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.

TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD PO BOX 151489 DALLAS, TX Dec. 21, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews and records review, the hospital failed to ensure that a safe environment was provided for 1 (Patient #2) of 13 inpatients who required inpatient services as evidenced by the following:

Patient #1 demonstrated psychotic and agitated behavior upon admission and physically assaulted two hospital staff (Personnel #11 and #12). During the assault, hospital staff (Personnel #9 and #10) barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the assaultive behavior of Patient #1. Patient #1 went into Patient #2's room at 01:10 AM on 12/08/2011 and proceeded to stepped on Patient #2's head repeatedly until Patient #2 became unresponsive. Patient #2 sustained head injuries which required transfer and admission to an acute care hospital on the morning of 12/08/11.

This practice placed the health and safety of the 13 inpatients in Immediate Jeopardy.

Cross refer to Tag 0144 and 0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records review, the facility failed to ensure a safe environment for 1 (Patient #2) of 13 inpatients who resided on the Adult North Unit.

Patient #1 demonstrated psychotic and agitated behavior upon admission and physically assaulted two hospital staff (Personnel #11 and #12). During the assault, hospital staff (Personnel #9 and #10) barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the assaultive behavior of Patient #1.

Patient #1 went into Patient #2's room and proceeded to step on Patient #2's head repeatedly until Patient #2 became unresponsive. Patient #2 sustained head injuries which required transfer and admission to an acute care hospital on the morning of 12/08/11.

This practice placed all of the 13 inpatients' health and safety in Immediate Jeopardy.

Findings Included:

1) Patient #1's demographic profile with a print date of 12/07/11 reflected, "Patient #1 was a [AGE] year old disabled male admitted on [DATE] timed at 18:24 PM..."

The Pre-assessment screening form dated 12/07/11 reflected, "loxapine 50 mg (milligrams) at bedtime, Xanax 2 mg three times a day, hydrocodone 5 mg 4-6 times a day...not been taking medications since I left hospital around 11/01..." The document was not signed by the patient nor the physician and/or the admission staff under the signature section of the document.

The Integrated assessment dated [DATE] timed at 18:00 PM reflected, "Patient dropped off by ambulance from group home...I see Lucifer, devil, demons...I've been off my meds (medications) they were at my mothers birth, they want me to sell my soul to the devil...they have long horns, you didn't (did not) see what I see...I saw the holy grail...increased agitation, increased anxious...history of psychosis...I don't (do not) care about life or death anymore...paranoid ideation, history of schizophrenia or bipolar disorder, severe anxiety/panic, rapid mood shifts, severe insomnia, loose associations, flight of ideas, obsessions, auditory/visual hallucinations..." The document was signed by the social worker on 12/07/11 at 18:05 PM and the physician on 12/07/11 at 2000.

Patient #1's High Risk Notification Alert form dated 12/07/11 reflected, "Psychosis...elopement...agitation..."

The physician's orders dated 12/07/11 timed at 18:00 PM reflected, "Admit to AP (Adult Psychiatric) unit." No orders for medication were written at this time.

The 12/07/11 multidisciplinary note timed at 19:00 PM reflected, "A [AGE] year old white male with psychosis admitted ...patient has been off meds (medications) came from group home...delusional, agitated, auditory hallucinations...seeing Lucifer the devil and demons.."

The Physician Psychiatric Evaluation dated 12/07/11 timed at 21:00 PM reflected, "Patient #1 acutely psychotic...they have long horns, agitated, delusional, wandering, pacing on the unit...allergies Haldol, Prolixin, Buspar, Zoloft, Depakote and Lithium...uncooperative, irritable, labile, speech rapid, flight of ideas, tangential, loose associations...judgement and insight poor..."

The physician orders dated 12/07/11 timed at 21:00 PM reflected, "Psychosis...precautions EP's (elopement precautions)...medications loxitane 50 mg at HS (hour of sleep), Xanax 2 mg (milligrams) po (by mouth) now..."

The 12/07/11 Restraint/Seclusion Order/Record timed at 23:00 PM reflected, "Physical restraint, emergency medication...danger to others...maximum time restrained 8 minutes...behaviors cursing, yelling, uncooperative, jumping and running around in the unit...verbal de-escalation/redirection, 1:1 processing...refused medication...patient agreed to calm down...at 23:05 PM IM (Intramuscular) Ativan 2 mg, IM Benadryl 50 mg...medication effective patient calmed down..." The evening nurse signed the document at 23:08 PM and the physician signed the document at 00:05 AM.

The 12/07/11 multidisciplinary note timed at 23:30 PM reflected, "Pt (patient) agitated rapid pressured speech, psychotic. Pt refusing to take meds ordered by doctor. Cursing and yelling at staff needing frequent redirection. Dr. (Doctor) notified. Emergency meds (medications) given IM (Intramuscular) Ativan and Benadryl 50 mg given at 22:50 PM..."

The Restraint/Seclusion Order/Record dated 12/08/11 timed at 01:30 AM reflected, "Physical restraint, danger to others...patient beat up staff and other peer. Patient was stomping peers head...patient to calm down...medication given "no."


2) Patient #2's demographic profile with a print date of 11/26/11 reflected, "Patient #2, a [AGE] year old female was admitted [DATE]..."

The physician's orders dated 12/08/11 timed at 01:15 AM reflected, "Pt (patient) transferred to...ER (emergency room ) for evaluation of head injury..."

