring close observation and document every hour.


At 1:03 PM on 6/24/2013 staff #7 documented, "patient very agitated, saying that "they" are going to take her kids away, pulling off telemetry stickers and O2 sensor and reaching for IV site. Staff #5 and I at bedside, attempting to calm patient agreed to wait until AMA paperwork prepared. Patient calmer once she was assured that she was going to be able to leave. Patient denied having thoughts of suicide or of harming herself." This entry was not labeled as or indicated by the nurse as being a late entry but in fact was a late entry made by staff #7. The entry was made after the patient was allowed to leave the facility at 7:40 AM on 6/24/2013.


A review of the document in the medical record, dated 6/24/2013, timed 7:40 AM and titled "Discharge of Patient from Hospital Against Medical Advice" revealed, "This is to certify that patient #6, a patient in ETMC Jacksonville is leaving or being taken from this institution. I hereby acknowledge that this action to be against the advice of the attending physician(s) and/or hospital authorities. I have been informed of the possible/probable dangers to my health that may result from leaving the hospital at this time, including but not limited to: (nurse entered) further thoughts of harming self/others, fall, death. Patient demands that meds be given back to her, states that " they will not kill her." This document was signed by patient #6 and witnessed by staff #5 and #7.


Theere was no evidence in the patient's medical record contained that law enforcement officers were notified of patient #6 demands to leave the hospital or when she finally left the hospital.


There was no evidence in the patient's medical record that the attending physician was notified of patient #6's demands to leave the hospital or when she was discharged from the hospital.


There was no evidence in the patient's medical record that patient's family of the patient was notified of her demands to leave the hospital or when she was discharged from the hospital unaccompanied.


A review of the policy titled, "MANAGEMENT OF PSYCHIATRIC EMERGENCIES" revealed, "Patients should be screened upon admission and then their psychosocial status should be reassessed every shift. Any patient admitted with a psychiatric emergency should be admitted to the Intensive Care Unit for at least the first 24 hours of hospitalization .....
A patient with a confirmed psychiatric condition should he transferred to a psychiatric facility as soon as possible.


1.0 All patients presenting as direct admit or to Emergency Department should be screened for active thoughts of suicide,


1.1 A complete suicide risk assessment should be performed on an patient's with a positive screen.
1.2 The patient should he placed in Special Precautions based upon the Suicide Risk Assessment Score.
1.3 The patient should then be reassessed every shift for onset of suicidal ideation.
1.4 The physician should be notified immediately of any positive screen.


2.0 Special Precautions may be initiated based on the Suicide Risk Evaluation Scoring. 10-13 = Low Risk, 13-16 = SP III, 17-19 = SP II, 20 or above = SP I
2.1 SP 111: Close Observation Monitor (COM) Monitored ever, one hour
SP 11: Documentation every 30 minutes
SP I: Documentation every 15 minutes
2 2 The Special Precautions protocol should be implemented.
2.3 Patients placed on Special Precautions should be assessed daily with orders modified or discontinued as necessary.
2.4 If, after the initial 24 hours of hospitalization , the patient continues to require Level 1or II special precautions he/she should remain in ICU.
2.4.1 A patient who no longer requires Level 1 or II monitoring after the first 24 hours may be transferred to a general nursing unit. The patient should be assigned the room closes to the nurses ' station.


3.0 The Special Precaution order should be continued until discontinued or modified by the physician


There was no evidence in the patient's medical record that the care of the psychiatric patient was addressed.


A review of the document titled, "SUBTITLE C. TEXAS MENTAL HEALTH CODE, CHAPTER 573. EMERGENCY DETENTION, SUBCHAPTER A. APPREHENSION BY PEACE OFFICER OR TRANSPORTATION FOR EMERGENCY DETENTION BY GUARDIAN:

Sec. 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT.

(a) A peace officer, without a warrant, may take a person into custody if the officer:
(1) has reason to believe and does believe that:
(A) the person is mentally ill; and
(B) because of that mental illness there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained; and
(2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.

(b) A substantial risk of serious harm to the person or others under Subsection (a)(1)(B) may be demonstrated by:
(1) the person's behavior; or
(2) evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person cannot remain at liberty.

(c) The peace officer may form the belief that the person meets the criteria for apprehension:
(1) from a representation of a credible person; or
(2) on the basis of the conduct of the apprehended person or the circumstances under which the apprehended person is found.

(d) A peace officer who takes a person into custody under Subsection (a) shall immediately transport the apprehended person to:
(1) the nearest appropriate inpatient mental health facility; or
(2) a mental health facility deemed suitable by the local mental health authority, if an appropriate inpatient mental health facility is not available.

(e) A jail or similar detention facility may not be deemed suitable except in an extreme emergency.

