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 record review and interview the hospital failed to ensure the rights of three of three patients (Patient #5, #12, and #13) to attend school.

1) Fifteen-year-old Patient #5's anxiety increased due to inability to complete her school work while at the hospital

2) Eleven-year old Patient #12 attended special education classes prior to his hospitalization . The patient liked school.

3) Seventeen year old Patient #13 was enrolled in special education classes prior to her suicide attempt.

Findings included:

1) Patient #5 was hospital admitted on [DATE] with suicidal ideation of stabbing herself or overdose on medications.

Group therapy progress notes dated 04/27/15 at 13:00 reflected the patient had "high expectations of herself" in school and was anxious and frustrated that she did not get to complete her schoolwork at the hospital.

Group therapy progress notes dated 04/28/15 at 11:00 noted the patient was frustrated and stated she did not belong in the hospital but needed to do her schoolwork.

Psychosocial evaluation dated 04/28/15, untimed, noted the patient was a "good" student in advanced classes.

2) Patient #12 was hospital admitted on [DATE] with suicidal ideation to run into traffic. He was enrolled in special education classes prior to his hospital admission.

During an interview on 09/09/15 at 11:50 Patient #12 stated he liked school.

3) Patient #13 was hospital admitted on [DATE] with an overdose of medication. The patient attended special education classes before her suicide attempt.

Personnel #5 stated on 09/08/15 that "no school program has been set up. There is no teacher."

The Teen's Bill of Rights reflected the basic right that "the hospital has to have someone come in to teach you so you don't fall behind in your schoolwork."

The Texas Administrative Code 25 Part 1 Chapter 404 Subchapter E Rule 404.162(c) noted the Teen's Bill of Rights...will be used as the formal document for rights notification for individuals admitted to psychiatric hospitals..."

Based on record review, interview, and observation, the hospital failed to ensure the rights of three of three patients (Patient #9, #13, #12) to receive care in a safe setting. Post-incident interventions had not been implemented three months after the inpatient suicide-by-hanging attempt, and objects potentially usable in patient self-harm were found accessible to patients during the survey.

1) Nineteen-year old Patient #9 had been admitted with suicidal ideation. The patient was on routine 15 minute staff observations. On 05/29/15, a day when the patient's condition had not been evaluated by a psychiatrist, she took a bed sheet, tied it over the door of the day-room and hung herself.

2) Patient #13 was hospital admitted on [DATE] to the hospital's adolescent unit with an overdose on medication. The patient had unsupervised access to a chemical. The Suicide Severity Rating Scale had not been used during the patient admission process as outlined in the hospital's action plan.

3) Patient #12 was hospital admitted on [DATE] to the pediatric/adolescent unit with suicidal thoughts. The patient's suicidal severity had not been assessed as outlined in the hospital's action plan.

Findings included:

1) Patient #9's Psychiatric Evaluation dated 05/25/15 at 11:06 reflected the patient was a [AGE] year old widow brought to hospital by police after she was found standing on a bridge. The patient's husband had schizophrenia and shot himself a week prior to the patient's arrival to the hospital. The patient was grieving. Prior to her hospital admission, the patient had parked her car and walked barefoot to an interstate overpass. Police were called and were afraid she would jump off the bridge. The patient had attempted suicide five times in the past. She minimized her symptoms.

Physician Discharge Summary noted that Patient #9 remained suicidal on 05/27/15 and 05/28/15. The patient felt helpless and hopeless. She minimized her symptoms and asked to be discharged . She was quiet and withdrawn on the unit. On 05/29/15 Patient #9 was observed on the phone, upset and crying. After spending some time in her room, Patient #9 told staff she wanted to go to the day room and work on a puzzle. Staff went to the day room and "found the doors shut with a white sheet knotted twice on top of the closed door." Staff members "pushed the door open and found that the patient had tied the sheet around her neck ...unresponsive and pulseless."

There was no physician signed progress note dated 05/29/15.