The 12/08/11 multidisciplinary note timed at 01:10 AM reflected, " MHT (Mental Health Technician) entered pt (patient) room at 01:10 AM finding Patient #2 on the floor being kicked in the head by male pt. Male pt subdued in room while RN (Registered Nurse) evaluated pt's injury. 911 and Dr...called. Pt vitals were (B/P) 207/96, P (Pulse) 63, R (Respirations) 14 labored. Neurological check found pt to be verbally unresponsive ...however, pt was able to turn to side for continued evaluation. Orientation x (times) 0 (zero)...body assessment done,injuries contained to head. Pt was bleeding from mouth and blood found on cheek close to eye. EMS (emergency medical system) arrived at 01:13 AM on unit."

The acute care hospital's Trauma Admission History and Physical dated 12/08/11 reflected, "[AGE] year old female found down in room...states she was assaulted by fists...complains of pain...not alert...right pupil 3 mm (millimeters) reactive...left 4 mm reactive...laceration to left eye and left cheek...left frontal scalp hematoma, intraventricular blood, partially calcified mass...diffuse cerebral edema..."

On 12/16/11 at 12:00 PM (Personnel #10) was interviewed. (Personnel #10) stated she arrived for the 11-7 shift and observed Patient #1 sitting in a chair nodding off. Patient #1 suddenly bolted and went to a female patient's room. (Personnel #10) stated (Personnel #11) went after Patient #1. Patient #1 began pushing, hitting and swinging at (Personnel #11). (Personnel #11) backed into the hall and Patient #1 chased (Personnel #10, #11 and #9) towards the nursing station where they remained during the crisis. (Personnel #12 and #11) remained out on the unit with Patient #1. (Personnel #10) stated Patient #1 continued to hit, kick and punch (Personnel #11 and #12). (Personnel #11 and #12) made it into the nursing station. (Personnel #12) then wedged himself against the door after Patient #1 broke the nursing station door. (Personnel #10) stated she went into the medication room and heard Patient #1 was in another patient's room. (Personnel #10) stated when she went to Patient #2's room (Personnel #14) was holding Patient #1 down on the bed and Patient #2 was bleeding on the floor. (Personnel #10) said Patient #2 did not respond verbally and was sent to the ER (emergency room ).

(Personnel #10) was asked by the surveyor why the staff barricaded themselves in the nursing station leaving the other patients on the unit in harms way. (Personnel #10) stated she was afraid of the patient and guessed the staff did not protect the other patients on the unit.

On 12/16/11 at 12:15 PM (Personnel #9) was interviewed. (Personnel #9) stated when she arrived for the 11-7 shift on 12/07/11 she saw Patient #1 came to the lounge carrying clothes and wearing only boxers. (Personnel #11) provided Patient #1 a hospital gown to wear. Patient #1 sat down in the lounge and started nodding off to sleep. Patient #1 then suddenly bolted and went to a female patient's room. (Personnel #9) stated (Personnel #10 and #11) went after the patient. (Personnel #11) made it to the room first. Patient #1 began attacking (Personnel #11). (Personnel #11) backed out of the room into the hall. (Personnel #12) came to help. (Personnel #9 and #10) went to the nursing station. Patient #1 was kicking and hitting (Personnel #11 and #12) out on the unit. The two staff came into the nursing station and the door was closed. Patient #1 broke the door to the nursing station and (Personnel #12 and #13) wedged themselves against the door so Patient #1 could not come into the nursing station. (Personnel #9) stated Patient #1 did assault Patient #2 while in her room.

(Personnel #9) was asked how the hospital staff ensured the patients on the unit were safe. (Personnel #9) stated the unit staff could not handle Patient #1 and she was afraid of the patient.

On 12/16/11 at 3:30 PM (Personnel #2) was interviewed. (Personnel #2) stated Patient #1 was agitated when he arrived on the unit. She stated she asked the intake staff if the physician had written any medication orders. (Personnel #2) said the intake staff told her the nursing staff would have to call the physician. (Personnel #2) stated she called the physician several times for medication for Patient #1. (Personnel #2) said the physician finally came up to the unit at 21:00 PM, and wrote orders for po (by mouth) medications.

On 12/16/11 at 7:40 PM (Personnel #27) was interviewed. (Personnel #27) stated Patient #1 was seen in the lobby of the screening area. (Personnel #27) said when she went out to the desk she saw the ambulance paper work and read the patient's name off. She stated a woman in the lobby area who was waiting was filling out the pre-assessment form for Patient #1. (Personnel #27) stated the physician briefly spoke to Patient #1. (Personnel #27) stated Patient #1 was extremely agitated and was scaring the people sitting in the lobby. She stated the physician wrote orders to admit to the adult psychiatric unit. She stated the patient needed to get on the unit right away. (Personnel #27) stated she did not sign the pre-admit assessment and validated the document was to be signed by her and the physician.

On 12/16/11 at approximately 8:30 PM (Personnel #12) was interviewed. (Personnel #12) stated he was assigned to the south unit and he began doing rounds. He stated he heard (Personnel #9) holler his name and he ran towards the nursing station. He stated as he was running (Personnel #9) ran into the nursing station. (Personnel #12) said he saw Patient #1 running/swinging at (Personnel #11). Patient #1 was punching and hitting at (Personnel #11) when (Personnel #11) fell down. Patient #1 kicked and punched (Personnel #11) in the head. (Personnel #12) said he attempted to intervene and grab the patient. (Personnel #12) stated (Personnel #11) was bleeding. (Personnel #12) said Patient #1 hit him in the head.

