A federal report clears the Soldiers & Sailors Emergency Department of allegations that an aggressor should not have been discharged five hours before he allegedly murdered his mother and her dog.

It’s been almost a year since a Dresden area woman was brutally attacked and her dog was killed— allegedly by her son — Paul Khouzam, 38, a man with a violent criminal history who had been evaluated by a physician, a psychiatrist, and others at Soldiers & Sailors Memorial Hospital emergency department and released just hours before.

The woman — Magda Khouzam-Daoud, M.D. a former employee of Finger Lakes Health, the health care system that owns Soldiers & Sailors Memorial Hospital — clung to life in a Rochester hospital until her death Oct. 18, 2018.

Since the crime and Khouzam’s indictment on second-degree murder and other charges, questions about the crime and his treatment at the emergency department have hung over people in the medical field, law enforcement, and the community at large.

Through a lengthy Freedom of Information Act process, The Chronicle-Express secured information about Khouzam’s care at the Soldiers & Sailors Memorial Hospital emergency department on Aug. 5, 2018.

A partially redacted ACTS Complaint/Incident Investigation Report received in June from Centers for Medicare & Medicaid Services provides some details about the night of Aug. 5.

The Federal Critical Access Hospital Allegation survey was conducted Aug. 13 and 14, 2018 after media reports of the case came to the attention of officials in Rochester. Inspectors concluded that the allegation that Khouzam should not have been discharged from the emergency department could not be substantiated and no citations were issued to the hospital.

Hospital officials say federal HIPAA privacy laws prevent them from commenting on a specific patient and his or her care, so many of the questions about how and why certain decisions were made remain unanswered in a public forum.

But the facts documented in the survey report and other sources show:

• The investigation did not include interviews with the Yates County Sheriff Deputies who transported Khouzam to the hospital.

• Khouzam was known to emergency department staff, who also knew he was on probation, and were aware of his criminal history and previous in- and out-patient psychiatric care, and had previous contact with him for acute medical issues. But during interviews, the attending MD and at least one staff person said they did not notice anything unusual about his behavior. Yet, the next day, a S&S staff person advised Yates County Jail officials, where he was held following arraignment, that suicide watch jail procedures should continue.

• The decision to discharge Khouzam was made within 45 minutes of his entry to the ED.

• In accordance with hospital procedures, Khouzam was never evaluated in person by a psychiatrist. The crisis counselor and the emergency department doctor evaluated him and consulted with the on-call psychiatrist. This team decided to discharge him with an appointment at the outpatient clinic the next day. Hospital officials say HIPPA regulations prohibit them from notifying law enforcement of a patient’s discharge.

• S&S hospital officials say this tragic community-based incident was not a hospital incident.

Details help form a timeline

Details in the partially redacted report help fill in a timeline of the incidents of Aug. 5 and 6. However, additional details from the Yates County Sheriff’s Office are not available because of the ongoing judicial proceedings. The Sheriff’s Office has denied The Chronicle-Express’s request for 911 center recordings, documents, notes, and reports under a Freedom of Information request.

A timeline built from information from the survey report and details from the preliminary arrest and investigation reports from the Sheriff’s Office follows:

Aug. 5, 2018

7:22 p.m.: Yates County Sheriff’s Deputies transported Khouzam to the emergency department on a 9.41 Mental Hygiene Law. The arrest report stated, “(Khouzam) has not taken medications for the last few days. He is paranoid and felt like he was going to hurt himself. (He) stated he hit his head on the wall a few times and he thought he was God. New York State Mental Hygiene Law states that any peace officer or police officer may take into custody any person who appears mentally ill and is conducting him/herself in a manner which is likely to result in serious harm to the person or others. Such officer may direct removal or remove such person to any hospital pending his/her examination or admission to any such hospital.

7:46 p.m.: ED Nursing Triage Assessment: “Patient states the holy spirit told him to stop taking his medication. He is laughing at Sheriffs, then weeping seconds later.” The nurse documents that he is cooperative.

7:58 p.m.: Nursing Psychological Assessment: “Cooperative but fearful. States he has a psychiatric history of bipoloar disorder. He denies thoughts of harming self or others.”

