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 and interview, the facility failed to protect patient information from unauthorized access in 1 (Central Supply Storage) of 14 areas toured.

Findings were as follows:

During a tour of the facility with Staff #3 and Staff #4, the Central Supply Storage area was accessed. This room had supplies for patient rooms, patient care items, sterile supplies, office supplies, patient monitoring equipment, flammable liquid storage locker, and fire suppression equipment to include emergency shutoffs. Also observed in this room were seven cardboard boxes without lids on them. Inside the boxes were files and stacks of papers that contained patient Protected Health Information (PHI) to include:

Patient full name
Services received
Account number
Admission Time
Length of stay
Insurance authorization number
Primary payer
Secondary payer
Referral source
Room number assigned

Interview was conducted with Staff #3 and Staff #4. Staff #3 stated, she was not aware that the boxes contained that kind of information. Staff #4 stated that a staff member had recently left and these were the contents of the staff member's desk. Staff #3 and Staff #4 could not provide a list of all of the staff that had access to the Central Supply Storage area and potentially to the protected information in open boxes.

Review of Policy HP 100.01 General Staff Responsibilities was as follows:


It shall be the policy of Hickory Trail Hospital of Desoto, Texas, to take reasonable efforts to limit access by Hickory Trail Hospital staff to the classes of information necessary to carry out their duties and to limit incidental uses or disclosures of protected health information.

(45 CFR 164.514(d)(2)(ii) and 45 C FR 164.530 (c)(2)(ii))

All staff members are responsible for safeguarding the privacy of patient health information. Specific staff responsibilities under these privacy policies and procedures will be listed in the staff member's job description."

The procedures for all staff members did not include processes or expectations for all staff member to ensure that PHI was secured when no longer used. Policy HP 1400.04 General Staff Responsibilities defined unsecured PHI as:

"PHI is "Unsecured" when it is not rendered unusable, unreadable or indecipherable to unauthorized individuals through the use of encryption and/or destruction."
Based on observation, review of records, and interview, the facility failed to ensure patient care areas were free from hazards to psychiatric patients in 3 areas (Patient Intake/Lobby, Unit 4 and Patient Room #401, and Courtyard) out of 14 toured.

Findings included:

A tour of the facility was conducted with Staff #3 and Staff #4 on the afternoon of 8-27-2018.

Patient Intake/Lobby

During a tour of the patient intake/lobby area, two rooms were observed to be patient waiting areas. The rooms both had hex-head screws with a linear slot for a common screwdriver installed in the window and air-conditioner covers. These screws were not tamper resistant and could be easily removed by a psychiatric patient. The sharp point of the screw could then be used by a psychiatric patient in an attempt to harm themselves. Staff #4 confirmed the findings.

Patient Room #401

Staff #3 confirmed that Patient Room #401 was cleaned and ready to receive a patient. Patient Room #401 was observed to have a wall mounted air-conditioner. The air conditioner did not have a secure protective cover to prevent psychiatric patients from accessing electrical and mechanical components. The cover was found to be easily removed.

Patient Room #401 was observed to have an electrical outlet on the wall with four plug outlets. The outlet did not have mechanical covers to prevent access by psychiatric patients. The outlet on the bottom right was observed to be black with what appeared to be scorch marks.

Staff #4 was interviewed during the tour. Staff #4 confirmed that these were not tamper resistant plugs. Staff #4 stated, the power to the wall outlets had been shut off. This was to prevent harm to psychiatric patients who would be using the room. Staff #4 stated, the power to the outlets would only be turned on if medical equipment were needed in the room. Initially Staff #4 stated, the black marks were "magic marker" that had smeared. A close-up observation of the plug revealed it to be scorch marks that extended from the surface, into the plug. Staff #4 confirmed these were scorch marks. The four-plug outlet was tested and found to have power to it.

Staff #4 stated that all of the secure air-conditioning covers in all patient rooms on Unit #4 had been removed when the new air-conditioners had been installed. Covers had not been replaced in any of the room on Unit 4 prior to allowing patients to occupy the rooms. Staff #4 could not provide an exact date of air-conditioner replacement, but indicated it had been in July sometime.

An interview with Staff #4 was conducted on 8-28-2018. Staff #4 stated that he conducts environmental rounds twice a week. When asked if staff performed safety rounds of patient care areas and used a checklist of items to observe for, Staff #4 stated he fills out a form of his findings, but does not have a checklist of unsafe conditions staff should observe for.


A courtyard between the patient dining area and the patient care areas was observed. Staff #4 confirmed that patients traveled through the courtyard when going to and returning from meals. The courtyard was observed to have walkway/patio areas constructed out of dissimilar materials (concrete, paving bricks, and tile) at different heights. Tiles were observed to be missing and graded concrete transitions between uneven heights were crumbling and missing in places. These uneven surfaces presented a trip hazard to patients who may be confused, or have balance problems due to medications for their psychiatric condition.