(Personnel #12) stated (Personnel #9 and #10) left them out on the unit alone with no assistance and left the other patients on the unit to fend for themselves.

On 12/18/11 at 6:22 PM (Personnel #11) was interviewed. (Personnel #11) stated Patient #1 was agitated and had rage in his eyes. (Personnel #11) said he did the best he could to contain Patient #1 but needed assistance from the other staff on the unit at the time. He stated he felt alone and the nurses did nothing. (Personnel #11) stated all the staff had been trained on how to handle aggressive patients.

(Personnel #11) stated the nurses just stood by and watched them get beat up. (Personnel #11) stated the patient had already attempted to go into a different female patient's room earlier. (Personnel #11) stated it was an unsafe environment for the staff and the patients.

On 12/19/11 at 12:15 AM (Personnel #14) was interviewed. (Personnel #14) stated he was working the 11-7 AM shift on the night of 12/07/11 and 12/08/11. (Personnel #14) stated (Personnel #15) called him to go to the....building north side adult unit. He stated he saw (Personnel #9 and #10) on the south side. (Personnel #14) said he heard loud talking in one of the patient's rooms. Patient #1 was in the room he jumped towards me so I backed up to find out what was going on and why I was needed on the unit. I heard a thump and went into the door of the room, a female was on the floor and Patient #1 was kicking the patient in the head, blood was everywhere. The patient saw me and struck me a couple of times. (Personnel #14) stated he wrapped Patient #1 with his arms and he and Patient #1 fell on top of the bed. (Personnel #14) stated he used his leverage to hold Patient #1 down on the bed. (Personnel #14) stated he could hear the female patient (Patient #2) gurgling. He stated it seemed as if it was forever before anyone came. He stated he hollered for help and needed an ambulance for the female patient on the floor. (Personnel #14) said (Personnel #15) came down. He stated (Personnel #15) did not help hold Patient #1 but left to get (Personnel #13 and #17). He stated many of the patients were awake, upset and scared. He stated one of the patients yelled "Y'all let her get beat up." (Personnel #14) said all the staff were trained to get involved in a code and not barricade themselves in the nursing station.

On 12/19/11 at 12:40 AM (Personnel #15) was interviewed. (Personnel #15) stated she was on duty 12/07/11 11:00 PM to 07:00 AM on 12/08/11. (Personnel #15) stated she sent (Personnel #14) and a technician from another unit to help. (Personnel #17 and #15) ran upstairs to the unit. (Personnel #9, #10 and #13) were holding the nursing station door shut. (Personnel #11) was bleeding. (Personnel #15) stated she asked where (Personnel #14) was. No one knew. (Personnel #15) stated she heard someone calling for help. She stated she went to see and found (Personnel #14) holding Patient #1 down on the bed. (Personnel #13 and #17) responded and removed Patient #2 out of the room. (Personnel #15) said she returned to the nursing station to call the ambulance. She stated there were several patients out in the hall at the time.

On 12/20/11 at 11:40 AM (Personnel #8) was interviewed. (Personnel #8) stated admissions told him Patient #1 was too psychotic to be in the lobby of the assessment area. (Personnel #8) stated Patient #1 was sent directly to the unit. (Personnel #8) stated he found out later the ambulance had dumped him off and the patient did not see the physician. (Personnel #8) stated he arrived on the adult unit at 21:00 PM. He stated he received a call requesting emergent medication for Patient #1 after he left the unit. (Personnel #8) was asked if he saw Patient #1 while in the lobby of the assessment area. (Personnel #8) stated "no."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interviews and records review the hospital failed to ensure a safe environment free from physical abuse for 1 (Patient #2) of 13 inpatients who resided on the Adult North Unit.

Patient #1 demonstrated psychotic and agitated behavior upon admission and physically assaulted two hospital staff (Personnel #11 and #12) at which time hospital staff (Personnel #9 and #10) barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the assaultive behavior of Patient #1.

Patient #1 went into the room of Patient #2 and proceeded to assault her at 1:10 AM on 12/28/2012. Patient #1 stepped on Patient #2's head repeatedly until Patient #2 became unresponsive. Patient #2 sustained head injuries which required transfer and admission to an acute care hospital on the morning of 12/08/11.

This practice placed all of the 13 inpatients on the unit in an Immediate Jeopardy situation for high potential for injury.

Findings Included:

1) Patient #1's demographic profile with a print date of 12/07/11 reflected, "Patient #1 was a [AGE] year old disabled male admitted on [DATE] timed at 18:24 PM..."

The Pre-assessment screening form dated 12/07/11 reflected, "loxapine 50 mg (milligrams) at bedtime, Xanax 2 mg three times a day, hydrocodone 5 mg 4-6 times a day...not been taking medications since I left hospital around 11/01..." The document was not signed by the patient nor the physician and/or the admission staff under the signature section of the document.

The Integrated assessment dated [DATE] timed at 18:00 PM reflected, "Patient dropped off by ambulance from group home...I see Lucifer, devil, demons...I've been off my meds (medications) they were at my mothers birth, they want me to sell my soul to the devil...they have long horns, you didn't see what I see...I saw the holy grail...increased agitation, increased anxious...history of psychosis...I don't care about life or death anymore...paranoid ideation, history of schizophrenia or bipolar disorder, severe anxiety/panic, rapid mood shifts, severe insomnia, loose associations, flight of ideas, obsessions, auditory/visual hallucinations..." The document was signed by the social worker on 12/07/11 at 18:05 PM and the physician on 12/07/11 at 2000.

