TEXOMA MEDICAL CENTER

TMC BEHAVIORAL HEALTH CENTER IN SHERMAN, TEXAS

October 19, 2014 STATEMENT OF DEFICIENCIES
SOURCE: Centers for Medicare & Medicaid Services
Based on records review, interviews and observations, the hospital failed to provide
care in a safe clinical environment for 1 of 12 patients (Patient #8).
1) On 09/23/14, staff failed to put safety measures in place for Patient #8 that could
have prevented the suicidal intent of tying a knotted sheet around his neck and
resulted in breathing problems after, although Patient #8 had reported to staff the
intentions to use a sheet to commit suicide by hanging less than 24 hours earlier.
2) Items identified during initial observation on 10/08/14, that could be used by
patients to carry out self-harm were still readily accessible to patients more than 24
hours later on 10/09/14.
Findings included:
1) Patient #8's admission orders dated 09/22/14, at 16:50, reflected the patient was
on suicide precautions and had potential for self-harm.
Nursing Notes dated 09/22/14, at 20:50, noted Patient #8 reported suicidal
thoughts and planned to hang himself with a sheet.
Case Management Note dated 09/23/14, at 15:56, reflected the patient had been
depressed for a very long time and wanted "to end it all."
Nursing Note dated 09/23/14, at 18:20, reflected a nursing technician found Patient
#8 with a bed sheet wrapped around his neck. The bed sheet was knotted on top of
the door. Patient #8 stated he wanted to hang himself with the sheet.
On 10/09/14, at 11:07, Hospital Employee #11 was interviewed about the incident
and stated she had been notified of the incident but the patient "was attention
seeking." Hospital Employee #11 denied awareness of Patient #8's suicidal
thoughts prior to the incident.
On 10/09/14, at 13:00, Hospital Personnel #1 was asked about the incident and
stated, "Nothing was done about it yet."
Hospital Employee #13 stated during an interview on 10/09/14, at 14:00, she saw a
knotted sheet outside the closed patient door and had to push her way into the
room because the patient partially blocked the door. With the help from another
nurse, Hospital Employee #13 was able to untie the knots and remove the sheet.

The patient had trouble breathing after the incident. Hospital Employee #13 denied
awareness of Patient #8's suicidal intention prior to the incident.
Hospital Policy BHC V.5 titled Self harm/Suicide Prevention, dated 07/2013,
reflected that staff members were to review suicide prevention education sheets.
The hospital provided Suicide Awareness pamphlet, undated, noted that suicide
warning signs included talking about suicide or death, or "ending it all."
2) A two-drawer cabinet filled with multiple compact discs (CDs), digital video
discs (DVDs), and video tapes breakable into sharp edges was observed accessible
to a female patient who was by herself in the dayroom in the hospital's PCU
(Progressive Care Unit) on 10/08/14 at 14:50. Staff members were behind the
nurses' station.
Hospital Personnel #2 acknowledged on 10/08/14, at 14:50, that CDs and DVDs
could be used for self-harm and would be removed.
On 10/09/14, at 16:55, the same two drawers were observed again with CDs, DVDs,
and video tapes. Hospital Personnel #2 witnessed the items at that time and stated
she had delegated the task of removing the items the day before and it did not get
done.
On 10/09/14, at 15:30, Hospital Personnel #5 was asked whether she was worried
about patient safety and stated, "Yes, because staff stays behind the nurses'
station."