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.

HICKORY TRAIL HOSPITAL 2000 N OLD HICKORY TRAIL DESOTO, TX Jan. 9, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital.

A) The Medical Staff failed to protect and promote patient rights for 1 of 1 patient (Patient #5). Patient #5 was voluntarily admitted to the hospital. Patient #5 signed a four hour letter to be discharged and was informed OPC (Order of Protective Custody) paperwork was filed. The hospital failed to file the OPC paperwork and held Patient #5 without legal documentation.

B) The hospital failed to ensure that patient grievances were investigated and the results, date of completion and the steps taken on behalf of the patients were followed for 6 of 6 patients (Patient #1, #3, #25, #26, #27 and Patient #43).

Findings include:

A) Patient #5 was a voluntary patient who signed a four hour letter to be discharged . The physician wrote an order to OPC Patient #5. The OPC paperwork was not filed with the court and Patient #5 remained in the hospital until transferred to Hospital B on 09/12/12. (Cross Refer to A0049 and A0115)

B) Patient grievances were not investigated for Patients #1, #3, #25, #26, #27 and Patient #43. (Cross Refer to A0123)
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interviews and records review, the Governing Body failed to ensure that medical staff provided quality of care for 1 of 1 patient (Patient #5). Patient #5 was voluntarily admitted to the hospital. Patient #5 signed a four hour letter to be discharged and was informed that OPC (Order of Protective Custody) paperwork was filed. The hospital failed to file the OPC paperwork and held Patient #5 without legal documentation and against her will.

Findings included:

The 09/07/12 medical history and physical examination reflected, "Patient #5 is a [AGE] year old female with history of major depressive disorder who was transferred from ......hospital for further evaluation and management of severe depression ......patient states she took 16 tablets of 10 mg (milligrams) of Ambien .....she was later sent to the ER (emergency room ) where she was treated with activated charcoal .......admits to being depressed......"

The physician Inpatient Admission Orders dated 09/07/12 timed at 14:30 PM reflected, "Voluntary status......close observation for suicide precautions......"

The request to discontinue treatment was signed and initiated by Patient #5 on 09/11/12 timed at 09:08 AM.

The 09/11/12 patient care flow sheet dated 09/11/12 timed at 09:00 AM reflected, "Requested to leave AMA (against medical advice) wrote four hour letter.......wants to go back to work before she gets fired.....notified ordered OPC......at 21:34 PM......pleasant but requesting to transfer to another facility......patient instructed to talk to......patient states Dr. not willing to cooperate.....will pass on in report......"

The physician psychiatric progress note dated 09/11/12 timed at 10:30 AM reflected, "Patient resistant to continue treatment.....signed 4 hour letter......treatment team concerned about patient's safety.....recommend OPC....."

The physician orders dated 09/11/12 timed at 10:30 AM reflected, "Start OPC....."

The physician orders dated 09/12/12 timed at 12:15 PM reflected, "Transfer to.......Hospital B........involuntary status under OPC......."

The 09/11/12 physician psychiatric note dated 09/11/12 timed at 10:30 AM reflected, "Patient resistant to continue treatment......signed 4 hour letter recommend OPC (order of protective custody)......."

The Patient Care Flow Sheet dated 09/12/12 timed at 20:30 PM reflected, "discharged to Hospital B.......no suicidal ideations..."

On 12/27/12 at 12:25 PM, Personnel #1 was interviewed. The surveyor asked Personnel #1 to review Patient #5's medical record. Personnel #1 stated he wrote an order to OPC (order of protective custody) Patient #5 after Patient #5 requested to be discharged on the morning of 09/11/12. Personnel #1 stated he felt Patient #5 needed to be OPC'd due to Patient #5's most recent second attempt of overdosing on medications. Personnel #1 reviewed the medical record and could not find any OPC paperwork. Personnel #1 stated Patient #5 was transferred the next day to Hospital B with the OPC in process. Personnel #1 was asked whether he signed the OPC paperwork. Personnel #1 stated he could not remember. Personnel #1 stated he thought the paperwork was completed when the patient was transferred to Hospital B. Personnel #1 validated that Patient #5's rights were violated when the OPC paperwork was not completed after Patient #5's written request to be discharged .

