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.


Based on interview and record review, the facility failed to protect one (1) of 15 sampled patients ' right to be free from abuse.

The facility failed to investigate an allegation of physical abuse made by Patent ID # 2.

Findings include:

TX # 896

Record review on 11-12-13 of complaint intake narrative dated 10-17-13,read: " physically abused by staff 10/02/13 when refused his meds ...stated he (Patient ID # 2) refused meds because he had not seen the doctor ...was placed in seclusion ...stated he was taken advantage of by 3 men staff member tackled him ... "

Record review on 11-14-13 of Patient ID # 2 ' s Discharge Summary ( dated 10-11-13) revealed he was a [AGE] year old admitted on an emergency detention warrant because he was paranoid, grandiose, hyperreligious, delusional, and aggressive. He was driving his car recklessly. Patient ID # 2 was discharged in 10-10-13 with follow-up appointments and changes in medication

Record review on 11-14-13 of facility form titled " Customer Care/Concern, " dated 10-02-13, completed by Patient ID # 2, read: " ...Last night before lights out, I refused my meds because I have some allergic reactions ...around 10:05 p.m. I was holding my head in my hands, just resting and then (Tech # 9) starts calling my name.....they (named 2 others) proceeded to fight me and took me to the quiet room... I defended myself as well as I could. I kicked, scratched, and bit ...After this, they administered the shot. I yelled and screamed ...After they administered the Ativan, I decided to walk around, not 2 minutes after they abused me. (Tech # 9) decided to come in and body slam (sic) my body on the bed in the quiet room. My left hip is in excruciating pain. "

Further review of this " customer care form " revealed an attached page that was undated and unsigned. This paper listed the following: " bruise left side of forehead, bruises left arm, left wrist, left forearm. Bruise: right upper thigh rear, left upper thigh front... admits to biting Tech ID # 9 and Tech ID # 10) but not before they came after him... " There was no other information provided on this paper.

Interview on 11-14-13 at 2:55 p. m. with Director of Nurses (DON) ID # 2 she stated this incident was investigated by the Human Resources (HR) person, who was presently out of state. The DON was attempting to contact the HR person. She went on to say that whenever there was suspected abuse it was immediately reported to the Risk Manager. The alleged perpetrator was suspended during the investigation.

Interview on 11-14-13 at 2: 35 p.m. with Tech ID # 9, he stated he was unaware of the allegations of abuse by Patient ID # 2. He went on to say the HR person had not informed him or interviewed him regarding Patient ID # 2. He was not aware of any investigation of alleged abuse by Patient ID # 2.

Record review of facility policy titled " Patient Abuse and Neglect In-House Patients, " dated 09-19-2013, read: " Procedure ...4. Once the CEO receives such a report, he or his designee will immediately institute a preliminary investigation of the allegation: A. The attending physician shall be notified, B. Notification of the abuse to parents, guardian, spouse, or other relatives, C. Should the preliminary investigation warrant a full in investigation, the alleged perpetrator may be suspended, without prejudice, until he investigation is completed ...10. Within 10 days of receiving the allegation ...the Patient Advocate shall; submit to Administration a final report of the investigation and action taken ... "