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.

MAGNOLIA BEHAVIORAL HOSPITAL OF EAST TEXAS 22 BERMUDA LANE LONGVIEW, TX June 18, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, review of records, and interview, the Governing Body failed to provide adequate resources and oversight to ensure the facility was able to provide a safe care setting for all patients and protect patient rights. The facility failed to:

A) protect the vulnerable geriatric population from aggressive and violent acute adults, resulting in patient injury,

B) conduct investigations after patient injuries/assaults and take appropriate actions to ensure the safety of all patients,

C) provide a safe environment for patients undergoing alcohol and drug detoxification,

D) provide adequate monitoring of patients who were sent out of the facility for medical examination/evaluation, and

E) ensure that safe discharge plans with appropriate physician examination/orders were in place prior to allowing patients to discharge

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

F) protect a patient's right to refuse treatment in 1 (Patient #36) of 1 chart reviewed

G) appropriately identify and investigate allegations of abuse and neglect in order to protect all patients in 2 out of 2 abuse allegations reported on grievance forms in the month of June 2019.

Cross-Refer to Tag A0131 and A0144
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of records, and interview, the facility failed to provide a safe care setting for all patients and protect patient rights. The facility failed to:

A) protect the vulnerable geriatric population from aggressive and violent acute adults, resulting in patient injury,

B) conduct investigations after patient injuries/assaults and take appropriate actions to ensure the safety of all patients,

C) provide a safe environment for patients undergoing alcohol and drug detoxification,

D) provide adequate monitoring of patients who were sent out of the facility for medical examination/evaluation, and

E) ensure that safe discharge plans with appropriate physician examination/orders were in place prior to allowing patients to discharge

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross Refer to Tag A0144 for findings A through E

F) protect a patient's right to refuse treatment in 1 (Patient #36) of 1 chart reviewed
Cross Refer to Tag A0131 for findings F

G) appropriately identify and investigate allegations of abuse and neglect in order to protect all patients in 2 out of 2 abuse allegations reported on grievance forms in the month of June 2019.
Cross Refer to Tag A0145 for findings G
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of record and interview, the facility failed to protect a patient's right to refuse treatment in 1 (Patient #36) of 1 chart reviewed.

Findings were as follows:

Patient #36 was voluntarily admitted on Thursday, 4-4-2019, at 1:42 PM with a diagnosis of Bipolar disorder and substance use disorder. The patient was placed on suicide precautions, homicide precautions, and seizure precautions due to detox from alcohol. The patient was placed on a detox protocol for benzodiazepines (a group of drugs commonly known as minor tranquilizers) on 4-5-2019 at 4:00 PM. On Friday, 4-5-2019, at 7:20 PM, an order was written to "Discharge per Administrative Order. MD notified." The order was signed by the nurse as Telephone order read back (Staff #13 who was the previous hospital administrator). No physician order for discharge was found in the chart.

Review of Social Services notes from 4-5-2019 at 2:30 PM indicated the patient "displays symptoms of psychosis including: unclear speech patterns, paranoid thinking, grandiosity, and delusional behaviors. Unable to identify how accurate information given from pt. is on assessment due to psychosis."

The patient was not seen by a psychiatrist while at the facility. The psychiatric nurse practitioner (PNP) evaluated the patient on 4-5-2019 at 3:00 PM. The PNP notes stated the patient's chief complaint was "I was having suicidal (and) homicidal thoughts again". The PNP describes the patient as "rambly (sic), flight of ideas, delusional thoughts, grandiosity, foul language, pressured speech." Justification for inpatient care was listed as "Patient is potential or actively dangerous to self, others, or property with need for controlled environment. Patient is gravely disabled due to inability to care for self, hallucinations, delusions, agitation, anxiety, depression or other factors resulting in loss of functioning. Patient requires treatment for intoxication or withdrawals or has high potential due to inability to abstain despite active participation in less restrictive environment."

Review of nursing notes for 4-5-2019 at 6:00 PM indicated the nurse had given the patient the medication Ativan, witnessed the patient crush it up with his fingers and then inhale it. There was no indication that the physician was notified at that time. At 6:43, the patient was lying on the floor, unresponsive. Emergency Medical Services (EMS) and the physician were called. Patient vital signs were stable at 6:45 PM, 6:46 PM, and patient was responsive at 6:48 PM and assisted to the couch. At 6:52 PM EMS arrived and vital signs remained stable.