On 12/27/12 at 12:40 PM Personnel #11 was interviewed. Personnel #11 informed the surveyor she could not find any OPC paperwork which had been filed on Patient #5. Personnel #11 stated the paperwork obviously never made it to the chart and Patient #5 was transferred to the other hospital without it. On 12/27/12 at 02:01 PM Personnel #11 informed the surveyor she checked further into the missing OPC paperwork and said none was filed for Patient #5.

On 12/29/12 at 01:20 PM Personnel #7 was interviewed. Personnel #7 stated in October of 2012 the facility realized they did not have enough people who could notarize. Personnel #7 was asked by the surveyor if he was aware that Patient #5 was held without the legal documentation being completed. Personnel #7 stated "no" he was not aware of this event until it was brought to his attention by the surveyor.

On 01/03/12 at 01:00 PM Personnel #15 (Hospital B) was interviewed by telephone. Personnel #15 stated that Patient #5 was reported to be on an OPC (order of protective custody) upon transfer to Hospital B. Personnel #15 stated when Patient #5 arrived to Hospital B, there was no paperwork provided which indicated an OPC was in progress. Personnel #15 stated the situation was a "mess" as the physician orders were written with involuntary and then had to be changed to voluntary.

The Hospital packet which includes the Basic Rights for all Patients: reflected, "Voluntary Patients-Special Rights.....you have the right to be discharged from the hospital within four hours of requesting discharge.......three reasons why you would NOT be allowed to go.....third......you may be detained longer than four hours if your doctor has reason to believe you might meet the criteria for court-ordered services or emergency detention because......you are likely to cause serious harm to yourself......doctor must examine you in person within 24 hours of your filing the discharge request......you must be allowed to leave the hospital upon completion of the in-person examination unless your doctor confirms that you meet the criteria for court-ordered services and files an application for court-ordered services......even if an application for court-ordered services is filed, you cannot be detained at the hospital beyond 04:00 PM of the first business day following the in-person examination......the law is written to ensure that people who do not need treatment are not committed.......any person who intentionally causes or helps another person cause the unjust commitment of a person to a mental hospital is guilty of a crime punishable by a fine.......and/or imprisonment in county jail for up to one year......."

The Hospital Policy entitled, "Involuntary Admissions Obtaining an OPC Voluntary to Involuntary with a revision date of 10/2010: reflected, "Procedure for In-house initiated involuntary procedure...the patient requests to leave AMA (against medical advice) and the physician believes the patient is still an imminent risk to self .......once the physician has decided to request Court-Ordered Mental Health Services......court liaison is notified by the physician or unit staff.......application completed and notarized .......court liaison contacts the Mental Health Court...documents must be faxed before 02:00 PM......when the physician prepares the Certificate of Medical Examination......should remember these documents could very well be presented in court .......the physician must write or print legibly...the OPC is served to the patient at the hospital by Mental Health Constable usually within 24 hours of being issued......."

The Medical Staff Bylaws with a revision date of 11/30/2011 reflected, "The purposes of the Medical Staff are; to ensure...all patients receiving treatment from the Facility receive uniform quality patient care that is provided in a highly ethical manner...and report to and be accountable to the Governing Body......."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews and records review, it was determined that the Hospital failed to protect and promote patient rights.

A) Patient #5 was voluntarily admitted to the hospital. Patient #5 signed a four hour letter to be discharged and was informed that OPC (Order of Protective Custody) paperwork was filed. The hospital failed to file the OPC paperwork and held Patient #5 without legal documentation and against her will.

B) The Hospital failed to ensure patient grievances were investigated and the results and date of completion and the steps taken on behalf of the patient were followed for 6 of 6 patients (Patient #1, #3, #25, #26, #27 and Patient #43).

Findings included:

A) Patient #5 was a voluntary patient who signed a four hour letter to be discharged . The physician wrote an order to OPC Patient #5. The OPC paperwork was not filed with the court and Patient #5 remained in the Hospital until transferred to Hospital B on 09/12/12. (Cross Refer to A0116)

B) Patient grievances for (Patient #1, #3, #25, #26, #27 and Patient #43) hospitalized for psychiatric issues were not investigated. (Cross Refer to A0123)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interviews and records review, the hospital failed to ensure 1 of 1 patient (Patient #5's) rights were not violated and met the notice of rights requirements were met. Patient #5 was voluntarily admitted on [DATE]. Patient #5 signed a four hour letter 09/11/12 at 09:08 AM to be discharged and was informed OPC (Order of Protective Custody) paperwork was filed. The hospital failed to file the OPC paperwork and held Patient #5 without legal paperwork and against her will until she was transferred to Hospital B on 09/12/12.

