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.

The hospital failed to provide a safe environment and protect an adolescent patient from self-harm, as the patient was found to have committed suicide within 24 hours after discharged from the hospital.

The hospital failed to protect and promote the patient's rights by not providing the patient the necessary services needed to avoid self harm.

The hospital's registered nurse failed to perform a Suicide Risk Assessment at the time of the patient's discharge from the hospital to avoid physical harm.

The hospital failed to inform the on-call psychiatrist of the patient exhibiting self-abusive behavior and making threats of causing physical harm to self.

Cross Refer to 482.13(c)(2), 482.13(c)(3),
Based on a review of facility documentation, clinical record, and staff interview, the facility failed to ensure the rights of the patient by not providing a safe secure environment and not protecting the patient from self-harm.


Facility policy entitled "Observation, Patient" No: PC-032, Revised: 2/17, Reviewed: 08/2016, states in part, "In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observation can be increased by the RN anytime there is a concern but only a psychiatric practitioner may decrease the level. Procedure: The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change:
" 15 minute
" 5 minute
" One-to-one
The physician may also order a precaution level of observation for:
" Suicide
" Assault
" Elopement
" Seizure
" Fall
" Sexual Acting Out.

Facility policy entitled Patient Rights, included the following:
"All patients have the following rights:
" You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
" You have the right to appropriate treatment in the least restrictive appropriate setting available. This is the setting that provides you with the highest likelihood for improvement and is not more restrictive of your physical or social liberties than is necessary for the most effective treatment and for protections against any dangers which you might pose to yourself or others.
In an interview with staff #5 Risk Manager, stated that the information she obtained during her investigation, was that patient was taken to the front lobby by staff to be discharge from the hospital to her uncle (guardian). Staff call Austin Police Department because the patient became agitated and refused to leave with her guardians. Patient banged her head and stated she would kill herself if she had to leave with her guardian. As police and uncle were walking to the car with the patient, she ran from them across the street. The patient was discovered the following morning at a construction site. Austin Police Detective reported that he believes the patient committed suicide the same day she ran off, but waiting to confirm time of death. He confirmed that cause of death was suicide by hanging.

The above findings were confirmed in an interview with the Staff # 5 Risk Manager on the morning of 10/16/2017 in the facility conference room.
Based on records review, document reviews, and interviews, the hospital Registered Nurse failed provide nursing services necessary to prevent an adolescent patient from self-physical harm as patient banged her head and threatened to kill herself when in the facility's front area lobby.


Facility policy entitled "Suicide Risk Assessment" NO: PC-045, Revised: 9/2017, Reviewed: 09/2017 states in part,
" "In addition to completion of the prescribed frequencies, the patient's suicide risk shall be assessed on as needed/ongoing basis as indicated by the patient's clinical and/or behavioral presentation. Suicide risk assessments shall be completed and documented by the registered nurse, social services, and psychiatrist."
" If any suicide risk assessment renders information that has potential to immediately affect patient safety and/or results in a score of High or Severe, the psychiatrist shall be contacted immediately. This applies to the initial and all subsequent suicide risk assessments. The psychiatrist shall order the appropriate level of observation based on results of the suicide risk assessment and additional patient specific information based on previous knowledge of the patient or as reported by staff. Documentation of consult and subsequent physician orders are noted in the patient chart.
" A suicide risk assessment (SRA form) will be completed by the Registered Nurse as part of the discharge process.
" The psychiatrist will assess and document risk of suicide or self-harm prior to discharge.
" If clinical staff has any concern about discharging a patient due to imminent risk of harm to self or others the psychiatrist and CEO will be contacted. (was added 9/2017 after the incident).
Review of the patient's clinical record revealed a Suicide Risk Assessment was performed on 8/29/17 1550 included the following: SRA Total Score 23 - Overall Risk Level - Low 17-24 total score 23. Patient's guardian arrival at the hospital to pick up the patient. The patient was at the facility's front lobby at approximately 8:45 P.M. The R.N was called when the patient began displaying self-abusive behavior and she was verbally threatening to kill herself if she had to leave with her guardian. Registered Nurse asked staff to call the police. The Registered Nurse failed to assess the patient and complete a "Suicide Risk Assessment" as per hospital policy before the patient walked out of the hospital's lobby area. Once outside the hospital the patient ran way. Neither uncle did not go after the patient. The patient was discovered the following morning in construction site near the hospital, she was found to be deceased -suicide by hanging.

The above findings were confirmed in an interview with the CEO on the morning of 10/17/2017 in the facility conference room.