The patient refused to go with EMS to the local hospital to be checked out. When notified, Staff #13 directed the nurse to discharge the patient if he refused to go to the hospital. The patient did not want to leave the hospital, so Staff #13 directed the nurse to call the local police to remove the patient from the property with no discharge placement. The patient was discharged with the police to escort him off of the property. At 9:40 PM, when the police were removing the patient, staff had the patient sign a statement saying he was requesting to be discharged .

This was all done without a physician order and/or a psychiatrist completing a face-to-face evaluation of the patient to ensure that the patient was safe to discharge, placing the patient at risk of possible death.

An interview was conducted with Staff #4. Staff #4 stated this incident had not been investigated by Risk Management. Staff #4 was unaware that a patient had been discharged for refusing treatment without a physician evaluation or order.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, review of records, and interview, the facility failed to provide a safe care setting for all patients. The facility failed to:

A) protect the vulnerable geriatric population from aggressive and violent acute adults, resulting in patient injury,

B) conduct investigations after patient injuries/assaults and take appropriate actions to ensure the safety of all patients,

C) provide a safe environment for patients undergoing alcohol and drug detoxification,

D) provide adequate monitoring of patients who were sent out of the facility for medical examination/evaluation, and

E) ensure that safe discharge plans with appropriate physician examination/orders were in place prior to allowing patients to discharge.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings included:

On the morning of 6-17-2019 an interview was conducted with Staff #1. Staff #1 explained that only one unit was open due to low patient census. Staff #1 stated this arrangement had been in place for approximately one month prior to his employment with the hospital. Staff #1 explained he had been employed for approximately one month. Staff #1 was not able to provide an exact date of the units being combined but estimated it to be sometime in April. Staff #1 stated the patients on Unit 4 consisted of dual-diagnosis patients (psychiatric disorder with a co-occurring substance abuse disorder) and acute adult population. When asked about geriatric patients on the unit, Staff #1 stated they do not have a geriatric unit.

Review of the census provided showed that there were 5 out of 19 patients on the unit that ranged in age from [AGE] years old to [AGE] years old. There were 6 out of 19 patients in their 20's. When asked about the geriatric population on the unit, Staff #1 stated that the hospital accepts the geriatric age range but does not have a geriatric program. Staff #1 stated that one of the closed units was being renovated so that a geriatric program could be added.

On 6-17-2019, a tour of the facility was conducted with Staff #1 and Staff #2 present. Upon arrival to the unit, all patients were on the unit. Three people were observed to be sleeping on the couches in the day room, covered with blankets. The noise level was loud, with one geriatric patient (Patient #2) pacing the unit and occasionally shouting. Staff #1 explained that patients are not allowed in their rooms during the day-time with room doors locked to prevent patients from isolating themselves and refusing to attend programming. One patient (Patient #1), who was detoxing, was completely covered, including her head. The patient was not able to be observed for any physical problems associated with going through detox. Registered Nurse (RN), Staff #11, was asked about the patient, and did not know which patient was under the blanket in order to know to be observing for physical symptoms of [DIAGNOSES REDACTED]

The [AGE]-year-old geriatric patient (Patient #3) was observed sitting by herself with a metal walker sitting beside her chair. The metal walker could have been picked up by any of the acute/aggressive patients and used as a weapon to hurt any of the other patients or staff. `

RN, Staff #9 was asked about Patient #3. Staff #9 stated the patient initially had remained in her room, refusing to come out. She was now coming out of her room and was not allowed back into her room during the daytime per policy. Staff #1 was asked to provide the hospital policy that directed staff to lock patients out of their room during daytime hours. Staff #1 later confirmed that no such policy could be found.

Review of incident reports for the month of June showed that the following violent actions occurred during Patient #3's stay:

On 6-1-2019, a [AGE]-year-old female became violent, attempting to punch another patient, resulting in a restraint and seclusion. This incident was identified on the log as being closed.

On 6-2-2019, the same [AGE]-year-old female patient became violent, attacking staff, resulting in several staff members taking the patient to the floor, restraining the patient, and then secluding the patient. This incident was identified on the log as being closed.

On 6-2-2019, a [AGE]-year-old male patient began throwing cups and chairs in the cafeteria, was threatening staff, yelling and cursing, was taken back to the unit and placed in seclusion.

On 6-2-2019, a [AGE]-year-old male patient became violent and attacked staff, punching and hitting staff, resulting in staff restraining patient and placing in seclusion. This incident was identified on the log as being closed.