Findings included:

A) The 09/07/12 medical history and physical examination reflected, "Patient #5 is a [AGE] year old female with history of major depressive disorder who was transferred from.......hospital for further evaluation and management of severe depression......patient states she took 16 tablets of 10 mg (milligrams) of Ambien......she was later sent to the ER (emergency room ) where she was treated with activated charcoal...admits to being depressed......"

The physician Inpatient Admission Orders dated 09/07/12 timed at 14:30 PM reflected, "Voluntary status......close observation for suicide precautions......"

The request to discontinue treatment was signed and initiated by Patient #5 on 09/11/12 timed at 09:08 AM.

The 09/11/12 patient care flow sheet dated 09/11/12 timed at 09:00 AM reflected, "Requested to leave AMA (against medical advice) wrote four hour letter......wants to go back to work before she gets fired......notified ordered OPC......at 21:34 PM......pleasant but requesting to transfer to another facility......patient instructed to talk to......patient states Dr. not willing to cooperate......will pass on in report......."

The physician psychiatric progress note dated 09/11/12 timed at 10:30 AM reflected, "Patient resistant to continue treatment.......signed 4 hour letter........treatment team concerned about patient's safety......recommend OPC......"

The physician orders dated 09/11/12 timed at 10:30 AM reflected, "Start OPC......"

The physician orders dated 09/12/12 timed at 12:15 PM reflected, "Transfer to......Hospital B.......involuntary status under OPC......"

The 09/11/12 physician psychiatric note dated 09/11/12 timed at 10:30 AM reflected, "Patient resistant to continue treatment.......signed 4 hour letter recommend OPC (order of protective custody)......."

The Patient Care Flow Sheet dated 09/12/12 timed at 20:30 PM reflected, "discharged to Hospital B........no suicidal ideations..."

On 12/27/12 at 12:25 PM, Personnel #1 was interviewed. The surveyor asked Personnel #1 to review Patient #5's medical record. Personnel #1 stated he wrote an order to OPC (order of protective custody) Patient #5 after Patient #5 requested to be discharged on the morning of 09/11/12. Personnel #1 stated he felt that Patient #5 needed to be OPC'd due to Patient #5's most recent second attempt of overdosing on medications. Personnel #1 reviewed the medical record and could not find any OPC paperwork. Personnel #1 stated Patient #5 was transferred the next day to Hospital B with the OPC in process. Personnel #1 was asked whether he signed the OPC paperwork. Personnel #1 stated he could not remember. Personnel #1 stated he thought the paperwork was completed when the patient was transferred to Hospital B. Personnel #1 validated that Patient #5's rights were violated when the OPC paperwork was not completed after Patient #5's written request to be discharged .

On 12/27/12 at 12:40 PM Personnel #11 was interviewed. Personnel #11 informed the surveyor she could not find any OPC paperwork which had been filed on Patient #5. Personnel #11 stated that the paperwork obviously never made it to the chart and Patient #5 was transferred to the other hospital without it. On 12/27/12 at 02:01 PM Personnel #11 informed the surveyor that she checked further into the missing OPC paperwork and said none was filed for Patient #5.

On 12/29/12 at 01:20 PM Personnel #7 was interviewed. Personnel #7 stated in October of 2012 that they realized the facility did not have enough people who could notarize. Personnel #7 was asked by the surveyor if he was aware Patient #5 was held without the legal documentation being completed. Personnel #7 stated "no" he was not aware of this event until it was brought to his attention by the surveyor.

On 01/03/12 at 01:00 PM Personnel #15 (Hospital B) was interviewed by telephone. Personnel #15 stated that Patient #5 was reported to be on an OPC (order of protective custody) upon transfer to Hospital B. Personnel #15 stated that when Patient #5 arrived to Hospital B, there was no OPC paperwork provided which indicated that an OPC was in progress.

