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Based on a review of clinical records, video surveillance, facility documentation and interviews with staff, the governing body failed to provide adequate oversight of the hospital, as facility staff failed to follow the facility's policies and procedures, and the facility failed to have a policy and procedure for addressing patient abuse and neglect. This has the potential to adversely affect all patients who are treated at the facility.

Findings were:

The hospital failed to follow their own policies and procedures, "Patient Rights and Responsibilities" and also "Levels of Observation and Care".

The facility also failed to provide a policy and procedure addressing patient abuse and neglect. On 10-1-14, staff #9 confirmed that the facility did not have a policy regarding abuse and neglect.

The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.

Cross Refer to:
A0057

Based on a review of clinical records, video surveillance, facility documentation and interviews with staff, the chief executive officer failed to provide effective oversight of the hospital. The hospital failed to follow their own policies and procedures and also failed to provide a policy and procedure addressing patient abuse and neglect.


Findings were:


A review of the unit surveillance video for 8-12-14 for patient #1 was conducted by the surveyor. The video was viewed from 9:37 on 8-12-14 to 10:02 on 8-12-14. The following was observed:


? 0937:04 seconds - Staff #5 was seen standing in hallway, outside the door of patient #1's room.


? 0938:25 seconds - Staff #2 and Staff #7 walked up and entered patient #1's room.


? 0939:44 seconds - Staff #3 and Staff #5 entered patient #1's room.


? 0940:22 seconds - Staff #3, Staff #2 and Staff #4 exit patient #1's room, carrying the patient by her arms and legs. Staff #3 carried the patient's legs, Staff #2 carried the patient's right arm and staff #4 carried the patient's left arm. The above listed 3 staff members deposited patient #1 on the floor of the hallway, outside the door of her room. Staff #7 and Staff #1 (already in room) exited the patient's room but did not touch the patient. Door was pulled shut behind patient. During the duration of the next 20 minutes, patient continued to lie on the floor of the hallway during which time other mobile patients walked around her and wheelchair-bound patients wheeled around her. Staff #1 stood in constant attendance off to the side of the patient.


? 1001:09 seconds - A set of keys was handed to Staff #5 and she appeared to use a key to unlock patient #1's room. Patient #1 got up off the floor and entered her room.



At any time while the patient was lying on the floor, she could have been injured by patients walking or operating their wheelchairs around her.



Facility policy & procedure titled "Patient Rights and Responsibilities" stated, in part, "POLICY - El Paso Psychiatric Centers (EPPC) policy is to preserve the patient's basic human rights during hospitalization.


5.2 RIGHTS
M. Respect and Dignity: The patients have the right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual ...
O. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned."



The patient #1's observation/precaution levels throughout her stay were as follows:

? 7-30-14 at 0216 - 1:1 eyesight w/q 15 minute checks if asleep
? 7-30-14 at 1655 - 1:1 eyesight continuous
? 7-31-14 at 1636 - 1:1 eyesight continuous
? 8-1-14 at 2347 - 1:1 eyesight continuous
? 8-1-14 at 2351 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-2-14 at 1807 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-3-14 at 1820 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-4-14 at 1644 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-5-15 at 1533 - 1:1 eyesight continuous
? 8-6-14 at 1731 - 1:1 eyesight continuous
? 8-7-14 at 1139 - Intensive Observation Service (q 15 min checks per policy)
? 8-7-14 at 1657 - 1:1 eyesight continuous
? 8-8-14 at 2354 - 1:1 eyesight continuous
? 8-9-14 at 1359 - 1:1 eyesight continuous
? 8-10-14 at 1750 - 1:1 eyesight continuous
? 8-11-14 at 1445 - 1:1 arm's length continuous
? 8-12-14 at 1412 - 1:1 arm's length continuous
? 8-13-14 at 1511 - 1:1 arm's length continuous
? 8-14-14 at 1739 - 1:1 arm's length continuous
? 8-15-14 at 1735 - 1:1 arm's length continuous
? 8-16-14 at 2000 - 1:1 arm's length continuous
? 8-17-14 at 1125 - 1:1 arm's length continuous
? 8-18-14 at 1333 - 1:1 arm's length continuous
? 8-19-14 at 1918 - 1:1 eyesight continuous
? 8-19-14 at 2104 - 1:1 arm's length continuous
? 8-21-14 at 1446 - Intensive Observation Service



The patient remained on Intensive Observation Service through the end of her stay.