On 6-5-2019, a [AGE]-year-old female sat next to another patient during smoke break and put her lit cigarette on the other patient's arm.

On 6-7-2019, a [AGE]-year-old female patient attacked another patient, resulting in restraint and seclusion. Later in the day, she attempted to attack the same patient again, resulting in a second restraint and seclusion. This incident was identified on the log as being closed.

On 6-8-2019, a [AGE]-year-old female patient attacked staff, resulting in restraint and seclusion. This incident was identified on the log as being closed.

On 6-9-2019, a female patient only identified by first name, charged and jumped on another patient, resulting in restraint and seclusion. Later in the day, she attacked the same patient again, resulting in a second restraint and seclusion. Later in the evening, she attacked the same patient again, punching the patient in the lip, resulting in a third restraint and seclusion, and the victim of the attack requiring "first aid" to her lip. The attacker was placed on unit restrictions. When explained that she was on unit restrictions, the patient went to the day room, knocked over tables and hit the trash can, and was yelling and screaming. This resulted in a fourth restraint and seclusion for this patient.

On 6-10-2019, a [AGE]-year-old female attempted to attack another patient, resulting in restraint and seclusion.

On 6-13-2019, a [AGE]-year-old female turned over tables and trash cans and stood in the day area of Unit 4, yelling. The patient threw a deck of cards at a male patient and hit him in the head. This resulted in a restraint and seclusion.

On 6-13-2019, a [AGE]-year-old male became upset because he was locked out of his room and staff would not let him enter it. He became violent, knocking items off the wall, throwing items to the ground, reaching over the counter in the nursing station to throw more items on the ground, resulting in a restraint and seclusion. The patient was transferred to a local hospital for evaluation of injuries sustained during this incident. This incident was identified on the log as being closed.

On 6-13-2019, during a "crisis with another patient", a [AGE]-year-old female was found standing in the hallway without any clothes on. She was taken to her room to get dressed. After the nurse left her to get dressed, she came out of her room without clothes on again and had to be taken back to her room. This incident was identified on the log as being closed.

On 6-14-2019, the same female patient attacked a male patient. The male patient was taken inside. The female patient then stripped out of her clothing while outside on a fresh air break. The patient was wrapped in a sheet and brought back to the unit to get dressed.

The Risk Manager was asked to provide copies of the closed incident investigations with conclusions and any actions that had been taken as a result. The Risk Manager stated that the incidents in June were open and she had not investigated any of them. The Risk Manager was asked why the log showed 23 of the 32 incidents in June as being investigated and closed. The Risk Manager stated, "I don't know why I marked them as closed."

Patient #3 was subjected to being present during 17 acts of aggression and/or violence with patients being taken down by staff and placed in restraints and seclusions during the 17-day period, 5-30-2019 to 6-17-2019. During this time, Patient #3 was using a metal walker that could have been taken from her at any time by the aggressive and violent patients and used a weapon against her, other patients, or staff. When asked for a hospital policy or procedure for the monitoring of patients with medical equipment or devices, Staff #1 was unable to provide a policy or procedure. Review of Patient #3's chart did not show any orders for or documentation of increased monitoring of the patient while using the equipment so that she and others could be kept safe while housed with violent and aggressive patients.

Review of the Complaints and Grievance Log for May showed that on 5-15-2019 a male patient filed a grievance stating that, "Patients need to be sorted by psych complaints; on different units."

5-21-2019, 59-year-old, Patient #37, filed a grievance stating that she was attacked from behind and punched in the head by an aggressive and violent adult male patient. Patient #37 was using a wheelchair for mobility during her stay, and did not see the male patient come up behind her.

On 5-24-2019 a female patient filed a grievance stating the following:
"After arriving, I was placed in the pshyc. (sic) ward that was originally designed to hold patients with severe psychosis and depressed or recoving (sic) patients.

The minute I arrived a woman was screaming, cursing, running around the room and throwing things. Another man was doing the same. We have not had a moments peace.

Finally, today, one of these same inmates physically assaulted 2 nurse's (sic) and blind-sided a patient in a wheel chair with a punch to the left side of her face."

On 5-23-2019, another female patient filed a grievance stating the following:
"After he assaulted two techs and another patient, the man was kept on the unit. They can only keep him in the quiet room so long. He has to be let out at some point. Even though officers had to be called, he is still here. This is not good for the mental health of the other people here. It is not good for the physical health of the others either."