8:08 p.m.: Physician Assessment: “Patient states that he cannot explain what is going on, but a lot of stuff has happened the last few days. Admits to not taking his medication for the last three days, but took them this morning after reminded by mother. Physical exam, blood, drug and alcohol toxicology unremarkable. The Crisis Counselor evaluated (him) and discussed with the psychiatrist on call. They agreed that (he) may be safely discharged home with follow-up tomorrow at the mental health clinic.”

9:30 p.m.: A Crisis ED Assessment was completed, which resulted in a lethality risk assessment of “moderate” and a violence risk assessment of ‘moderate.”

“He declined to give information regarding previous domestic violence, criminal trespass, orders of protection and child abuse. He denied animal abuse and fire setting. The clinician concluded he did not meet the standard for inpatient admission due to denying suicidal ideation, homicidal ideation, visual stimulation and violent outburst. He is not presenting as acutely psychotic or depressed.”

10:10 p.m.: After he was assessed as having a mood disorder with antisocial traits, he was discharged with instructions for an appointment at the outpatient mental health clinic at 12:30 p.m. Aug. 6.

Aug. 6, 2018

5:52 a.m.: The Yates County Sheriff’s Office received a call from Seneca County 911 reporting a call they took from Arrowhead Beach Road near the village of Dresden (cell phone calls from the western side of Seneca Lake often go to cell towers on the eastern side of the lake). Information about who placed the call has not been released by the Sheriff’s Office.

5:59 a.m.: Responding deputies took Khouzam into custody as he walked along Arrowhead Beach Road. Deputies found the victim, bludgeoned and stabbed by dangerous instruments, unconscious and bleeding in the basement. They also found a small dog inside the home, allegedly killed by Khouzam. The victim was transported to Strong Memorial Hospital in Rochester, where she underwent emergency surgery for head and upper body injuries.

10 a.m.: Soldiers & Sailors Staff Psychiatrist made correction notations to the ED Crisis Assessment completed at 9:30 p.m. the previous night, changing the lethality risk assessment to “low” and violence risk assessment also to “low.”

The staff psychiatrist’s notes include the following statement: “Legal history obtained and no history of violence to others reported in the past.”

However, Khouzam has had multiple encounters with law enforcement, and was serving 5 years probation for felony 3rd-degree criminal mischief in Schuyler County, and 3 years probation for a 2016 DWI conviction in Geneva. He also has multiple prior arrests and contacts with law enforcement in Yates, Schuyler, Ontario, and Wayne Counties, according to Yates County Sheriff Ron Spike and earlier reporting.

In 2006 Khouzam allegedly grabbed his estranged girlfriend by the throat, threw her over a couch and into a bookcase. He did so in front of a 6-month-old baby. Khouzam was charged with burglary, menacing, and endangering the welfare of a child.

In 2014 Khouzam struck a Dresden resident, then punched a New York State Trooper who responded to the 911 call. The trooper used pepper spray on Khouzam, who was transported to Soldiers & Sailors Memorial Hospital in Penn Yan for a mental health evaluation. The trooper was not injured. Khouzam was arraigned in Torrey Town Court and remanded to Yates County Jail.

Also in 2014, Khouzam was convicted of criminal mischief and sentenced to 5 years probation in Schuyler County.

In 2017 he was arrested in Ontario County and charged with operating a motor vehicle while impaired by drugs.

Oct. 18, 2018

Magda Khouzam-Daoud, 67, died at a Monroe County hospice care facility.

Nov. 1, 2018

Paul Khouzam was indicted on murder and other charges.

April 9, 2019

Khouzam is found to be “an incapacitated person at this time;” and committed to a secure psychiatric facility for no longer than one year.

The Criminal Case

Aug. 6, 2018, Khouzam was charged with 1st-degree assault, and 1st-degree burglary, both Class B felonies; and aggravated cruelty to an animal, also a felony. He was arraigned and sent to Yates County Jail awaiting grand jury action. Bail has been set at $1 million cash or $2 million bond.

A Yates County Grand Jury indicted Khouzam with 2nd-degree murder, 1st-degree burglary, two counts of 3rd-degree criminal possession of a weapon, and aggravated cruelty to animals on Nov. 1, 2018.