A review of the "Close Observation Documentation Form" (s) completed throughout the stay for patient #1 revealed no indication of precaution type or monitoring frequency on any of the 28 forms used throughout the patient's stay.


Facility policy & procedure titled "Levels of Observation and Care" stated, in part:


1.0 "POLICY
It is the policy of El Paso Psychiatric Center (EPPC) to constantly assess the degree of harm or threat of harm to self or others of all admitted patients and to place a patient determined to be a suicide/harm risk on special precautions. EPPC patients will be assessed throughout their length of stay for levels of observation and care. Observation is required to ensure safety and to therapeutically manage the patient.


5.0 Procedures
5.6 The twenty-four (24) hour Close Observation Documentation form will be complete for all observations and become a part of the patients' permanent medical record. This form is complete by the assigned SST and will be filed in the chart by the unit clerk or designee."


In an interview with staff #9 on 10-1-14 at 3:40 pm, the surveyor asked again to review the facility's policy regarding abuse and neglect (a policy requested several times during the survey). Staff #9 confirmed that the facility did not have a policy regarding abuse and neglect.


The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.

Based on a review of documentation and surveillance video, as well as interviews with staff, the hospital failed to ensure that the rights of the patients were protected and promoted. Physical restraint was applied to a patient even though the patient was not presenting risk of harm to themselves or others. The patient was not monitored at the proper level prescribed by the physician throughout her stay. The facility failed to have a policy and procedure for addressing patient abuse and neglect.


Findings were:


A patient was allowed to lie on the floor while other patients moved around her and she was not monitored at the level ordered by the physician throughout her stay. Cross Refer to: A0144

A patient was forcibly removed from a location despite the fact that she was neither violent nor aggressive and the facility was unable to furnish a policy regarding abuse and neglect. Cross Refer to: A0145

Restraint was imposed for reasons other than to ensure the immediate physical safety of the patient, a staff member, or others. Cross Refer to: A0154

Based on a review of written and video documentation, the facility failed to ensure that patient #1 received care in a safe setting. A patient was allowed to lie on the floor while other patients moved around her and she was not monitored at the level ordered by the physician throughout her stay.


Findings were:


A review of the unit surveillance video for 8-12-14 for patient #1 was conducted by the surveyor. The video was viewed from 9:37 on 8-12-14 to 10:02 on 8-12-14.


The following was observed:


? 0937:04 seconds - Staff #5 is seen standing in hallway, outside the door of patient #1's room.


? 0938:25 seconds - Staff #2 and Staff #7 walked up and entered patient #1's room.


? 0939:44 seconds - Staff #3 and Staff #5 entered patient #1's room.


? 0940:22 seconds - Staff #3, Staff #2 and Staff #4 exited patient #1's room, carrying the patient by her arms and legs. Staff #3 carried the patient's legs, Staff #2 carried the patient's right arm and staff #4 carried the patient's left arm. The above listed 3 staff members deposited patient #1 on the floor of the hallway, outside the door of her room. Staff #7 and Staff #1 (already in room) exited the patient's room but did not touch the patient. Door was pulled shut behind patient. During the duration of the next 20 minutes, patient continued to lie on the floor of the hallway during which time other mobile patients walked around her and wheelchair-bound patients wheeled around her. Staff #1 stood in constant attendance off to the side of the patient.


? 1001:09 seconds - A set of keys was handed to Staff #5 and she appeared to use a key to unlock patient #1's room. Patient #1 got up off the floor and entered her room.


At any time while the patient was lying on the floor, she could have been injured by patients walking or operating their wheelchairs around her.