Patient #1's High Risk Notification Alert form dated 12/07/11 reflected, "Psychosis...elopement...agitation..."

The physician's orders dated 12/07/11 timed at 18:00 PM reflected, "Admit to AP (Adult Psychiatric) unit." No orders for medication were written at this time.

The 12/07/11 multidisciplinary note timed at 19:00 PM reflected, "A [AGE] year old white male with psychosis admitted ...patient has been off meds (medications) came from group home...delusional, agitated, auditory hallucinations...seeing Lucifer the devil and demons..."

The Physician Psychiatric Evaluation dated 12/07/11 timed at 21:00 PM reflected, "Patient #1 acutely psychotic...they have long horns, agitated, delusional, wandering, pacing on the unit...allergies Haldol, Prolixin, Buspar, Zoloft, Depakote and Lithium...uncooperative, irritable, labile, speech rapid, flight of ideas, tangential, loose associations...judgement and insight poor..."

The 12/07/11 Restraint/Seclusion Order/Record timed at 23:00 PM reflected, "Physical restraint, emergency medication...danger to others...maximum time restrained 8 minutes...behaviors cursing, yelling, uncooperative, jumping and running around in the unit...verbal de-escalation/redirection, 1:1 processing...refused medication...patient agreed to calm down...at 23:05 PM, IM (Intramuscular) Ativan 2 mg (Milligrams), IM Benadryl 50 mg...medication effective patient calmed down..." The evening nurse signed the document at 23:08 PM and the physician signed the document at 00:05 AM.

The 12/07/11 multidisciplinary note timed at 23:30 PM reflected, "Pt (patient) agitated rapid pressured speech, psychotic. Pt refusing to take meds ordered by doctor. Cursing and yelling at staff needing frequent redirection. Dr. (Doctor) notified. Emergency meds (medications) given IM (Intramuscular) Ativan and Benadryl 50 mg given at 22:50 PM..."

The Restraint/Seclusion Order/Record dated 12/08/11 timed at 01:30 AM reflected, "Physical restraint, danger to others...patient beat up staff and other peer. Patient was stomping peers head...patient to calm down...medication given "no."


2) Patient #2's demographic profile with a print date of 11/26/11 reflected, "Patient #2 a [AGE] year old female was admitted [DATE]..."

The physician's orders dated 12/08/11 timed at 01:15 AM reflected, "Pt (patient) transferred to...ER (emergency room ) for evaluation of head injury..."

The 12/08/11 multidisciplinary note timed at 01:10 AM reflected, " MHT (Mental Health Technician) entered pt (patient) room at 01:10 AM finding Patient #2 on the floor being kicked in the head by male pt. Male pt subdued in room while RN (Registered Nurse) evaluated pt's injury. 911 and Dr...called. Pt vitals were (B/P) 207/96, P (Pulse) 63, R (Respirations) 14 labored. Neurological check found pt to be verbally unresponsive...however, pt was able to turn to side for continued evaluation. Orientation x (times) 0 (zero)...body assessment done, injuries contained to head. Pt was bleeding from mouth and blood found on cheek close to eye. EMS (emergency medical system) arrived at 01:13 AM on unit. EMS assessed pt and transported off unit..."

The acute care hospital's Trauma Admission History and Physical dated 12/08/11 reflected, "[AGE] year old female found down in room...states she was assaulted by fists...complains of pain...not alert...right pupil 3 mm (millimeters) reactive...left 4 mm reactive...laceration to left eye and left cheek...left frontal scalp hematoma, intraventricular blood, partially calcified mass...diffuse cerebral edema..."

On 12/16/11 at 12:00 PM (Personnel #10) was interviewed. (Personnel #10) stated when she arrived for the 11-7 shift on 12/07/11 the evening shift was calling a silent code for Patient #1 to give him an injection. (Personnel #10) stated a little later she observed Patient #1 sitting in a chair nodding off. Patient #1 suddenly bolted and went to a female patient's room. (Personnel #10) stated (Personnel #11) went after Patient #1. Patient #1 began pushing, hitting and swinging at (Personnel #11). (Personnel #11) backed into the hall and Patient #1 chased (Personnel #10, #11 and #9) towards the nursing station where they remained during the crisis. (Personnel #12 and #11) remained out on the unit with Patient #1. (Personnel #10) stated Patient #1 continued to hit, kick and punch (Personnel #11 and #12). (Personnel #11 and #12) made it into the nursing station. (Personnel #12) then wedged himself against the door after Patient #1 broke the nursing station door. (Personnel #10) stated she went into the medication room and heard Patient #1 was in another patient's room. (Personnel #10) stated when she went to Patient #2's room (Personnel #14) was holding Patient #1 down on the bed and Patient #2 was bleeding on the floor. (Personnel #10) said Patient #2 did not respond verbally and was sent to the ER (emergency room ).

(Personnel #10) was asked by the surveyor why the staff barricaded themselves in the nursing station leaving the other patients on the unit in harms way. (Personnel #10) stated she was afraid of the patient and guessed the staff did not protect the other patients on the unit.

