At approximately 7:00 a.m. on August 8, 2007, a fire alarm went off in the west corridor affecting housing Units 5 through 12. Normal procedure requires the evacuation of all patients when a fire alarm sounds, and evacuation procedures are to be in effect until the fire alarm is cleared by fire personnel.

The problem reported herein occurred on Unit 7. The Unit 7 staff claimed to have done a "sweep" of all the rooms on that unit, and forced everyone they found off the unit. As the unit staff inspected and ensured that each room was empty of patients, the staff then locked the door of that room. After "clearing" each room on the unit and escorting the patients to a small outside courtyard, hospital police officers and staff members conducted a patient count to ensure all patients were indeed evacuated from the unit and accounted for.

Unit 7 patients report that Senior Psychiatric Technician ' Miriam Joya "cleared" the unit and was the last staff to leave and lock the door behind herself.

After the evacuating of Unit 7 was supposedly complete, Officer Lander of the hospital's Department of Police Services (" DPS") discovered three patients were not accounted for. Officer Lander believed the missing patients were at the Dining Hall, and went there where she did indeed find the three missing patients.

When Officer Lander returned to the evacuation site and reported the location of the three missing patients, the Unit 7 count was CLEARED.

A few minutes later the Fire Marshal cleared the alarm and allowed the staff and patients to reenter the building and return to their rooms. Each room had to be unlocked before the patients could then reenter.

It was then that patient Michael St. Martin informed Senior Psychiatric Technician Joya that he thought they had left one patient in his room inside the building during the evacuation. According to St. Martin Joya then said, "No, I personally saw Mr. G.P. z outside and verified he was out of the building."

Mr. St. Martin states that he then requested Officer Lander accompany him to the treatment room, which had recently been converted to patient housing. 3 Officer Landers did then accompany St. Martin to the converted treatment room, now patient housing room. Officer Lander then unlocked the door, where they did indeed find Mr. G.P. asleep in his bed. He had to have been there all the time, as he could not have reentered the locked room.

It appears that staff failed to check this new patient room in their sweep of the unit. This time, the fire alarm was caused by staff on Unit 10 catching an electric shaver charging cord in the paper shredder causing it to short-out. This time there was no actual fire and no one was hurt.
Had this been a real fire, Mr. G.P. would have been locked in his room, locked in the building, and in real danger of serious smoke inhalation or even death. Furthermore, since the rooms are never locked except under special situations such as a fire drill, some staff member with keys must have actually locked the door without actually checking to see whether or not the room was occupied. Senior Psychiatric Technician Miriam Joya was the shift supervisor on Unit 7, and as such had the ultimate responsibility to ensure all patients had been evacuated. Not only did she fail to adequately perform this function, but after being confronted, she continues to deny any responsibility.