The patient 1's observation/precaution levels throughout her stay were as follows:

? 7-30-14 at 0216 - 1:1 eyesight w/q 15 minute checks if asleep
? 7-30-14 at 1655 - 1:1 eyesight continuous
? 7-31-14 at 1636 - 1:1 eyesight continuous
? 8-1-14 at 2347 - 1:1 eyesight continuous
? 8-1-14 at 2351 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-2-14 at 1807 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-3-14 at 1820 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-4-14 at 1644 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-5-15 at 1533 - 1:1 eyesight continuous
? 8-6-14 at 1731 - 1:1 eyesight continuous
? 8-7-14 at 1139 - Intensive Observation Service (q 15 min checks per policy)
? 8-7-14 at 1657 - 1:1 eyesight continuous
? 8-8-14 at 2354 - 1:1 eyesight continuous
? 8-9-14 at 1359 - 1:1 eyesight continuous
? 8-10-14 at 1750 - 1:1 eyesight continuous
? 8-11-14 at 1445 - 1:1 arm's length continuous
? 8-12-14 at 1412 - 1:1 arm's length continuous
? 8-13-14 at 1511 - 1:1 arm's length continuous
? 8-14-14 at 1739 - 1:1 arm's length continuous
? 8-15-14 at 1735 - 1:1 arm's length continuous
? 8-16-14 at 2000 - 1:1 arm's length continuous
? 8-17-14 at 1125 - 1:1 arm's length continuous
? 8-18-14 at 1333 - 1:1 arm's length continuous
? 8-19-14 at 1918 - 1:1 eyesight continuous
? 8-19-14 at 2104 - 1:1 arm's length continuous
? 8-21-14 at 1446 - Intensive Observation Service


The patient remained on Intensive Observation Service through the end of her stay.


A review of the "Close Observation Documentation Form" (s) completed throughout the stay for patient #1 revealed no indication of precaution type or monitoring frequency on any of the 28 forms used throughout the patient's stay.


Facility policy & procedure titled "Levels of Observation and Care" stated, in part:


1.0 "POLICY
It is the policy of El Paso Psychiatric Center (EPPC) to constantly assess the degree of harm or threat of harm to self or others of all admitted patients and to place a patient determined to be a suicide/harm risk on special precautions. EPPC patients will be assessed throughout their length of stay for levels of observation and care. Observation is required to ensure safety and to therapeutically manage the patient.


5.0 Procedures
5.6 The twenty-four (24) hour Close Observation Documentation form will be complete for all observations and become a part of the patients' permanent medical record. This form is complete by the assigned SST and will be filed in the chart by the unit clerk or designee."


Facility policy & procedure titled "Patient Rights and Responsibilities" states, in part, "POLICY - El Paso Psychiatric Centers (EPPC) policy is to preserve the patient's basic human rights during hospitalization.


5.2 RIGHTS
M. Respect and Dignity: The patients have the right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual ...
O. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned."


The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.

Based on review of documentation, review of video surveillance and interviews with staff, the hospital failed to ensure that patient #1 was free from all forms of abuse. The patient was forcibly removed from a location despite the fact that she was neither violent nor aggressive and the facility was unable to furnish a policy regarding abuse and neglect.

Findings were:

A review of the unit surveillance video for 8-12-14 for patient #1 was conducted by the surveyor. The video was viewed from 9:37 on 8-12-14 to 10:02 on 8-12-14. The following was observed:

? 0937:04 seconds - Staff #5 is seen standing in hallway, outside the door of patient
#1's room.

? 0938:25 seconds - Staff #2 and Staff #7 walk up and enter patient #1's room.

? 0939:44 seconds - Staff #3 and Staff #5 enter patient #1's room.

? 0940:22 seconds - Staff #3, staff #2 and Staff #4 exit the patient #1's room, carrying the patient by her arms and legs. Staff #3 carries the patient's legs, staff #2 carries the patient's right arm and staff #4 carries the patient's left arm. The above listed 3 staff members deposit patient #1 on the floor of the hallway, outside the door of her room. Staff #7 and staff #1 (already in room) exit the patient's room but do not touch the patient. Door is pulled shut behind patient. During the duration of the next 20 minutes, patient continues to lie on the floor of the hallway during which time other mobile patients walk around her and wheelchair-bound patients wheel around her. Staff #1 stands in constant attendance off to the side of the patient.

? 1001:09 seconds - A set of keys is handed to staff #5 and she appears to use a key to unlock patient #1's room. Patient #1 gets up off the floor and enters her room.



In an interview with staff #8 on 10-1-14 at 1:30 pm, he stated that he had been one of the training specialists for the last 5 years. When asked if there was a technique or procedure taught to staff during PMAB (Prevention and Management of Aggressive Behavior) training (or any training) that supported picking up a non-violent patient up by any means and moving them from one location to another, staff #8 stated that there was not. Staff #8 stated that PMAB is used strictly to de-escalate a violent patient or a patient that is at increased risk for becoming violent. Staff #8 stated that staff members are to only "put hands on" a patient if the patient is harming themselves or someone else.