Staff #4 stated they were in process of having the concrete cut back and permanent transitions placed. When asked for the work orders, estimates, or contracts, Staff #4 stated he had not contacted any contractors about the work to obtain any estimates. This project had not been studied with a written proposal for correction made.
Based on observation and interviews, the facility failed to protect the patients from neglect and abuse by not allowing the patient to have access to drinking water, without rationing from the staff, or at staff convenience.

During a tour of the children and adolescent unit on 8/27/18, revealed the unit was separated by a locked door. One side for boys and one side for girls. On the boy's side there was a water cooler. Paper cups were available to pull down and use for water. The water cooler was found to be broken and there was no water available for the boys to drink. On the girls side the water cooler was working but there were no cups available.

An interview was conducted with staff #15 (RN) on 8/27/18. Staff #15 was questioned by the surveyor concerning the patient's ability to have access to drinking water. Staff #15 stated she was not aware the boys water cooler was broken. Staff #15 reported that the girls did not have cups because "they throw them down and waste them, or they throw water on each other." Staff #15 reported the patients could come to the nurse's station and get a drink. It was observed that the staff was controlling the water access to the children. The children had to ask for water from the staff. The children did not have easy access to the basic need of water. Staff #3 confirmed the findings.

Based on review of records and interview, the facility failed to take timely step to thoroughly and objectively investigate allegations of sexual abuse made by a patient against staff in 1 (Patient #6) of 2 patient allegations reviewed.

Findings included:

On 1-30-2018, Patient #6 reported an allegation of sexual abuse by a staff member to her outpatient therapist and the Director of Outpatient Services. The event was alleged to have occurred on 1-22-2018 or 1-23-2018.

This allegation was reported to Staff #3, the Risk Manager. Staff #3 spoke with Patient #6 per a written statement dated 1-31-2018. Per the written statement, 'I told (Patient #6) that she was welcomed to call the police if she wanted and she reports "I did". I told (Patient #6) that I would investigate her concerns and if the police needed information than (sic) they would reach out to me.'

No further action was taken on the investigation until 3-1-2018. On that date, Staff #1 received an email from a Detective at the Desoto Police Department requesting information regarding a report that had been made concerning these allegations and any information on the identity of the alleged staff member involved. Staff #1 forwarded the email to Staff #6.

A statement was provided by Staff #12 on 3-1-2018. The statement read:

"Im (Staff #12) on the dates of 1/22-1/23 I was the tech on Unit 1. I didn't kiss (Patient #6) in her room as she accusses me. Her and her roomate where aware of the time I was in her room when they where awake." (sic)

Review of pay records showed that Staff #12 worked on 1-31-2018, 2-1-2018 and 2-2-2018, the days immediately after the allegations were made by Patient #6. Review of the personnel file for Staff #12 revealed he had never been placed on administrative leave pending the outcome of an investigation.

Interview was conducted with Staff #3. Staff #3 stated, she did not take action on the investigation because she believed the patient "wasn't credible". When asked how it was possible for her to determine the allegations were true or not without investigating, she stated that the patient told different versions of the story. When asked why Staff #12 wasn't removed at the time until the allegations had been thoroughly investigated. Staff #3 stated that the patient hadn't named him. When asked how she identified Staff #12 for a written statement on 3-1-2018, Staff #3 stated after investigation, Staff #12 was the only possible person who could have been involved.

No further records of investigation to include review of video or statements of other staff present was made. No attempt was made to interview the Patient #6's roommate. No documentation of CEO, Physician, or Corporate notification was found. No documentation was found of steps taken to ensure the safety of a vulnerable population while an investigation was in process.

The policy and procedure for investigation allegations of sexual abuse was requested. Policy NS600.18 Sexually Acting Out & Sexual Victim Prevention policy was provided. This policy addressed sexual abuse allegations of patients against patients. It did not address the process or procedure for investigating allegations against staff. Staff #6 was asked if she had a policy for investigating allegations against staff and protecting patients during the process. Staff #6 denied having a policy.
Based on observation and interview, the facility failed to maintain a safe environment in two areas (Central Supply and Medical Records Storage) out of 14 areas toured.

Findings included:

A tour of the facility was conducted with Staff #3 and Staff #4 on the afternoon of 8-27-2018.

Central Supply Area

During a tour of the Central Supply area, emergency fire suppression plumbing was observed to be located in the corner. An area on the floor was taped off with yellow and black striped tape to indicate the area necessary for access to the emergency shut-off valve. Three pieces of medical equipment for monitoring patient vital signs were observed to be stored in front of and blocking access to the emergency shut-off valve. This was within the taped off area.

