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EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX 79902 Feb. 22, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, medical record review, and review of facility and court documents, the facility failed to obtain informed consent from the legally authorized representative prior to the administration of psychoactive medications and failed to admit Patient #1, who had a legal guardian, in accordance and as allowed under state law, Texas Health and Safety Code, Chapters 573 or 574.

Findings were:

Review of Guardianship papers filed June 11, 2009 in the Probate Court of El Paso County, Texas provided by the complainant stated that " 2. [Patient #1] is not capable of giving informed consent to medical treatment and medical services ...6. That [Patient #1] is incapacitated and unable to perform certain tasks for himself ...NOW THEREFORE, IT IS HEREBY ORDERED, ADJUDGED AND DECREED: 1. That [the parents of Patient #1] are hereby appointed Guardians of the Person of [Patient #1] ( " Ward " ) and are hereby granted the following limited and specific duties and powers to act in the Ward ' s behalf: a. The power to consent to medical and psychiatric treatment for Ward ...2. [Patient #1] posses [sic] the following functional limitation: a. He is unable to consent to medical and psychiatric treatments. "

Review of facility policy, Informed Consent for Medication Administration stated " Documentation of Informed Consent: Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient admitted under the voluntary, emergency, or OPC provisions of Texas statues [sic] or his legal authorized representative. This executed form will establish a rebuttal presumption of valid consent and will be retrained [sic] in the medical record. "

Review of facility policy, Informed Consent for Medication Administration further stated, " PATIENTS admitted UNDER TEXAS STATUES [sic]: Psychoactive mediations [sic] may not be administered to a patient admitted under the voluntary, emergency, or Order of Protective Custody provisions of Texas statues [sic] without informed consent, except in an emergency or a situation which, in the opinion of the treating physician, indicates the possible [sic] of immediate physical or mental deterioration of the patient, or indicated the possibility of immediate physical injury or death of the patient or other persons in the hospital. "

Review of the Physician Progress Note in the medical record for Patient #1 on 12/6/11 at 4:40 pm stated " Thought processes are very concrete. Insight and judgment are impoverished. Overall intellectual functioning clearly is significantly impoverished. "

Review of the record for Patient #1 revealed the form " Consent to Treatment with Psychoactive Medication " was signed by Patient #1 and not his legally authorized representative for the following psychoactive medications: Trazadone, signed on 12/4/11; Prozac, signed on 12/4/11; Tegretol, signed on 12/4/11; and Seroquel, signed on 12/7/11.

Review of a document provided by the facility Assistant Administrator on 2/21/12 in the conference room entitled, " Guardianship for Texas with Disabilities, Thirteenth Edition, March 2, 2011 " from Disability Rights, Texas, stated on page 4 " D. ADMISSION TO RESIDENTIAL SERVICES A guardian may not voluntarily admit an incapacitated person to a public or private inpatient psychiatric facility...If such services are necessary, the guardian must apply for emergency or respite care or for involuntary commitment .... "

Review of facility policy, " Admission Guidelines " stated " University Behavioral Health of El Paso will comply with all regulatory standards related to the admission of patients to a psychiatric hospital ...8. The patient must have the capacity to consent for treatment as determined by the physician or the hospital must initiate emergency detention proceedings in accordance with the Texas Health and Safety Code. "

Review of the medical record revealed that Patient #1 was admitted on a Voluntary Admission status and not an emergency detention or other legal commitment status. The Psychiatric Evaluation dated 12/5/11 stated, " Patient #1 is a [AGE]-year-old Caucasian male who was brought in by his mother on a voluntary basis due to aggressive behaviors at home. " The " Clinical Assessment " completed on 12/4/11 stated that " Pt came in as a walk-in accompanied by legal guardian. "

The facility " Consent for Treatment " admission form for Patient #1 was signed and dated by the mother/guardian of Patient #1 at his admission on 12/4/11. Other admission documents were signed and dated by mother/guardian of Patient #1 on 12/4/11, including the " Patient ' s Bill of Rights " form, the " UBH of El Paso Philosophy for Seclusion and Restraint " form, the " Acknowledgment Form " acknowledging receipt of the Patient Handbook, the " Patient Disclosure Form " , the " Authorization for Release of Protected Information " , the " Consent to Release Information " , the " Assessment Service Disclosure Statement and Consent to Assessment " form, and the " Notice of Health Information Privacy Practices " form. The " Assessment Service Disclosure Statement and Consent to Assessment " form had a handwritten " x " in the space marked " Patient unable to sign due to mental status. " There was no evidence provided or found in the medical record that the patient was admitted under any legal commitment status.

In an interview with the Chief Executive Officer, Assistant Administrator, and Chief Nursing Officer on 12/22/12, they confirmed the above findings and that Patient #1, who had a legal guardian, was admitted on a voluntary basis.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on a review of facility policies, medical record, and staff interviews, the facility failed to ensure and document the supervision of nursing care for each patient.

Findings were:

Review of facility policy " Patient Assessment Nursing Flow Sheet " stated " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form: Diet: note percentage of meals eaten. "

Review of the record for Patient #1 revealed that the percentage of meal eaten was not documented for dinner on 2 out of 3 inpatient days, including 12/6/11 and 12/7/11. Orders for Patient #1 included Trazadone, a psychoactive medication which should be taken with a meal or a snack; and Tegretol, a psychoactive medication which should be taken with meals. Both of these medications would necessitate monitoring of meal intake.

Review of facility policy issued by Nursing Services stated, " Vital Signs Monitoring " stated " 1. All patients will have vital signs taken on admission and daily thereafter for the first 72 hours of hospitalization unless ordered more frequently by the attending physician or designee. 2. Vital signs consist of Blood Pressure, Temperature, Pulse, Respirations, and Pulse Oximeter readings. "

Review of the record for Patient #1 revealed that blood pressure, temperature, pulse, and respirations were not documented on 1 of 3 inpatient days (12/5/11), and that pulse oximeter readings were not documented for 3 of 3 inpatient days (12/4, 12/5, and 12/6). In addition, for one entry on 12/6/11, the temperature was recorded as " 60 " , and the pulse was recorded as " 18. "