In an interview with staff #9 on 10-1-14 at 3:40 pm, the surveyor asked again to review the facility's policy regarding abuse and neglect (a policy requested several times during the survey). Staff #9 confirmed that the facility did not have a policy regarding abuse and neglect.


The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.

Based on a review of written and video documentation as well as an interview with staff, the facility failed to ensure that the patient was free from physical abuse. Restraint was imposed for reasons other than to ensure the immediate physical safety of the patient, a staff member, or others.

Findings were:


A review of the unit surveillance video for 8-12-14 for patient #1 was conducted by the surveyor. The video was viewed from 9:37 on 8-12-14 to 10:02 on 8-12-14.


The following was observed:


? 0937:04 seconds - Staff #5 is seen standing in hallway, outside the door of patient
#1's room.


? 0938:25 seconds - Staff #2 and Staff #7 walked up and entered patient #1's room.


? 0939:44 seconds - Staff #3 and Staff #5 entered patient #1's room.


? 0940:22 seconds - Staff #3, staff #2 and Staff #4 exited the patient #1's room, carrying the patient by her arms and legs. Staff #3 carried the patient's legs, staff #2 carried the patient's right arm and staff #4 carried the patient's left arm. The above listed 3 staff members deposited patient #1 on the floor of the hallway, outside the door of her room. Staff #7 and staff #1 (already in room) exited the patient's room but did not touch the patient. Door was pulled shut behind patient. During the duration of the next 20 minutes, patient continued to lie on the floor of the hallway during which time other mobile patients walked around her and wheelchair-bound patients wheeled around her. Staff #1 stood in constant attendance off to the side of the patient.


? 1001:09 seconds - A set of keys was handed to staff #5 and she appeared to use a key to unlock patient #1's room. Patient #1 got up off the floor and entered her room.



In an interview with staff #8 on 10-1-14 at 1:30 pm, he stated that he had been one of the training specialists for the last 5 years. When asked if there was a technique or procedure taught to staff during PMAB (Prevention and Management of Aggressive Behavior) training (or any training) that supported picking up a non-violent patient up by any means and moving them from one location to another, staff #8 stated that there was not. Staff #8 stated that PMAB is used strictly to de-escalate a violent patient or a patient that is at increased risk for becoming violent. Staff #8 stated that staff members are to only "put hands on" a patient if the patient is harming themselves or someone else.


The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.

Based on a review of clinical records, interviews with staff, review of video surveillance, and review of facility documentation, the nursing services were not adequately supervised by a registered nurse. This has the potential to adversely affect all patients who are treated at the facility.

Findings were:

The nursing care of each patient was not assigned to nursing personnel in accordance with the competence of the nursing staff available, resulting in a violation of a patient's right to care in a safe setting and the right to be free from abuse or harassment. The patient was also restrained needlessly and placed in a location (following the restraint) where she could have potentially suffered physical injury. Additionally, no staff instruction or retraining was performed following the incident involving patient #1 on 8-12-14.


Cross Refer to:
A0397

Based on a review of clinical records, video surveillance, facility documentation and interviews with staff, the nursing care of each patient was not assigned to nursing personnel in accordance with the competence of the nursing staff available, resulting in a violation of a patient's right to care in a safe setting and the right to be free from abuse or harassment. The patient was also restrained needlessly and placed in a location (following the restraint) where she could have potentially suffered physical injury. Additionally, no staff instruction or retraining was performed following the incident involving patient #1 on 8-12-14.


Findings were:


A review of the unit surveillance video for 8-12-14 for patient #1 was conducted by the surveyor. The video was viewed from 9:37 on 8-12-14 to 10:02 on 8-12-14.


The following was observed:

? 0937:04 seconds - Staff #5 is seen standing in hallway, outside the door of patient #1's room.

? 0938:25 seconds - Staff #2 and Staff #7 walked up and entered patient #1's room.


? 0939:44 seconds - Staff #3 and Staff #5 entered patient #1's room.