The Hospital packet which included the Basic Rights for all Patients: reflected, "Voluntary Patients-Special Rights...you have the right to be discharged from the hospital within four hours of requesting discharge...three reasons why you would NOT be allowed to go...third...you may be detained longer that four hours if your doctor has reason to believe you might meet the criteria for court-ordered services or emergency detention because...you are likely to cause serious harm to yourself...doctor must examine you in person within 24 hours of your filing the discharge request...you must be allowed to leave the hospital upon completion of the in-person examination unless your doctor confirms that you meet the criteria for court-ordered services and files an application for court-ordered services...even if an application for court-ordered services is filed, you cannot be detained at the hospital beyond 04:00 PM of the first business day following the in-person examination...the law is written to ensure that people who do not need treatment are not committed...any person who intentionally causes or helps another person cause the unjust commitment of a person to a mental hospital is guilty of a crime punishable by a fine...and/or imprisonment in county jail for up to one year..."

The Hospital Policy entitled, "Involuntary Admissions Obtaining an OPC Voluntary to Involuntary with a revision date of 10/2010: reflected, "Procedure for In-house initiated involuntary procedure...the patient requests to leave AMA (against medical advice) and the physician believes the patient is still an imminent risk to self ...once the physician has decided to request Court-Ordered Mental Health Services...court liaison is notified by the physician or unit staff...application completed and notarized ...court liaison contacts the Mental Health Court...documents must be faxed before 02:00 PM...when the physician prepares the Certificate of Medical Examination...should remember these documents could very well be presented in court ...the physician must write or print legibly...the OPC is served to the patient at the hospital by Mental Health Constable usually within 24 hours of being issued..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interviews and records review, the hospital failed to ensure resolution/investigation of grievances and/or the results of the grievance process was completed for 6 of 6 patient grievances (Patient #1, #3, #25, #26, #27 and Patient #43).

Findings included:

1) Patient #1's Pre-Assessment Screening dated 09/01/12 reflected, "No thoughts of harming self...no thoughts of harming others...no overdose of medications...no harming self physically...no abuse of street drugs or prescription pills...no abuse of alcohol..."

On 12/28/12 at 10:42 AM Personnel #2 was interviewed. Personnel #2 stated she was asked to review a complaint from Patient #1. Personnel #2 stated that the complainant felt the intake assessor and the physician were rude, threatening and unprofessional. Personnel #2 was asked to provide the investigation and/or follow-up with the complainant. No follow-up information was provided other than a written termination for the intake assessor.

On 12/28/12 at 11:00 AM Personnel #8 was interviewed. Personnel #8 was asked what was done regarding the above complaint that the physician was rude and unprofessional. Personnel did not provide any further information which indicated the event was investigated.

On 01/08/12 at 09:00 AM Personnel #12 was interviewed by telephone. Personnel #12 stated he did not remember any hospital personnel contacting him regarding the above event.

2) Patient #3's Psychosocial Assessment update dated 09/04/12 reflected, "Patient is a step down from inpatient due to bipolar disorder, most episode depressed...willing to engage in treatment, absence of plan, intent, or means, physically active..."

The 09/21/12 progress note refected, "Patient reported she was not feeling up to coming as the sessions have been intense...will be at sessions 09/24/12..."

On 12/20/12 at approximately 01:23 PM Personnel #4 was interviewed. Personnel #4 was asked if Patient #3 filed a written and/or verbal complaint or grievance. Personnel #4 stated "No."

On 12/20/12 at approximately 07:00 PM, Patient #3 was interviewed by telephone. Patient #3 stated that she spoke with Personnel #4 and placed a written complaint under Personnel #4's door. Patient #3 stated that she informed Personnel #4 that a patient on the van was bothering her. Patient #3 stated that no follow-up was done by Personnel #4. Patient #3 further stated that one of the therapists was heavy handed during group and was very abrasive towards her. Patient #3 stated that Personnel #4 was aware of her complaint but did nothing to address it. Patient #3 stated she decided not to complete the outpatient program.