Personnel #3 stated on 08/12/15 at approximately 13:35 that on the day of the incident, Patient #9 was upset after receiving disturbing family news and "staff did not pick up how upset she was." Staff opened the day room for Patient #9 to do puzzles. The dayroom was not visible from the nurses' station. The patient "got a bed sheet from her room and hang herself in the day room..." Personnel #3 stated a new suicide severity rating scale was implemented after the event.

2) The Memorandum of Transfer (MOT) Physician Note dated 09/09/15 at 00:40 reflected Patient #13 was hospital admitted after overdosing on 36 tablets of Advil PM.

Patient #13 was interviewed on 09/09/15 at 12:15 and acknowledged she had overdosed on Advil.

A blue bin with a brush and anti-perspirant ("for external use only") was observed on 09/09/15 at 11:50 in Room 256 occupied by Patient #13. Personnel #10 acknowledged the bin and stated it was supposed to be checked out for hygiene and returned to staff.

Review of Patient #13's chart did not reflect the completion of a suicide severity rating scale.

3) Patient #12's Pre-Admission Exam document reflected Patient #12 was hospital admitted on [DATE] at 22:38 for suicidal thoughts to stab himself or run into traffic.

The Physician's Preadmission Examination Orders dated 09/08/15 at 23:49 reflected that Patient #12's admitting diagnoses included Major Depressive Disorder, Severe, with Psychotic Behavior.

Review of Patient #12's chart did not reflect the completion of the suicide severity rating scale.

On 09/09/15 at approximately 11:30 Personnel #10 denied that Patient #13 and Patient #12 received screening with the suicide severity rating scale tool as outlined in the post-incident action plan.

Observations on the hospital's adult and pediatric/adolescent units reflected objects that were accessible to patients and could potentially be used for self-harm. Unsafe objects included a metal domino box and a plastic spoon on the pediatric/adolescent unit on 09/09/15 at 11:45. Personnel #10 acknowledged and removed both objects at that time and stated that plastic spoons were supposed to be accounted for by staff. A Teen's Bill of Rights with staples were observed and acknowledged by Personnel #1 and/or Personnel #10 in patient-occupied Room #253 on 08/12/15 at 12:50 and in Room # 221 on 09/09/15 at 11:15.

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for one of one patient (Patient #5). Although aware of Patient #5's prehospital dose of antianxiety medication, nursing did not provide the patient with the correct dose until more than 48 hours after her admission. Patient #5 suffered increased anxiety through the first three days of treatment.

Findings included:

1) The Nurse-to-Nurse Report from the transferring acute care hospital, undated, timed at 03:09, reflected Patient #5's home medications included Gabapentin (Neurontin) 600 mg (milligram) twice daily.

The Memorandum of Transfer (MOT) Physician Note reflected Patient #5 was hospital admitted on [DATE] at 04:03. Patient #5 was suicidal and planned to stab herself with a knife. She was failing Algebra and had high school anxiety.

Personnel #6's Physician Orders dated 04/24/15 at 11:40 noted Patient #5 to have her medication regimen started that day and included Neurontin 300 mg by mouth twice daily for anxiety. The physician ordered nursing staff to confirm Patient #5's medication dosages with her mother.

Medication Administration Record (MAR) reflected Patient #5 did not receive her Neurontin medication on 04/24/15. The patient received Neurontin 300 mg on 04/25/15 twice and on 04/26/15 at 09:00 AM.

Personnel #6's Physician Progress Notes dated 04/26/15 at 11:06 reflected Patient #5's family notified nursing staff that the patient took Neurontin 600 mg twice daily. On 04/26/15 at 11:35 Personnel #6 wrote an order to increase Neurontin to 600 mg by mouth daily. The order was not noted by nursing staff until nine hours later.

Personnel #6 noted on 04/27/15 at 11:06 that Patient #5's anxiety "is gradually decreasing now that she is getting her full dose of Neurontin."

During an interview on 09/08/15 at 15:30 Personnel #6 acknowledged the findings and stated he did not know "why there was a two day gap."