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.
| TEXOMA MEDICAL CENTER | 5016 S US HIGHWAY 75 DENISON, TX 75020 | Oct. 9, 2014 |
| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on records review and interviews, the hospital failed to provide an effective oversight of the nursing service. The nursing staff failed to follow the hospital policy and identify high risk for self-harm in 2 of 12 patients (Patient #1 and #8) who attempted to kill themselves during their inpatient hospitalization stay. Cross refer to A0395 Based on record review and interviews, it was determined that the deficient practices found posed an immediate jeopardy to the health and safety of patients that had the likelihood to cause harm. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on records review and interviews, the hospital failed to ensure that a registered nurse effectively supervised the nursing care and appropriately evaluated the risk for self harm for 2 of 12 patients (Patient #1 and #8) in accordance withthe hospital's nursing policy. 1) Although aware of Patient #1's history of self-injurious behavior, nursing staff failed to implement safety measures adequate to prevent the patient from causing serious self-harm by attempting to strangle himself on 07/26/14. 2) On 09/23/14, nursing staff failed to implement safety measures that could have prevented Patient #8 from tying a knotted sheet to the door and around his neck that resulted in breathing problems after. Patient #8 had reported to nursing staff his intentions to use a sheet to commit suicide by hanging less than 24 hours earlier. Findings included: 1) Patient #1's comprehensive admission screening dated 07/26/14, at 00:10, reflected the patient suffered from psychosis with suicidal ideation after jumping through a glass window. Admission orders noted by nursing staff on 07/26/14, at 02:00, reflected suicide precautions for Patient #1. Suicide assessment dated by nursing staff on 07/26/14, at 02:15, noted "none." Nursing Notes dated 07/26/14, noted that at 05:40, Patient #1 was found on the floor of his patient room. He was "unconscious with long elastic bandage around [his] neck ...not breathing ..." Periorbital edema (swelling around eyes) and a "small amount of blood" were noted in the patient's mouth. The patient had "superficial abrasions" around his neck. ED Physician Record dated 07/26/14, at 06:30, noted Patient #1 presented with "self-strangulation..." from the hospital's behavioral health center. The patient was "...unconscious with difficulty breathing...was emergently intubated on arrival for respiratory distress and airway protection...blood pressure was 184/110 mmHg...in severe distress...ill-appearing." Diagnoses included Asphyxiation and Strangulation, Suicide Attempt, Hypoxic Brain Injury, and Respiratory Failure. Hospital Employee #5 stated on 10/09/14, at 14:45, she "did not think ...[Patient #1] was actively suicidal and didn't impress me as a major threat" during the patient admission. 2) Patient #8's admission orders dated 09/22/14, at 16:50, reflected the patient was on suicide precautions and had potential for self-harm. Nursing Notes dated 09/22/14, at 20:50, noted Patient #8 reported suicidal thoughts and planned to hang himself with a sheet. A Case Management Note dated 09/23/14, at 15:56, reflected the patient had been depressed for a very long time and wanted "to end it all." Nursing Notes dated 09/23/14, at 18:20, reflected a nursing technician found Patient #8 with a bed sheet wrapped around his neck. The bed sheet was knotted on top of the door. Patient #8 stated he wanted to hang himself with the sheet. Hospital Employee #13 stated during an interview on 10/09/14, at 14:00, she saw a knotted sheet outside the closed patient door and had to push her way into the room because the patient partially blocked the door. With the help from another nurse, Hospital Employee #13 was able to untie the knots and remove the sheet. The patient had trouble breathing after the incident. Hospital Employee #13 denied awareness of Patient #8's suicidal intention prior to the incident. Hospital Nursing Policy BHC V.5 dated 07/2013 was titled Self Harm/Suicide Prevention and reflected "...high risk for self harm patients will be identified by ongoing evaluation from admission to discharge. Safe guards will be implemented to protect and intervene with high risk individuals." |
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| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on records review, interviews, and observations, the hospital failed to ensure that patients received care in a safe environment for 1 of 12 patients (Patient #8). 1) Although staff was aware of Patient #8's history of self-harm behavior at a previous inpatient facility and the patient displayed suicide warning signs during his first 24 hours of inpatient treatment, staff failed to put safety measures in place on 09/23/14 which could have prevented the patient from slinging a knotted sheet over the door to his room and tying it around his neck. The patient had breathing difficulties after the incident. 2) Items that could be used for self-harm were readily accessible for patient's use on 10/08/14. Twenty-four (24) hours after the initial observation, these items were still accessible to patients in spite of administration's commitment to remove them after they were identified by the surveyor. Based on record review, interviews, and observation, it was determined that the deficient practices found posed an immediate jeopardy to the heath and safety of patients that had the likelihood to cause harm. Cross refer to A0144 |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on records review, interviews and observations, the hospital failed to provide care in a safe clinical environment for 1 of 12 patients (Patient #8). 