The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX 79902 April 12, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of training files and review of 1 of 3 clinical records there was a failure to ensure a safe treatment environment by using an unapproved restraint procedure resulting in a patient injury.
Findings:

Citing patient #1, an [AGE] year old male, was admitted to the facility on [DATE] due to severe aggressive behavior.
A progress note written by personnel #21, psychiatric technician(Psych Tech) reflected the following:

2/15/2011 12:50pm " Patient walked out of school saying his throat was hurting..........he sat in the hallway threatening a peer with "I ' m going to beat you up." Patient then went into another peers's room and scratched his arm. Writer intervened. The patient then attempted to hit peer with his fist then grabbed writer by the shirt. Writer grabbed patient by the wrists. Patient then threw himself to the ground. A pop from his arm was heard."

An X-ray performed on 2/16/2011 diagnosed : Supracondylar fracture of the left humerous.

Review of the personnel file for personnel #21 reflected current training in non violent crisis intervention. A post test following training noted " In order to diffuse a dangerous situation resist any temptation to grab the patient"

During interview at 8:15am on 4/12/2011 personnel #21 stated he did grab the patient's wrists and did not let go when the patient threw himself on the floor. Personnel #21 stated " grabbing the patient's wrists was a "natural reaction."