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.

RUSK STATE HOSP 805 N DICKINSON DR RUSK, TX 75785 June 22, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon record review and interview, the governing body failed to


A. ensure a safe and secure environment of care. One (1) of 1 (#7) employee brought a loaded handgun to the workplace and carried the weapon into a patient's room. While employee #7 was in the patient's room, patient #1 obtained the handgun and carried the loaded handgun on his person for an undetermined amount of time throughout the unit.

B. ensure compliance with their own policy titled "Safety Plan, Workplace Violence - " Handguns and Other Weapons."

C. develop and implement patient safety policies related to possession of handguns or weapons by employees, patients, or visitors in patient care areas.

Refer to TAG A0144
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon record review and interview, the facility failed to


A. ensure a safe and secure environment of care. One (1) of 1 (#7)employee brought a loaded handgun to the workplace and carried the weapon into a patient's room. While employee #7 was in the patient's room, patient #1 obtained the handgun and carried the loaded handgun on his person for an undetermined amount of time throughout the unit.
B. ensure compliance with their own policy titled "Safety Plan, Workplace Violence - " Handguns and Other Weapons " .
C. develop and implement patient safety policies related to possession of handguns or weapons by employees, patients, or visitors in patient care areas.

Refer to TAG A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based upon record review and interview, the facility failed to provide a safe and secure environment of care. One (1) of 1 (#7)employee brought a loaded handgun to the workplace and carried the weapon into a patient's room. While employee #7 was in the patient ' s room, patient #1 obtained the handgun and carried the loaded handgun on his person for an undetermined amount of time throughout the unit. The facility failed to ensure compliance with their own policy titled "Safety Plan, Workplace Violence - " Handguns and Other Weapons " . The facility also failed to develop and implement patient safety policies related to possession of handguns or weapons by employees, patients, or visitors in patient care areas.
This deficient practice had the likelihood to affect the safety and security of all patients.

A review of a document provided by the facility revealed an incomplete timeline of events that occurred on or about 6/15/16, that lead to a patient having possession of a loaded handgun. The document was an attempt by the facility to establish a timeline after the facility reviewed surveillance videos. The time line does not establish when staff #7 entered the patient's room (dorm 104) with the loaded handgun. The timeline also does not establish when patient #1 took possession of the loaded gun.

4:46 a.m. Patient #1 exits his dorm room (dorm 104) and goes to the nurses' station then to the dayroom at 4:50 a.m.

4:57 a.m. Patient #1 re-enters his dorm room (dorm 104).

5:02:05 a.m. Patient #1 leaves his dorm room (dorm 104).

5:17:04 a.m. Employee, Staff #7, PNA (Patient Nurse Assistant), exits dorm 104 and locks the door so no other patients can enter.

5:17:32 a.m. Employee, Staff #7, PNA, enters nurses' station.

5:25 a.m. An employee enters dorm 104 carrying what appears to be linens and leaves them in the dorm, no other employee or patient enters. The employee leaves the dorm and door is locked so that patients cannot enter.

6:06 a.m. Patient #1 walks up to the nurses' station door and stands there for a couple of minutes. The staff are busy doing other things, RN is on the phone, and PNA is over doing something by the water machine.

6:08 a.m. PNA staff #8 walks over to the desk by the door and the patient says "Here, Here, I've got something for you" and holds out the gun. The PNA asks the patient "What you got there?" and that is when the RN, staff #9, walks over and sees the patient has a gun and tells him she needs to get a bag. Staff #9 gets what appears to be a white washcloth and the patient lays it on the washcloth. Staff #9 walks to the back of the nurses' station and lays the gun on the desk and picks up the phone and begins calling people. Security begins to arrive shortly after this. The employees that arrive are the following: security staff #10, security staff #11, security staff #12 and security staff #13.

6:23 a.m. Employee, staff #7, PNA, calls the nurses station and speaks to staff #15,
Nurse Manager, and tells her he thinks he forgot something on the ward. Staff #15 tells him that they found it and that he needs to come back up to the hospital.

6:30 a.m. Security #14 arrives in the nurses' station and labels the bag.

This statement was written at the bottom of the timeline. There was no signature to indicate who made this statement: "I wanted to let you know we watched the video and made sure that the patient did not enter the dorm room again after he left the room at 5:02 a.m. to when he turned the gun over to staff at 6:08 a.m. The patient was in the dayroom and from what I could see on the video he never took the gun out of his pocket until he walked up to the nurses station and turned it over to the staff. "

The timeline did not establish when staff #7 entered the dorm 104 and/or if this is when the gun came into the possession of patient #1.

A review of patient #1's clinical record revealed, the patient was admitted to the facility on on a 46B (Incompetent to stand trial) with an admission type of Competency Restoration. The pending charge was aggravated assault with a deadly weapon.

Review of the facility policy titled "Safety Plan, Workplace Violence - Handguns and other Weapons " revealed a policy that addressed "maintaining a safe, healthy and productive working environment." This policy addressed the safety of the employee in the workplace.
On page 5 of 6 of this policy, a section was found that was titled "C. Handguns and Other Weapons. The following statement was embedded in this section:
C. 9.b. " Employees licensed to carry a handgun are prohibited from carrying their handgun (concealed or openly) at a DSHS State Hospital " .
Review of hospital policies revealed the facility had no patient safety policies related to possession of handguns or weapons by employees, patients, or visitors.
An interview on 6/22/2016 at approximately 1:00 pm with staff #6 (interviewee) in the Superintendent's Conference Room confirmed an employee brought a loaded handgun to the work place and carried the weapon into a patient's room. The hand gun was left in the patient's room. The patient #1 found the gun and carried the loaded gun on his person for an undetermined amount of time. The patient eventually turned the hand gun to the nurses at the nurses' station. The interviewee confirmed staff #7 had no signed documentation that staff member had received the mandatory education on the handgun policy that was made available to managers in May to educate the employees. The interviewee was unable to provide the percentage of completion and/or provide an expected completion date for the education. The interviewee confirmed there had not been an investigation by the facility related to this incident. No staff had been interviewed, Patient #1 had not been interviewed, and the facility had not notified the police department regarding this incident. An investigation was being conducted by the Office of Inspector General (OIG) to address criminal ramifications of the case but the facility had not investigated the incident to develop and implement a plan to ensure patient safety was maintained.

This deficient practice was determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of the likelihood of harm, serious injury, and possibly subsequent death.