Yates County District Attorney Todd Casella states that 2nd-degree murder is a class A-I felony punishable by 25 years to life in prison. First-degree burglary is a class B violent felony, 3rd-degree criminal possession of a weapon is a class D felony, and aggravated cruelty to animals is a class E felony.

He was scheduled for arraignment Nov. 15.

Khouzam re-appeared in Yates County Criminal Court April 9. Shackled to the waist, with a long beard, and making no eye or audible contact with his attorney, Khouzam stood silently throughout the appearance.

According to Judge Jason Cook, two independent psychiatric reports ordered by the court, conducted by Dr. Richard Hoyt and Dr. Mark Reynolds, both found Khouzam to be “an incapacitated person at this time;” unable to recall events, understand the charges or criminal process, nor to assist in his defense, having no functional relationship with assigned attorney Robert Zimmerman.

Both Zimmerman and District Attorney Todd Casella requested that Cook issue an order of commitment.

Cook concurred and committed Khouzam to the New York State Commissioner of Mental Health for him to be held in an appropriate, secure, psychiatric facility for up to one year. He had been held in the Yates County Jail since his November 2018 indictment.

Finger Lakes Health Officials Respond to Questions

The Chronicle-Express submitted several questions to Finger Lakes Health Administrator Jose Acevedo in June. Lara Turbide, Vice President, Community Services, responded via email:

“As you are aware, there were no findings related to care delivered related to the information you requested. Any concerns or allegations related to patient care were unfounded and the review concluded with no citations issued.

“Related to any patient in general, health care providers care for patients based on clinical information, presentation, and a clinical assessment. Clinicians do not discriminate and/or deliver or withhold care based on other factors including past history or criminal record. Inpatient care, clinical status changes and documentation updates are part of the on-going clinical assessment process."

Questions and responses follow:

Q: What changes were made to S&S policies and procedures in response to this incident?

A: None

Q: What are the clinical standards for admitting a person with a “mood disorder” diagnosis or other psychiatric diagnoses?

A: A physician uses his/her substantial clinical training and experience and the diagnosis criteria and standards as defined by the DSM-V.

 

Q: Why did Soldiers & Sailors tell the Sheriff’s Office that Mr. Khouzam must not be taken off the suicide watch list if he was, in the emergency department, determined to not be a threat to himself?

A: Due to federal HIPAA privacy laws, we cannot comment on a specific patient or their care as you are aware.

 

Q: Why did the psychiatrist, within hours of Mr. Khouzam attacking his mother and killing her dog, reduce his Lethality Risk Assessment and Violence Risk Assessments to low after they had both been determined the night before as moderate?

A: Due to federal HIPAA privacy laws, we cannot comment on a specific patient or their care as you are aware.

 

Q: Mr. Khouzam has an easily accessible criminal record  that includes domestic violence, violent behavior toward law enforcement, and the Crisis ED Assessment Form documents “he has a history of legal issues regarding domestic violence, driving while intoxicated, criminal trespass and breaking an order of protection.”  Yet the psychiatrist “corrected” the Risk assessment to say “no history of violence to others reported in the past.”

A: Due to federal HIPAA privacy laws, we cannot comment on a specific patient or their care as you are aware.

 

Q: Was the psychiatrist aware of the alleged crime at the time of the change?

A: Due to federal HIPAA privacy laws, we cannot comment on a specific patient or their care as you are aware.

 

Q: When a patient is brought into the emergency department under 9.41 Mental Hygiene Law, is there any communication with law enforcement on the release or admission of the individual? If not, why? And do you think it might be advisable in the future?

A: Regardless of the diagnosis, or how a patient arrives at the Emergency Department, the patient care is provided based on clinical assessment and presentation. Patient information is protected by federal privacy laws and diagnosis and discharge information are aspects of this. A patient him/herself would the one to communicate about his or her discharge status to others regardless of who brought him/her to the Emergency Department.

 

Q: It was interesting to note that this incident came to the attention of state DOH officials through media reports. Please describe the procedures the hospital is required to follow in reporting serious incidents.

A: This was a heartbreaking, tragic community-based incident which resulted in a criminal investigation and arrest. It was not a hospital incident. Therefore, DOH reporting guidelines that we follow would not pertain.”