On 12/16/11 at 12:15 PM (Personnel #9) was interviewed. (Personnel #9) stated when she arrived for the 11-7 shift on 12/07/11 she was told in report that Patient #1 refused by mouth medications and required an injection. (Personnel #9) said Patient #1 came to the lounge carrying clothes and wearing only boxers. (Personnel #11) provided Patient #1 a hospital gown to wear. Patient #1 sat down in the lounge and started nodding off to sleep. Patient #1 then suddenly bolted and went to a female patient's room. (Personnel #9) stated (Personnel #10 and #11) went after the patient. (Personnel #11) made it to the room first. Patient #1 began attacking (Personnel #11). (Personnel #11) backed out of the room into the hall. (Personnel #12) came to help. (Personnel #9 and #10) went to the nursing station. The two staff came into the nursing station and the door was closed. Patient #1 broke the door to the nursing station and (Personnel #12 and #13) wedged themselves against the door so Patient #1 could not come into the nursing station. (Personnel #9) stated Patient #1 did assault Patient #2 while in her room.

(Personnel #9) was asked how the hospital staff ensured the patients on the unit were safe. (Personnel #9) stated the unit staff could not handle Patient #1 and she was afraid of the patient.

On 12/16/11 at 3:30 PM (Personnel #2) was interviewed. (Personnel #2) stated Patient #1 was agitated when he arrived on the unit. She stated she asked the intake staff if the physician had written any medication orders. (Personnel #2) said the intake staff told her the nursing staff would have to call the physician. (Personnel #2) stated she called the physician several times for medication for Patient #1. (Personnel #2) said the physician finally came up to the unit at 21:00 PM, and wrote orders for po (by mouth) medications.

On 12/16/11 at 7:40 PM (Personnel #27) was interviewed. (Personnel #27) stated Patient #1 was seen in the lobby of the screening area. (Personnel #27) said when she went out to the desk she saw the ambulance paper work and read the patient's name off. She stated a woman in the lobby area who was waiting was filling out the pre-assessment form for Patient #1. (Personnel #27) stated the physician briefly spoke to Patient #1. (Personnel #27) stated Patient #1 was extremely agitated and was scaring the people sitting in the lobby. She stated
the physician wrote orders to admit to the adult psychiatric unit. She stated the patient needed to get on the unit right away. (Personnel #27) stated she did not sign the pre-admit assessment and validated the document was to be signed by her and the physician.

On 12/16/11 at approximately 8:30 PM (Personnel #12) was interviewed. (Personnel #12) stated the patient received an injection at the change of shift and all the evening staff left after that. (Personnel #12) stated he was assigned to the south unit and he began doing rounds. He stated he heard (Personnel #9) holler his name and he ran towards the nursing station. He stated as he was running (Personnel #9) ran into the nursing station. (Personnel #12) said he saw Patient #1 running/swinging at (Personnel #11). Patient #1 was punching and hitting at (Personnel #11) when (Personnel #11) fell down. Patient #1 kicked and punched (Personnel #11) in the head. (Personnel #12) said he attempted to intervene and grab the patient.

(Personnel #12) stated (Personnel #9 and #10) left them out on the unit alone with no assistance and left the other patients on the unit to fend for themselves. (Personnel #12) stated he made it back to the nursing station along with (Personnel #11). Patient #1 then broke the nursing station door and he proceeded to hold the door shut along with (Personnel #13) who had come to the unit to help.

On 12/18/11 at 6:22 PM (Personnel #11) was interviewed. (Personnel #11) stated Patient #1 was agitated and had rage in his eyes. (Personnel #11) said he did the best he could to contain Patient #1 but needed assistance from the other staff on the unit at the time. He stated he felt alone and the nurses did nothing. (Personnel #11) stated all the staff had been trained on how to handle aggressive patients. (Personnel #11) stated the nurses just stood by and watched them get beat up. (Personnel #11) stated the patient had already attempted to go into a different female patient's room earlier.

(Personnel #11) stated it was an unsafe environment for the staff and the patients.

On 12/19/11 at 12:15 AM (Personnel #14) was interviewed. (Personnel #14) stated he was working the 11-7 AM shift on the night of 12/07/11 and 12/08/11. (Personnel #14) stated (Personnel #15) called him to go to the...building north side adult unit. He stated he saw (Personnel #9 and #10) on the south side. (Personnel #14) said he heard loud talking in one of the patient rooms. Patient #1 was in the room, he jumped towards me so I backed up to find out what was going on and why I was needed on the unit. I heard a thump and went into the door of the room, a female was on the floor and Patient #1 was kicking the patient in the head, blood was everywhere. The patient saw me and struck me a couple of times. (Personnel #14) stated he wrapped Patient #1 with his arms and both he and Patient #1 fell on top of the bed. (Personnel #14) stated he used his leverage to hold Patient #1 down on the bed. (Personnel #14) stated he could hear the female patient (Patient #2) gurgling. He stated it seemed as if it was forever before anyone came. He stated he hollered for help and needed an ambulance for the female patient on the floor. (Personnel #14) said (Personnel #15) came down. He stated (Personnel #15) did not help hold Patient #1 but left to get (Personnel #13 and #17). (Personnel #14) said the nurse and police came. He stated there seemed to be a problem finding some medications for Patient #1. (Personnel #14) stated he was left alone and he did not know the details of the problem on the unit when he arrived and what patient was involved. (Personnel #14) stated none of the staff were on the north side. He stated many of the patients were awake, upset and scared. He stated one of the patients yelled "Y'all let her get beat up." (Personnel #14) said all the staff were trained to get involved in a code not barricade themselves in the nursing station.