1) On 09/23/14, staff failed to put safety measures in place for Patient #8 that could have prevented the suicidal intent of tying a knotted sheet around his neck and resulted in breathing problems after, although Patient #8 had reported to staff the intentions to use a sheet to commit suicide by hanging less than 24 hours earlier. 2) Items identified during initial observation on 10/08/14, that could be used by patients to carry out self-harm were still readily accessible to patients more than 24 hours later on 10/09/14. Findings included: 1) Patient #8's admission orders dated 09/22/14, at 16:50, reflected the patient was on suicide precautions and had potential for self-harm. Nursing Notes dated 09/22/14, at 20:50, noted Patient #8 reported suicidal thoughts and planned to hang himself with a sheet. Case Management Note dated 09/23/14, at 15:56, reflected the patient had been depressed for a very long time and wanted "to end it all." Nursing Note dated 09/23/14, at 18:20, reflected a nursing technician found Patient #8 with a bed sheet wrapped around his neck. The bed sheet was knotted on top of the door. Patient #8 stated he wanted to hang himself with the sheet. On 10/09/14, at 11:07, Hospital Employee #11 was interviewed about the incident and stated she had been notified of the incident but the patient "was attention seeking." Hospital Employee #11 denied awareness of Patient #8's suicidal thoughts prior to the incident. On 10/09/14, at 13:00, Hospital Personnel #1 was asked about the incident and stated, "Nothing was done about it yet." Hospital Employee #13 stated during an interview on 10/09/14, at 14:00, she saw a knotted sheet outside the closed patient door and had to push her way into the room because the patient partially blocked the door. With the help from another nurse, Hospital Employee #13 was able to untie the knots and remove the sheet. The patient had trouble breathing after the incident. Hospital Employee #13 denied awareness of Patient #8's suicidal intention prior to the incident. Hospital Policy BHC V.5 titled Self harm/Suicide Prevention, dated 07/2013, reflected that staff members were to review suicide prevention education sheets. The hospital provided Suicide Awareness pamphlet, undated, noted that suicide warning signs included talking about suicide or death, or "ending it all." 2) A two-drawer cabinet filled with multiple compact discs (CDs), digital video discs (DVDs), and video tapes breakable into sharp edges was observed accessible to a female patient who was by herself in the dayroom in the hospital's PCU (Progressive Care Unit) on 10/08/14 at 14:50. Staff members were behind the nurses' station. Hospital Personnel #2 acknowledged on 10/08/14, at 14:50, that CDs and DVDs could be used for self-harm and would be removed. On 10/09/14, at 16:55, the same two drawers were observed again with CDs, DVDs, and video tapes. Hospital Personnel #2 witnessed the items at that time and stated she had delegated the task of removing the items the day before and it did not get done. On 10/09/14, at 15:30, Hospital Personnel #5 was asked whether she was worried about patient safety and stated, "Yes, because staff stays behind the nurses' station." |
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| VIOLATION: QAPI | Tag No: A0263 | |
| Based on records review and interviews, the hospital failed to maintain an effective, ongoing, data driven assessment and performance improvement program. Although the hospital had implemented an action plan correcting conditions on the patient units after Patient #1's incident of strangulation and asphyxiation 07/26/14, Patient #8's incident of self-injurious behavior of hanging himself with a sheet in his patient room on 09/23/14 remained uninvestigated up to the time of survey on 10/09/14. Cross refer to A0283. Based on record review and interviews, it was determined that the deficient practices found posed an immediate jeopardy to the health and safety of patients that had the likelihood to cause harm. |
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| VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES | Tag No: A0283 | |
| Based on records review and interviews, the hospital failed to set priorities for its performance improvement activities in that Patient #8's incident of self-harming behavior on 09/23/14, fifteen days prior to the survey, was not investigated and identified as an opportunity for improvement. Findings included: Patient #8's admission orders dated 09/22/14, at 16:50, reflected the patient was on suicide precautions and had potential for self-harm. Nursing Note dated 09/23/14, at 18:20, reflected a nursing technician found Patient #8 with a bed sheet wrapped around his neck. The bed sheet was knotted on top of the door. Patient #8 stated he wanted to hang himself with the sheet. Hospital Employee #3 acknowledged the incident on 10/09/14, at 09:45, and stated there was no review meeting after the incident. On 10/09/14, at 13:00, Hospital Personnel #1 was asked about the incident and stated, "Nothing was done about it yet" and she "did not get anything for a week." Hospital Personnel #1 stated she watched the surveillance tape of the incident and stated the tape was not available any longer. Hospital Employee #13 stated during an interview on 10/09/14, at 14:00, she was able to untie the knots and remove the sheet from Patient #8's neck. The patient had trouble breathing. The employee denied meeting with administration after the incident. Hospital Employee Physician #9 denied awareness of the incident during an interview on 10/09/14 at 12:45. An Organization Plan of Action Risk Reduction Strategies document dated 07/26/14 after Patient #1's attempt of self-strangualtion and asphyxiation reflected an ongoing action plan at the time of Patient #8's incident on 09/23/14. |
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