? 0940:22 seconds - Staff #3, Staff #2 and Staff #4 exited patient #1's room, carrying the patient by her arms and legs. Staff #3 carried the patient's legs, Staff #2 carried the patient's right arm and staff #4 carried the patient's left arm. The above listed 3 staff members deposited patient #1 on the floor of the hallway, outside the door of her room. Staff #7 and Staff #1 (already in room) exited the patient's room but did not touch the patient. Door was pulled shut behind patient. During the duration of the next 20 minutes, patient continued to lie on the floor of the hallway during which time other mobile patients walked around her and wheelchair-bound patients wheeled around her. Staff #1 stood in constant attendance off to the side of the patient.


? 1001:09 seconds - A set of keys was handed to Staff #5 and she appeared to use a key to unlock patient #1's room. Patient #1 got up off the floor and entered her room.


At any time while the patient was lying on the floor, she could have been injured by patients walking or operating their wheelchairs around her.


The patient's observation/precaution levels throughout her stay were as follows:

? 7-30-14 at 0216 - 1:1 eyesight w/q 15 minute checks if asleep
? 7-30-14 at 1655 - 1:1 eyesight continuous
? 7-31-14 at 1636 - 1:1 eyesight continuous
? 8-1-14 at 2347 - 1:1 eyesight continuous
? 8-1-14 at 2351 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-2-14 at 1807 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-3-14 at 1820 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-4-14 at 1644 - 1:1 eyesight w/q 15 minute checks if asleep
? 8-5-15 at 1533 - 1:1 eyesight continuous
? 8-6-14 at 1731 - 1:1 eyesight continuous
? 8-7-14 at 1139 - Intensive Observation Service (q 15 min checks per policy)
? 8-7-14 at 1657 - 1:1 eyesight continuous
? 8-8-14 at 2354 - 1:1 eyesight continuous
? 8-9-14 at 1359 - 1:1 eyesight continuous
? 8-10-14 at 1750 - 1:1 eyesight continuous
? 8-11-14 at 1445 - 1:1 arm's length continuous
? 8-12-14 at 1412 - 1:1 arm's length continuous
? 8-13-14 at 1511 - 1:1 arm's length continuous
? 8-14-14 at 1739 - 1:1 arm's length continuous
? 8-15-14 at 1735 - 1:1 arm's length continuous
? 8-16-14 at 2000 - 1:1 arm's length continuous
? 8-17-14 at 1125 - 1:1 arm's length continuous
? 8-18-14 at 1333 - 1:1 arm's length continuous
? 8-19-14 at 1918 - 1:1 eyesight continuous
? 8-19-14 at 2104 - 1:1 arm's length continuous
? 8-21-14 at 1446 - Intensive Observation Service


The patient remained on Intensive Observation Service through the end of her stay.


A review of the "Close Observation Documentation Form" (s) completed throughout the stay for patient #1 revealed no indication of precaution type or monitoring frequency on any of the 28 forms used throughout the patient's stay.


As the patient had a history of suicidal attempts and self-harm, failure on the nurse's part to ensure that the patient was properly monitored at the level ordered by her physician throughout her stay may have resulted to physical harm to the patient.


In an interview with staff #8 on 10-1-14 at 1:30 pm, he stated that he had been one of the training specialists for the last 5 years. When asked if there was a technique or procedure taught to staff during PMAB (Prevention and Management of Aggressive Behavior) training (or any training) that supported picking up a non-violent patient up by any means and moving them from one location to another, staff #8 stated that there was not. Staff #8 stated that PMAB is used strictly to de-escalate a violent patient or a patient that is at increased risk for becoming violent. Staff #8 stated that staff members are to only "put hands on" a patient if the patient is harming themselves or someone else.


In separate interviews with staff members #1, #2 and #4 on 10-1-14, all three staff stated to the surveyor that they had picked the patient up and removed her from her room and deposited her in the unit hallway at the instruction of the Registered Nurse on the unit.


Review of personnel files for staff #1, staff #2, staff #3, staff #4 and staff #5 revealed current CPR (cardiopulmonary resuscitation and PMAB (Prevention and Management of Aggressive Behavior) training that was also current on 8-12-14. The files revealed no evidence of additional training or re-training after 8-12-14.


In an interview with staff #9 on 10-1-14 at 3:40 pm, staff #9 verified that no additional training or re-training of staff had occurred following the incident with patient #1 on 8-12-14.


The above was verified in an interview with the Nurse Manager and the Quality Oversight Director on the afternoon of 10-1-14 in an administrative office.