On 12/19/11 at 12:40 AM (Personnel #15) was interviewed. (Personnel #15) stated she was on duty 12/07/11 11:00 PM to 07:00 AM on 12/08/11. (Personnel #15) stated (Personnel #9) called her three times. She stated (Personnel #9) said we have a code. (Personnel #15) stated she sent (Personnel #14) and a technician from another unit. (Personnel #17 and #15) ran upstairs to the unit. (Personnel #9, #10 and #13) were holding the nursing station door shut. (Personnel #11) was bleeding. (Personnel #15) stated she asked where (Personnel #14) was. No one knew. (Personnel #15) stated she heard someone calling for help. She stated she went to see and found (Personnel #14) holding Patient #1 down on the bed. (Personnel #13 and #17) responded and removed Patient #2 out of the room. (Personnel #15) said she returned to the nursing station to call the ambulance.

On 12/20/11 at 11:40 AM (Personnel #8) was interviewed. (Personnel #8) stated admissions told him Patient #1 was too psychotic to be in the lobby of the assessment area. (Personnel #8) stated Patient #1 was sent directly to the unit. (Personnel #8) stated he found out later the ambulance had dumped him off and the patient did not see the physician. He stated he received a call requesting emergent medication for Patient #1 after he left the unit. (Personnel #8) stated he received no phone calls from the nurses prior to him coming on the unit. (Personnel #8) was asked if he saw Patient #1 while in the lobby of the assessment area. (Personnel #8) stated "no."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews and records review, the Governing Body (GB) failed to ensure that a safe environment was provided for 1 (Patient #2) of 13 inpatients who required inpatient services as evidenced by the following:

Patient #1 demonstrated psychotic and agitated behavior upon admission and physically assaulted two hospital staff (Personnel #11 and #12) at which time hospital staff (Personnel #9 and #10) barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the assaultive behavior of Patient #1.

Patient #1 went into Patient #2's room at 01:10 AM on 12/08/2011. Patient #1 proceeded to assault Patient #2 by stepping on her head repeatedly until she became unresponsive. Patient #2 sustained head injuries which required transfer and admission to an acute care hospital on the morning of 12/08/11.

This practice placed all of the 13 inpatients on the unit on Immediate Jeopardy for injury.

Cross refer to A 049
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 (GB) failed to ensure a safe environment for 1 (Patient #2) of 13 inpatients who resided on the Adult North Unit. Patient #1 demonstrated psychotic and agitated behavior upon admission and physically assaulted two hospital staff (Personnel #11 and #12) at which time hospital staff (Personnel #9 and #10) barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the assaultive behavior of Patient #1.

Patient #1 went into the room of Patient #2 and proceeded to assault her at 1:10 AM on 12/28/2012. Patient #1 stepped on Patient #2's head repeatedly until Patient #2 became unresponsive. Patient #2 sustained head injuries which required transfer and admission to an acute care hospital on the morning of 12/08/11.

This practice placed all of the 13 inpatients on the unit in an Immediate Jeopardy situation for high potential for injury.

Findings Included:

1) Patient #1's demographic profile with a print date of 12/07/11 reflected, "Patient #1 was a [AGE] year old disabled male admitted on [DATE] timed at 18:24 PM..."

The Pre-assessment screening form dated 12/07/11 reflected, "loxapine 50 mg (milligrams) at bedtime, Xanax 2 mg three times a day, hydrocodone 5 mg 4-6 times a day...not been taking medications since I left hospital around 11/01..." The document was not signed by the patient nor the physician and/or the admission staff under the signature section of the document.

The Integrated assessment dated [DATE] timed at 18:00 PM reflected, "Patient dropped off by ambulance from group home...I see Lucifer, devil, demons...I've been off my meds (medications) they were at my mothers birth, they want me to sell my soul to the devil...they have long horns, you didn't see what I see...I saw the holy grail...increased agitation, increased anxious...history of psychosis...I don't care about life or death anymore...paranoid ideation, history of schizophrenia or bipolar disorder, severe anxiety/panic, rapid mood shifts, severe insomnia, loose associations, flight of ideas, obsessions, auditory/visual hallucinations..." The document was signed by the social worker on 12/07/11 at 18:05 PM and the physician on 12/07/11 at 2000.

Patient #1's High Risk Notification Alert form dated 12/07/11 reflected, "Psychosis...elopement...agitation..."

The physician's orders dated 12/07/11 timed at 18:00 PM reflected, "Admit to AP (Adult Psychiatric) unit." No orders for medication were written at this time.

The 12/07/11 multidisciplinary note timed at 19:00 PM reflected, "A [AGE] year old white male with psychosis admitted ...patient has been off meds (medications) came from group home...delusional, agitated, auditory hallucinations...seeing Lucifer the devil and demons..."

The Physician Psychiatric Evaluation dated 12/07/11 timed at 21:00 PM reflected, "Patient #1 acutely psychotic...they have long horns, agitated, delusional, wandering, pacing on the unit...allergies Haldol, Prolixin, Buspar, Zoloft, Depakote and Lithium...uncooperative, irritable, labile, speech rapid, flight of ideas, tangential, loose associations...judgement and insight poor..."

The 12/07/11 Restraint/Seclusion Order/Record timed at 23:00 PM reflected, "Physical restraint, emergency medication...danger to others...maximum time restrained 8 minutes...behaviors cursing, yelling, uncooperative, jumping and running around in the unit...verbal de-escalation/redirection, 1:1 processing...refused medication...patient agreed to calm down...at 23:05 PM, IM (Intramuscular) Ativan 2 mg (Milligrams), IM Benadryl 50 mg...medication effective patient calmed down..." The evening nurse signed the document at 23:08 PM and the physician signed the document at 00:05 AM.