On 12/27/12 at 10:15 AM, Personnel #4 was interviewed. The surveyor asked Personnel #4 again whether a complaint and/or grievance was given to him by Patient #3. Personnel #4 stated that Patient #3 gave him a written complaint about the therapist being too intense. Personnel #4 stated that he spoke with Patient #3 and counseled the therapist. The surveyor requested the written complaint from Personnel #4 and/or any evidence which indicated that Patient #3's grievance was investigated and what was done to address Patient #3's grievance. Personnel #4 stated he had nothing to show the surveyor.

3) Patient #25's Discharge Summary dated 10/10/2012 timed at 11:00 AM reflected, "15 year old...depressive disorder, status post overdose...treatment progress...initially guarded and seemed to be very anxious...responded well to treatment...participated in group therapy and milieu therapy..."

The Patient or Family Grievance/Complaint Form dated 10/09/11 timed at 03:11 PM reflected, "See summary of incident (attachment) assault...primary concern if for safety of..., but other inpatient members...why was this incident not disclosed to me by...staff...(attachment)...at 01:30 PM I was in my room...packing...(two peers) came in shoved me into my closet...I was knocked down...punched in the chin and neck/chest...staff came in and got them out..."

On 01/09/12 at 10:51 AM Personnel #3 was asked to review the above complaint/grievance. Personnel #3 stated that she had no further information on this event. Personnel #3 stated that the person previously responsible for investigating complaints left many of them blank and did not investigate the concern and/or follow-up with the complainant.

4) Patient #26's medical history and physical dated 10/22/12 timed 18:48 PM reflected, "Patient is a [AGE] year old with MDD (Major Depressive Disorder)...states she overdosed on multiple doses of Xanax....apparent suicide attempt..."

The Patient or Family Grievance/Complaint Form dated 10/26/12 timed at 03:28 PM reflected, "I was a patient of Dr...his comments were hurtful...expressed I was feeling better and needed to go back to work...due to financial reasons...his comment was "if you had succeeded in killing yourself you would not be going to work...asked about my rights to sign myself out because I came in voluntary...he said he would hold me for two weeks until the court hearing..."

The above document had no entries which indicated the patient advocate investigated the event and/or any corrective action was taken.

5) Patient #27's Psychiatric Evaluation dated 10/19/12 timed at 08:10 AM reflected, "[AGE] year old with a history of mood disorder, attention deficit disorder...increasingly disruptive and labile..."

The Patient or Family Grievance/Complaint Form dated 10/22/12 reflected, "I'm not satisfied with the behavioral and psychology needs that are being provided...another patient's medications were accessible to patient .....informed to give to another patient...when leaving 10/22/12...he was banging his head on the wall...kept saying it was not his fault...I want answers..." Handwritten in on the front of the document was "forward to Personnel #5."

On 12/20/12 at approximately 12:10 PM Personnel #5 was asked to provide the surveyor the investigation completed for the above event. Personnel #5 stated no further information was available.

6) Patient #43's Integrated Psychiatric assessment dated [DATE] timed at 15:53 PM reflected, "Patient presented as a [AGE] year old with depression because of work...patient was in the hospital due to harassment at work...anxiety is starting to affect her memory and she cannot focus..."

The Patient or Family Grievance/Complaint Form dated 10/11/12 written by Patient #43 reflected, "I kept asking the workers for a referral for a therapist that I could start going to see for stress and anxiety from work...I was asked if I felt like harming anyone, my reply was no...yet and still these people at...hospital still kept me against my will overnight...nurse was rude...not allow me to call my work...I was spoken to disrespectfully...I was threatened...kept against my will...I could not believe what was happening, that a person could come into a place for a referral and end up being held against their will...I felt so humiliated and belittled..."

On 12/20/12 at approximately 12:15 PM Personnel #5 stated that Patient #43's written grievance had not been investigated. Personnel #5 said no documentation from any hospital personnel was written.

The policy entitled, "Patient Family Grievance Process" with a review date of 06/2012 reflected, "Patients and their Families should have reasonable expectations of care and services...patient grievance is a written or verbal complaint...complaints documented...shall be addressed within 7 days or as soon after 7 days as possible...if the grievance is such that a resolution cannot be completed within 7 days....patient shall be informed in writing of the status...final resolution of all complaints will occur within 30 days and the complainant shall receive a written response including the review of the complaint, the outcome of the review and specific corrective actions taken...."