TEXOMA MEDICAL CENTER

TMC BEHAVIORAL HEALTH CENTER IN SHERMAN, TEXAS

July 26, 2014 STATEMENT OF DEFICIENCIES
SOURCE: Centers for Medicare & Medicaid Services
Based on records review and interviews, the hospital failed to ensure that a
registered nurse effectively supervised the nursing care and appropriately
evaluated the risk for self harm for 2 of 12 patients (Patient #1 and #8) in
accordance withthe hospital's nursing policy.
1) Although aware of Patient #1's history of self-injurious behavior, nursing staff
failed to implement safety measures adequate to prevent the patient from causing
serious self-harm by attempting to strangle himself on 07/26/14.
2) On 09/23/14, nursing staff failed to implement safety measures that could have
prevented Patient #8 from tying a knotted sheet to the door and around his neck
that resulted in breathing problems after. Patient #8 had reported to nursing staff
his intentions to use a sheet to commit suicide by hanging less than 24 hours
earlier.
Findings included:
1) Patient #1's comprehensive admission screening dated 07/26/14, at 00:10,
reflected the patient suffered from psychosis with suicidal ideation after jumping
through a glass window.
Admission orders noted by nursing staff on 07/26/14, at 02:00, reflected suicide
precautions for Patient #1.
Suicide assessment dated by nursing staff on 07/26/14, at 02:15, noted "none."
Nursing Notes dated 07/26/14, noted that at 05:40, Patient #1 was found on the
floor of his patient room. He was "unconscious with long elastic bandage around
[his] neck ...not breathing ..." Periorbital edema (swelling around eyes) and a "small
amount of blood" were noted in the patient's mouth. The patient had "superficial
abrasions" around his neck.
ED Physician Record dated 07/26/14, at 06:30, noted Patient #1 presented with
"self-strangulation..." from the hospital's behavioral health center. The patient was
"...unconscious with difficulty breathing...was emergently intubated on arrival for
respiratory distress and airway protection...blood pressure was 184/110 mmHg...in
severe distress...ill-appearing." Diagnoses included Asphyxiation and Strangulation,
Suicide Attempt, Hypoxic Brain Injury, and Respiratory Failure.

Hospital Employee #5 stated on 10/09/14, at 14:45, she "did not think ...[Patient
#1] was actively suicidal and didn't impress me as a major threat" during the
patient admission.