The 12/07/11 multidisciplinary note timed at 23:30 PM reflected, "Pt (patient) agitated rapid pressured speech, psychotic. Pt refusing to take meds ordered by doctor. Cursing and yelling at staff needing frequent redirection. Dr. (Doctor) notified. Emergency meds (medications) given IM (Intramuscular) Ativan and Benadryl 50 mg given at 22:50 PM..."

The Restraint/Seclusion Order/Record dated 12/08/11 timed at 01:30 AM reflected, "Physical restraint, danger to others...patient beat up staff and other peer. Patient was stomping peers head...patient to calm down...medication given "no."


2) Patient #2's demographic profile with a print date of 11/26/11 reflected, "Patient #2 a [AGE] year old female was admitted [DATE]..."

The physician's orders dated 12/08/11 timed at 01:15 AM reflected, "Pt (patient) transferred to...ER (emergency room ) for evaluation of head injury..."

The 12/08/11 multidisciplinary note timed at 01:10 AM reflected, " MHT (Mental Health Technician) entered pt (patient) room at 01:10 AM finding Patient #2 on the floor being kicked in the head by male pt. Male pt subdued in room while RN (Registered Nurse) evaluated pt's injury. 911 and Dr...called. Pt vitals were (B/P) 207/96, P (Pulse) 63, R (Respirations) 14 labored. Neurological check found pt to be verbally unresponsive...however, pt was able to turn to side for continued evaluation. Orientation x (times) 0 (zero)...body assessment done, injuries contained to head. Pt was bleeding from mouth and blood found on cheek close to eye. EMS (emergency medical system) arrived at 01:13 AM on unit. EMS assessed pt and transported off unit..."

The acute care hospital's Trauma Admission History and Physical dated 12/08/11 reflected, "[AGE] year old female found down in room...states she was assaulted by fists...complains of pain...not alert...right pupil 3 mm (millimeters) reactive...left 4 mm reactive...laceration to left eye and left cheek...left frontal scalp hematoma, intraventricular blood, partially calcified mass...diffuse cerebral edema..."

On 12/16/11 at 12:00 PM (Personnel #10) was interviewed. (Personnel #10) stated when she arrived for the 11-7 shift on 12/07/11 the evening shift was calling a silent code for Patient #1 to give him an injection. (Personnel #10) stated a little later she observed Patient #1 sitting in a chair nodding off. Patient #1 suddenly bolted and went to a female patient's room. (Personnel #10) stated (Personnel #11) went after Patient #1. Patient #1 began pushing, hitting and swinging at (Personnel #11). (Personnel #11) backed into the hall and Patient #1 chased (Personnel #10, #11 and #9) towards the nursing station where they remained during the crisis. (Personnel #12 and #11) remained out on the unit with Patient #1. (Personnel #10) stated Patient #1 continued to hit, kick and punch (Personnel #11 and #12). (Personnel #11 and #12) made it into the nursing station. (Personnel #12) then wedged himself against the door after Patient #1 broke the nursing station door. (Personnel #10) stated she went into the medication room and heard Patient #1 was in another patient's room. (Personnel #10) stated when she went to Patient #2's room (Personnel #14) was holding Patient #1 down on the bed and Patient #2 was bleeding on the floor. (Personnel #10) said Patient #2 did not respond verbally and was sent to the ER (emergency room ).

(Personnel #10) was asked by the surveyor why the staff barricaded themselves in the nursing station leaving the other patients on the unit in harms way. (Personnel #10) stated she was afraid of the patient and guessed the staff did not protect the other patients on the unit.

On 12/16/11 at 12:15 PM (Personnel #9) was interviewed. (Personnel #9) stated when she arrived for the 11-7 shift on 12/07/11 she was told in report that Patient #1 refused by mouth medications and required an injection. (Personnel #9) said Patient #1 came to the lounge carrying clothes and wearing only boxers. (Personnel #11) provided Patient #1 a hospital gown to wear. Patient #1 sat down in the lounge and started nodding off to sleep. Patient #1 then suddenly bolted and went to a female patient's room. (Personnel #9) stated (Personnel #10 and #11) went after the patient. (Personnel #11) made it to the room first. Patient #1 began attacking (Personnel #11). (Personnel #11) backed out of the room into the hall. (Personnel #12) came to help. (Personnel #9 and #10) went to the nursing station. The two staff came into the nursing station and the door was closed. Patient #1 broke the door to the nursing station and (Personnel #12 and #13) wedged themselves against the door so Patient #1 could not come into the nursing station. (Personnel #9) stated Patient #1 did assault Patient #2 while in her room.

(Personnel #9) was asked how the hospital staff ensured the patients on the unit were safe. (Personnel #9) stated the unit staff could not handle Patient #1 and she was afraid of the patient.

On 12/16/11 at 3:30 PM (Personnel #2) was interviewed. (Personnel #2) stated Patient #1 was agitated when he arrived on the unit. She stated she asked the intake staff if the physician had written any medication orders. (Personnel #2) said the intake staff told her the nursing staff would have to call the physician. (Personnel #2) stated she called the physician several times for medication for Patient #1. (Personnel #2) said the physician finally came up to the unit at 21:00 PM, and wrote orders for po (by mouth) medications.