On 5-23-2019, a male patient filed a grievance stating the following:
Tonight I witnessed a male patient named _______ (patient's first name) come up to a female paient (sic) in a wheelchair named ________ (patient's first name) + he suckered punched her in the left side of her head. After what I witnesd (sic) I don't feel safe here. I am bi-polar + what I saw was uncalled for. I have to mind to call my family and have them pick me up and leave!"

Staff #10 was asked to provide any information on the investigation and resolution of these grievances to include copies of the final letters provided to the patients. Staff #10 stated that she was new in this role and that she did not know if there had been investigations with letters sent to the patients. No evidence of an investigation or letters was provided by Staff #10.

Staff #4, the Risk Manager, was asked for any investigations that had been completed, along with conclusions and actions taken. Staff #4 stated she did not have any. When asked why, as Risk Manager, she did not have any documentation of investigations, along with conclusions and actions, Staff #4 stated she didn't have time. Staff #4 stated she was the only person who had been working on developing corrective action plans from the previous survey. When asked if she had asked the corporate leadership for assistance, she stated she had begged for assistance but was told she could do it herself. Staff #4 stated that these incidents, along with complaints and grievances are talked about daily in the Daily Flash Meeting, but had no documentation of any follow-up that may or may not have occurred after the meeting. As of the date of the survey, the practices that led up to geriatric patient injury continued.

Review of Patient #37's chart found that nursing notes and physician notes for the time period of the patient assault were missing. No documentation was found as to the exact date and time of the attack on patient #37. Patient #37's grievance was dated 5-21-2019. Social Services notes dated 5-20-2019 at 9:40 AM stated, "1:1 sesion (with) pt. re: trauma, experience @ MBH." A grievance filed by another patient was dated 5-23-2019 stating he had witnessed Patient #37 being hit in the head that evening. Nursing notes for 5-24-2019 indicate that the patient was sent to a local medical facility for evaluation of injuries after complaining to the nurse that she was in pain after being hit in the head by another patient on 5-23-2019. Notes from the medical facility indicate she had a hematoma to the left ear. No documentation of the attacks or nursing actions taken to assess patient injuries was found in the chart. It was unclear if the patient was attacked once or twice by the same aggressive and violent patient. Documentation provided by the facility indicate Patient #37 was assaulted twice; once prior to 5-21-2019 and once on 5-23-2019 with injury. Staff #4, Risk Manager, was unable to provide any documentation of the attacks or subsequent investigations completed by the hospital.

During a review of Patient #36's chart, it was found that the patient was discharged from the facility without physician involvement, a safe discharge plan, or a physician order.


During the tour of the facility on 6-17-2019, Patient #1, who had been sleeping on the couch, came up to the nursing station and told the surveyor that she needed to go to the hospital because she had [DIAGNOSES REDACTED] and was urinating blood. Staff #1 was immediately told of the patient request and RN Staff #11 was advised by Staff #1 to call the physician. Without any physical examination by nursing or medical staff, Staff #11 called the physician and obtained an order to transfer the patient to the local emergency room via ambulance with no indication that the patient was in an emergent situation. The patient was transferred by EMS without any of the Magnolia Behavioral Hospital staff accompanying her. On 6-18-2019, Staff #9 was asked for an update on the patient status. Staff #9 stated that the patient arrived at the local emergency room , told emergency room staff that she had a ride waiting on her and needed to go. Staff #9 stated the emergency room staff allowed her to leave Against Medical Advice (AMA). Since the patient did not have an escort or any paperwork to hold the patient involuntarily, the emergency department staff allowed her to leave AMA. It was unknown as to where the patient discharged .

The patient was still a patient of Magnolia Behavioral Hospital when transferred to the emergency department. She had been sent out for testing and evaluation not available at the facility. Since she had not been sent with appropriate escort, the medical staff of Magnolia was not advised of the patient request to be discharged . Therefore, the psychiatrist was not provided an opportunity to evaluate the patient for possible necessity of court commitment or a safe discharge. An order was obtained for discharge of patient from Magnolia after the patient had been allowed to go AMA from the other hospital.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observations, review of records, and interview, the facility failed to appropriately identify and investigate allegations of abuse and neglect in order to protect all patients in 2 out of 2 abuse allegations reported on grievance forms in the month of June 2019.

Findings included:

A Client Grievance Form for patient #39 from 6-9-2019 was reviewed. In the grievance form, Patient #39 described an incident when she became ill and vomited during meal time. Patient #39 accused a Mental Health Technician (MHT) of refusing to take her out of the cafeteria when she told him she was going to vomit. She left the cafeteria and entered the hallway where she vomited. She accused the MHT of following her and making her go back into the cafeteria by threatening her with unit restrictions.

