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 observation, interview and review of documentation the facility did not always ensure the safety of its patients during the admissions process.

Findings were:

Facility policy entitled "Intake Screening and Admissions Process" stated in part "Intake

? Meets individually with person and his/her family/significant other if applicable.
? Receives clinical information from referring professional if appropriate ...

Intake Coordinator/Case Manager:

? Encourages patient to turn over valuables (Such as money, credit cards, jewelry, checkbooks, etc.) and send home if they are accompanied by someone.
? If patient is alone, admissions staff will collect all valuables, itemize these valuables on the Patient's Money and Valuables Form, patient and staff will sign Record. These items will then be placed in the safe (using valuables envelopes). Additional items (clothing, etc.) over the allotted amount will be listed by Admission personnel and stored in the belongings storage room until discharge.
? Should the patient refuse to surrender his/her valuables, the admissions staff will have the patient sign a form stating that he/she takes full responsibility for items kept.
? Escorts patient to private area and conducts contraband search. After all contraband items have been removed from patient, escorts patient to treatment unit ...

Admitting Nurse/MHT:

? Performs a complete body search/assessment (if an intrusive search is required, an MD order is mandatory and the intrusive search must be performed by the physician) ....
? Ensures that patient's luggage, clothing, purses, etc. are carefully searched for contraband, sharp objects and other prohibited items."

Patients' Rights Handbook stated in part "You have the right to medically appropriate treatment. Should the treatment facility be unable to provide an active and appropriate medical treatment program, the patient should be discharged . You have the right to an individualized treatment plan and periodic reviews to determine your progress.

Individual Clients Rights:

2. The right to presumption of mental competency in the absence of a judicial determination to the contrary. Any questions regarding applicability of this right or a limitation on it should be referred for appropriate legal advice.
3. The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual.
4. The right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the patient and the protection of the community ...
24. The right to be free from mistreatment, abuse, neglect and exploitation ...."

On October 6, 2014, Patient # 1 was admitted to Oceans Behavioral Hospital of Abilene. During the admission but before he was assessed by the screener, he was left alone with all of his personal belongings. During this time, he claims to have taken "15 or 16 Valium." He reported this to admissions staff who sent him via EMS to Abilene Regional Medical Center where he was monitored and treated with Activated Charcoal.

The overdose of Valium is documented in the medical record of Patient # 1 in the Nursing Admissions Note, the Psychiatric Evaluation, emergency room Record of Abilene Regional Medical Center and the Discharge Summary.

In an interview with Staff Member # 2 (Social Worker), it was confirmed that Patient # 1 was left alone in a room with his personal belongings during the admissions process. It was acknowledged that the patient probably took the medication and shouldn't have been left alone.