(f) A person detained in a jail or a nonmedical facility shall be kept separate from any person who is charged with or convicted of a crime.


Sec. 573.002. PEACE OFFICER'S APPLICATION FOR DETENTION.
(a) A peace officer shall immediately file an application for detention after transporting a person to a facility under Section 573.001.

(b) The application for detention must contain:
(1) a statement that the officer has reason to believe and does believe that the person evidences mental illness;
(2) a statement that the officer has reason to believe and does believe that the person evidences a substantial risk of serious harm to himself or others;
(3) a specific description of the risk of harm;
(4) a statement that the officer has reason to believe and does believe that the risk of harm is imminent unless the person is immediately restrained;
(5) a statement that the officer's beliefs are derived from specific recent behavior, overt acts, attempts, or threats that were observed by or reliably reported to the officer;
(6) a detailed description of the specific behavior, acts, attempts, or threats; and
(7) the name and relationship to the apprehended person of any person who reported or observed the behavior, acts, attempts, or threats.


SUBCHAPTER C. EMERGENCY DETENTION, RELEASE, AND RIGHTS

Sec. 573.021. PRELIMINARY EXAMINATION.

(a) A facility shall temporarily accept a person for whom an application for detention is filed.

(b) A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility unless a written order for protective custody is obtained. The 48-hour period allowed by this section includes any time the patient spends waiting in the facility for medical care before the person receives the preliminary examination. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4 p.m. on the first succeeding business day, the person may be detained until 4 p.m. on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4 p.m. on the day the 48-hour period ends. If extremely hazardous weather conditions exist or a disaster occurs, the presiding judge or magistrate may, by written order made each day, extend by an additional 24 hours the period during which the person may be detained. The written order must declare that an emergency exists because of the weather or the occurrence of a disaster.

(c) A physician shall examine the person as soon as possible within 12 hours after the time the person is apprehended by the peace officer or transported for emergency detention by the person's guardian.

(d) A facility must comply with this section only to the extent that the commissioner determines that a facility has sufficient resources to perform the necessary services under this section.

(e) A person may not be detained in a private mental health facility without the consent of the facility administrator.

Sec. 573.022. EMERGENCY ADMISSION AND DETENTION.

(a) A person may be admitted to a facility for emergency detention only if the physician who conducted the preliminary examination of the person makes a written statement that:
(1) is acceptable to the facility;
(2) states that after a preliminary examination it is the physician's opinion that:
(A) the person is mentally ill;
(B) the person evidences a substantial risk of serious harm to himself or others;
(C) the described risk of harm is imminent unless the person is immediately restrained; and
(D) emergency detention is the least restrictive means by which the necessary restraint may be accomplished; and
(3) includes:
(A) a description of the nature of the person's mental illness;
(B) a specific description of the risk of harm the person evidences that may be demonstrated either by the person's behavior or by evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person cannot remain at liberty; and
(C) the specific detailed information from which the physician formed the opinion in Subdivision (2).

(b) A mental health facility that has admitted a person for emergency detention under this section may transport the person to a mental health facility deemed suitable by the local mental health authority for the area. On the request of the local mental health authority, the judge may order that the proposed patient be detained in a department mental health facility.

(c) A facility that has admitted a person for emergency detention under Subsection (a) or to which a person has been transported under Subsection (b) may transfer the person to an appropriate mental hospital with the written consent of the hospital administrator.

Sec. 573.025. RIGHTS OF PERSONS APPREHENDED, DETAINED, OR TRANSPORTED FOR EMERGENCY DETENTION.

(a) A person apprehended, detained, or transported for emergency detention under this chapter has the right:
(1) to be advised of the location of detention, the reasons for the detention, and the fact that the detention could result in a longer period of involuntary commitment;
(2) to a reasonable opportunity to communicate with and retain an attorney;
(3) to be transported to a location as provided by Section 573.024 if the person is not admitted for emergency detention, unless the person is arrested or objects;
(4) to be released from a facility as provided by Section 573.023;
(5) to be advised that communications with a mental health professional may be used in proceedings for further detention; and
(6) to be transported in accordance with Sections 573.026 and 574.045, if the person is detained under Section 573.022 or transported under an order of protective custody under Section 574.023.

(b) A person apprehended, detained, or transported for emergency detention under this subtitle shall be informed of the rights provided by this section:
(1) orally in simple, nontechnical terms, within 24 hours after the time the person is admitted to a facility, and in writing in the person's primary language if possible; or
(2) through the use of a means reasonably calculated to communicate with a hearing or visually impaired person, if applicable."