Interview was conducted with Staff #4. Staff #4 confirmed the taped off area was indicating a "no storage" area to prevent access to emergency equipment from being blocked.

Medical Records Storage

During a tour of the Medical Records Storage area, a large box was observed on the top overhead shelf in close proximity to a light fixture. The light fixture was observed to be without a protective cover over the four fluorescent tube bulbs. This created a hazardous situation should the box be moved and hit the glass tube bulbs. Shattering glass could cause injury to staff.

These conditions were confirmed by Staff #4.
Based on observation and interview, the facility failed to implement and monitor measures to ensure the environment was sanitary to prevent infection sources or the spread of infection in 7 (Exterior Trash Collection Area, Patient Laundry, Central Supply, Clean Equipment Storage, Clean Linen, Restraint and Seclusion Room, and Medical Records Storage Room) out of 14 areas toured.

A facility tour was conducted with Staff #3 and Staff #4 on the afternoon of 8-27-2018. Findings included:

Exterior Trash Collection

The exterior trash collection area was observed upon arrival to the facility. The trash dumpster's access lids and doors were opened. Trash was overflowing the top and bags of food were spilling out of the doors. Rotted food was observed on the ground along with opened condiment packages, Styrofoam food containers, and bagged trash. Litter and debris were observed to have collected at the back and along the sides of the containment wall.

Staff #4 was interviewed during the tour. Staff #4 stated that trash was picked up 6 days a week and that he has to pressure wash and clean the containment twice a week because of spillage. Staff #4 stated, the containment areas is "a mess every Monday". Staff #4 stated, he was working on getting an extra recycling container to take some of the waste out of the main trash container in order to keep it from overflowing. On 5-28-2018, a proposal for additional services dated 5/2/2018 was provided. Staff #4 stated, the proposal had been sent to the corporate office at that time, but corporate had failed to act upon it.

Patient Laundry Room

The patient laundry room was observed to have a sink set into a countertop with continuous backsplash. The caulking to seal the point where the countertop backsplash meets the wall was observed to be degraded and missing. This allowed for water splashed during sink operation and other debris to collect between the counter backsplash and wall. This allowed conditions for potential mold, mildew, and bacterial growth to grow as a potential source of infections.

Central Supply

During a tour of the central supply storage area, sterile supplies and patient use items were observed to be stored with office supplies and chemicals. Three pieces of patient monitoring equipment were found in a corner. These were observed to be dirty and contained used supplies on them.

Clean Equipment Storage

A room labeled Clean Equipment Storage was observed to also be storing housekeeping dirty floor dusters, mops and mop buckets, and dustpans.

Clean Linen Storage

A room labeled Clean Linen Storage was observed to have wadded up sheets on top of the clean linen cart and debris/trash on the floor.

Seclusion Room

A seclusion room was observed to have a restraint bed in it. Per Staff #3, mechanical restraints were not used in the facility and had not been used in "at least a year". A metal loop for tying mechanical restraints was observed to have material tied to it. The material appeared to be the type that was used to tie mechanical restraints. The material was heavily soiled and sticky with a buildup of dirt. Staff #3 was unable to determine how long the material had been on the metal loop.

An outer room for the seclusion room was found to have an unlocked closet in it. When the closet was opened, an opened bag of candy was observed to be stored on the shelf. Food items not properly stored can attract rodents and pests that spread disease.

The door to the seclusion room was found to have 5 pieces of two-sided tape stuck to it. This provided a surface for dirt and bacteria to collect and was not able to be properly cleaned.

Medical Records Storage Room

A room labeled Health Information Services Storage was observed to be a medical records storage room. The floor and shelves were observed to be littered with trash and debris. These conditions had the potential to attract rodents and pests that spread disease.

Staff #3 and Staff #4 confirmed these conditions.

A request was made to interview the Infection Control Nurse. No one was available for interview.


18 plastic patient trays were stacked wet.

The outside exterior of 2 warming trays were soiled with dust, grease and food particles.

Warming tray with food inside was soiled with carbon build up and grease.

The door frame going into the kitchen was soiled and dirty.

The floor behind the soda vending machine was soiled with trash, dead roaches, dust and dirt.

18 baking pans were found heavily soiled in carbon build up.

4 clean, plastic food containers, were found stacked wet.

Tiles were found cracked in the floor and missing on the baseboard trim.

The grease in the fryer was very dark and old. The fryer was soiled with excessive grease build up and food particles.

4 large cooking pans were found stacked wet.

5 large cooking pans were found to have a heavy carbon build up and were sitting on a shelf that was spoiled with food particles, grease, and dust.

10 large spice bottles were found to have no dates on opening or expiration.

A three tiered rolling cart was found to be soiled with dust, grease and food particles. Card board shipping boxes were found stored under a food preparation table.

The freezer door was found to have mildew growing on the door gasket.