"I was sick & he was just standing there saying that if I did not listen that he was going to put me on restrictions. That I wasn't goin to go smoke, go gym, no cafeteria. After I was done I went back to the cafeteria where he continue to taunt & agitate me & I felt very attacked." (sic)

Review of the form, Resolution to Patient Concern, dated 6-10-2019 showed that it had been completed by Staff #10. Staff #10 listed that the patient was concerned about "MHT was speaking to pt unproffesionaly, according to pt." (sic) The form contained a preprinted statement, "I tried the following interventions immediately to resolve the patient's concerns". Staff #10 listed the following, "reported to MHT Manager - ______ (Staff #12's first name) he will investigate / pt says review hallway.

The statement, "The patients concern was resolved immediately." was circled, "Yes". The patient and Staff #10 signed the form. The patient wrote "Please don't fire him" on the form. Another form, "Results:" was signed by the patient on 6-10-2019. The block was checked for the statement, "I am satisfied with the resolution to my complaint. I have talked with the Patient Advocate. I have received a written response to my grievance."

Staff #6 was asked to provide the video of the incident for review. Review of the video revealed the sequence of events occurred just as reported by the patient. No audio was available to confirm what had been said during the interaction.

Review of the incident reports for June did not show any recorded incidents of alleged abuse or neglect.

An interview was conducted with Staff #10. Staff #10 stated she did not complete any investigations. She stated she just reports complaints and grievances during the Daily Flash Meeting. Staff #1 was present during the interview and was asked if he knew of the allegations of abuse and neglect. Staff #1 stated he was aware that she had reported them during the Daily Flash Meeting but did not know who was investigating. When asked why she closed out the grievance and gave the patient a written response when no action had been taken or investigation completed, Staff #10 stated she had told the patient that Staff #12 was looking into it and that the patient did not want the MHT who made the threats to be fired. Since the patient was happy with that, she closed it out.


Staff #12, the manager of the MHTs, was interviewed. Staff #12 stated that he had not conducted an investigation or interviewed the MHT who accused of making the threatening statements to the patient and neglecting her medical needs. Staff #12 then went on to tell how this patient purposefully makes herself throw up to try to make staff angry. Staff #12 state he had been assigned this patient around the 6-7-2019 time frame, "a couple of days before this incident". Staff #12 stated she did the same thing to him and "cussed me out". When asked if this was all the patient's fault, Staff #12 replied, "Yes." When asked again, if he believed this was all the patient's fault, Staff #12 replied, "I don't know about this specific situation. I'm just telling you what happened to me."



A Client Grievance Form for patient #38 from 6-9-2019 was reviewed. In the grievance form, Patient #38 described an incident where Patient #32, a male patient, came into her room while she and her roommate were in there resting. Patient #32 told them that no one saw him come into the room and began "touching himself inappropiatly (sic) in front of us."

Staff #10 completed the Resolution to Patient Concerns form. Staff #10 listed as the patient concern, "Pt was possibly on 1:1 / Day Shift (Sunday 6-9-19)". The form contained a preprinted statement, "I tried the following interventions immediately to resolve the patient's concerns". Staff #10 listed the following, "review tape - reeducate staff - if pt was 1:1 will handle internally. Disciplinary- request therapist to speak w/pt. Pt was discharing (sic) + said it was ok not to speak w/therapist".

The statement, "The patients concern was resolved immediately." was circled, "Yes". The patient and Staff #10 signed the form. Another form, "Results:" was signed by the patient on 6-10-2019. The block was checked for the statement, "I am satisfied with the resolution to my complaint. I have talked with the Patient Advocate. I have received a written response to my grievance."

Staff #10 was interviewed. Staff #10 stated she did not investigate this incident. Staff #10 stated she was not aware of any tape review. Staff #10 stated that she was not aware of anyone handling the situation internally or any disciplinary action taken.

Staff #1 and Staff #10 were asked if the hospital had a policy or procedure for staff to follow when a patient is sexually acting out. Staff #1 confirmed that there was no policy or procedure that addressed how staff were to monitor or keep other patients safe when a patient was sexually acting out.

Staff #4 was interviewed. Staff #4 stated she was not aware of any allegations of abuse or neglect. Staff #4 confirmed that no employees were currently being investigated for allegations of abuse or neglect in Patient #38 and Patient #39 reported complaints.