A phone interview was conducted with the patient's attending physician #4 on 6/27/2013 at approximately 3:30 PM. The interview confirmed that there was no notification made to the physician that the patient demanded to leave the hospital or when the patient left the hospital. The physician confirmed that there was no physical or psychiatric assessment done on the patient prior to discharge. The attending physician informed the surveyor that she learned from staff #5 and #7 that patient #6 left the hospital on arrival at the hospital to make patient rounds on 6/24/2013 at approximately 1:00 PM. During the interview on 6/27/2013, the physician was asked why the patient was allowed to leave with a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" document in place. The physician denies being made aware of this document.


An interview with local law enforcement officer confirmed that there was no notification made regarding patient #6's demands to leave the hospital or when the patient left the hospital on [DATE]. The patient was found dead with a self inflicted gunshot wound on the same day that she was discharged from the hospital.

An interview was held with staff #7 on 6/27/2013 at 09:50 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and 9.


Staff #7 was the primary nurse caring for patient #6. Staff #7 revealed that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stated that she need to leave the hospital. The patient repeatedly said "they are going to take my children from me."


Staff #7 stated that staff #5 was in the room and attempted to calm the patient. The patient reached for the IV (intravenous catheter) and attempted to pull it out. Staff #7 reached over, covered the IV, and told the patient of the damage and injury that could be done by ripping out the IV. The patient told staff #7 to remove the IV or she will take it out herself. At the demand of the patient staff #7 removed the IV.


Staff #7 stated the patient signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in the attempt to kill herself, be returned. Staff #7 stated that the medications were returned to the patient.


Staff #7 stated that the patient was escorted off the property by staff #5 and allowed to leave unaccompanied by a responsible adult.


Staff #7 was asked about notification of law enforcement officers, attending physician or the patient's family. Staff #7 stated that there was no thought given to notifying law enforcement officers. Staff #7 informed the suruveyor that the patient would have been gone by the time the law enforcment officer responded.


Staff #7 denies knowing that there was a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" in place to detain the patient. Staff #7 was asked, would you not question if a detention warrant was not in place for a patient attempting suicide? Staff #7 stated, "No".


Staff #7 confirmed that the attending physician was not notified until patient rounds were made by the attending physician at approximately 1:00 PM on 6/24/2013. Staff #7stated that "the physician's never made the patients stay. If I would have called him, he would have said to let the patient sign an AMA form and let the patient leave."


When asked about notifying the patient's family, staff #7 stated that the patient didn't want them notified. Staff #7 was asked if staff #7 had knowledge that the patient had killed herself after being allowed to leave the hospital. Staff #7 replied "yes". Staff #7stated that "It was unfortunate the patient killed herself but if someone makes up their mind to kill themselves there is not much you can do to stop it. The patient was very agitated and aggressive. I had another patient on a ventilator that needed my attention and she wanted to leave the hospital and it was the patient's right."


An interview was held with staff #5 on 6/27/2013 at 10:30 AM in the Administrative Conference Room. The interview was witnessed by staff # 1, 2 and 9.


Staff #5 confirmed that patient #6 became agitated and aggressive after talking with the patient's mother and husband on the phone. The patient began pulling at the telemetry wires, stated she need to leave the hospital. The patient repeatedly said "they are going to take my children from me."


Staff #5 confirmed that the patient signed an AMA (Against Medical Advice) form and a contract that the patient would not harm herself or others. The patient demanded the remaining medications (Xanax) that were not taken earlier in the attempt to kill herself, be returned. Staff #5 confirmed the medications were returned to the patient.


Staff #5 stated that the patient was escorted off the property by staff #5 and allowed to leave unaccompanied by a responsible adult. Staff #5 informed the surveyor that, "The patient was very unsteady and there was fear the patient may fall and injure herself. That is why I walked the patient to the edge of the property and the patient walked off in the direction of the Whataburger restaurant."


Staff #5 was asked about notification of law enforcement officers, attending physician or the patient's family. Staff #5 stated that there was no thought given to notifying law enforcement pfficers. Staff #5 denied knowing there was a "Law Enforcement Officer Application for Detention of Person as Mentally Ill" in place to detain the patient.


Staff #5 confirmed that the attending physician was not notified at the time of the patient demanded to leave the hospital or when she finally left the hospital. Staff #5 was asked if the facility had provided education for caring for the mentally ill patient. Staff #5 stated, "no". Staff #5 was prompted by staff #1, that staff #5 had attended education for the care of the mentally that was provided by a local State hospital that cared for the mentally ill patient. Staff #5 replied, "yes I remember that. Yes the hospital has provided education".


In a combined interview with staff #1, #2 and staff #9 on 6/27/2013 at 11:30 AM in the Administrative Conference Room, all confirmed staff #5 and #7 failed to provide care to address the patient's psychiatric condition and failed to take measures to keep the patient safe. All confirmed that the staff failed to notify the attending physician, law enforcement officers or the patient's family of the change in the patient's condition, (increased agitation, aggressiveness towards herself and staff, demands to leave the hospital).