On 12/16/11 at 7:40 PM (Personnel #27) was interviewed. (Personnel #27) stated Patient #1 was seen in the lobby of the screening area. (Personnel #27) said when she went out to the desk she saw the ambulance paper work and read the patient's name off. She stated a woman in the lobby area who was waiting was filling out the pre-assessment form for Patient #1. (Personnel #27) stated the physician briefly spoke to Patient #1. (Personnel #27) stated Patient #1 was extremely agitated and was scaring the people sitting in the lobby. She stated
the physician wrote orders to admit to the adult psychiatric unit. She stated the patient needed to get on the unit right away. (Personnel #27) stated she did not sign the pre-admit assessment and validated the document was to be signed by her and the physician.

On 12/16/11 at approximately 8:30 PM (Personnel #12) was interviewed. (Personnel #12) stated the patient received an injection at the change of shift and all the evening staff left after that. (Personnel #12) stated he was assigned to the south unit and he began doing rounds. He stated he heard (Personnel #9) holler his name and he ran towards the nursing station. He stated as he was running (Personnel #9) ran into the nursing station. (Personnel #12) said he saw Patient #1 running/swinging at (Personnel #11). Patient #1 was punching and hitting at (Personnel #11) when (Personnel #11) fell down. Patient #1 kicked and punched (Personnel #11) in the head. (Personnel #12) said he attempted to intervene and grab the patient.

(Personnel #12) stated (Personnel #9 and #10) left them out on the unit alone with no assistance and left the other patients on the unit to fend for themselves. (Personnel #12) stated he made it back to the nursing station along with (Personnel #11). Patient #1 then broke the nursing station door and he proceeded to hold the door shut along with (Personnel #13) who had come to the unit to help.

On 12/18/11 at 6:22 PM (Personnel #11) was interviewed. (Personnel #11) stated Patient #1 was agitated and had rage in his eyes. (Personnel #11) said he did the best he could to contain Patient #1 but needed assistance from the other staff on the unit at the time. He stated he felt alone and the nurses did nothing. (Personnel #11) stated all the staff had been trained on how to handle aggressive patients. (Personnel #11) stated the nurses just stood by and watched them get beat up. (Personnel #11) stated the patient had already attempted to go into a different female patient's room earlier.

(Personnel #11) stated it was an unsafe environment for the staff and the patients.

On 12/19/11 at 12:15 AM (Personnel #14) was interviewed. (Personnel #14) stated he was working the 11-7 AM shift on the night of 12/07/11 and 12/08/11. (Personnel #14) stated (Personnel #15) called him to go to the...building north side adult unit. He stated he saw (Personnel #9 and #10) on the south side. (Personnel #14) said he heard loud talking in one of the patient rooms. Patient #1 was in the room, he jumped towards me so I backed up to find out what was going on and why I was needed on the unit. I heard a thump and went into the door of the room, a female was on the floor and Patient #1 was kicking the patient in the head, blood was everywhere. The patient saw me and struck me a couple of times. (Personnel #14) stated he wrapped Patient #1 with his arms and both he and Patient #1 fell on top of the bed. (Personnel #14) stated he used his leverage to hold Patient #1 down on the bed. (Personnel #14) stated he could hear the female patient (Patient #2) gurgling. He stated it seemed as if it was forever before anyone came. He stated he hollered for help and needed an ambulance for the female patient on the floor. (Personnel #14) said (Personnel #15) came down. He stated (Personnel #15) did not help hold Patient #1 but left to get (Personnel #13 and #17). (Personnel #14) said the nurse and police came. He stated there seemed to be a problem finding some medications for Patient #1. (Personnel #14) stated he was left alone and he did not know the details of the problem on the unit when he arrived and what patient was involved. (Personnel #14) stated none of the staff were on the north side. He stated many of the patients were awake, upset and scared. He stated one of the patients yelled "Y'all let her get beat up." (Personnel #14) said all the staff were trained to get involved in a code not barricade themselves in the nursing station.

On 12/19/11 at 12:40 AM (Personnel #15) was interviewed. (Personnel #15) stated she was on duty 12/07/11 11:00 PM to 07:00 AM on 12/08/11. (Personnel #15) stated (Personnel #9) called her three times. She stated (Personnel #9) said we have a code. (Personnel #15) stated she sent (Personnel #14) and a technician from another unit. (Personnel #17 and #15) ran upstairs to the unit. (Personnel #9, #10 and #13) were holding the nursing station door shut. (Personnel #11) was bleeding. (Personnel #15) stated she asked where (Personnel #14) was. No one knew. (Personnel #15) stated she heard someone calling for help. She stated she went to see and found (Personnel #14) holding Patient #1 down on the bed. (Personnel #13 and #17) responded and removed Patient #2 out of the room. (Personnel #15) said she returned to the nursing station to call the ambulance.

On 12/20/11 at 11:40 AM (Personnel #8) was interviewed. (Personnel #8) stated admissions told him Patient #1 was too psychotic to be in the lobby of the assessment area. (Personnel #8) stated Patient #1 was sent directly to the unit. (Personnel #8) stated he found out later the ambulance had dumped him off and the patient did not see the physician. He stated he received a call requesting emergent medication for Patient #1 after he left the unit. (Personnel #8) stated he received no phone calls from the nurses prior to him coming on the unit. (Personnel #8) was asked if he saw Patient #1 while in the lobby of the assessment area. (Personnel #8) stated "no."