The Centers for Medicare and Medicaid Services found that Timberlawn Mental Health System violated the conditions of participation for Medicare and Medicaid by failing to ensure that a safe environment was provided for its inpatients. A 25-year old male patient demonstrated psychotic and agitated behavior and physically assaulted two hospital staff. During the incident, hospital staff barricaded themselves in the nursing station leaving all 13 inpatients unsupervised and exposed to the dangerous patient. The patient proceeded to assault another patient by stepping on her head repeatedly until she became unresponsive. The female patient sustained head injuries and required transfer to an acute care hospital where she was evaluated as having diffuse cerebral edema, or swelling of the brain. One staff member “stated the unit staff could not handle Patient #1 and she was afraid of the patient.” Another told inspectors that after the aggressive patient was admitted at 18:00 PM, nursing staff “called the physician several times for medication,” and “the physician finally came up to the unit at 21:00 PM, and wrote orders for po (by mouth) medications.” In order to reestablish compliance with the CMS conditions of participation, Timberlawn revised its policies and training for behavior management emergencies, had a Corporate Clinical Training Coordinator retrain staff, and posted emergency numbers on all phones in patient care areas. Physicians were given access to two additional antipsychotic medications for emergencies, bringing the total to three, with doses stored in medication rooms for after-hours use.