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EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX 79902 Jan. 8, 2013
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that the notice of rights requirement were met.

Findings were:

Review of patient #1's medical record on 1/8/13 revealed the following:

On 12/10/12 the patient and a physician signed a voluntary admission form.

A nurses note dated 12/13/13 stated the following in part: "Pt (patient) was upset in the morning because he had 3 appointments today and was notified he will have to reschedule them even though pt became very upset, he was able to control himself and stated 'he was not going to act out because he did not want to be here any longer.' Processed with pt. Pt verbalized he will continue to be compliant with the program."

A nurse note dated 12/14/12 stated the following in part: "he (patient #1) wants a 2nd opinion, writer advised pt (patient) to let his attending know that ..."

A physician progress note, examination date 12/14/12, stated the following in part: "The patient is still fell ing very frustrated about the fact that he is healthier and requested to be seen for second opinion concerning his stay in the hospital."

A discharge summary, dictated on 12/17/12, stated the following in part: "He (patient #1) was attending all groups and activities, but on a daily basis, he was insisting on leaving and he was not sure about the compliance with his medication."

The "Patient's Bill of Rights" was signed by patient #1 on 12/9/12. The document stated in part:
"Voluntary Patients-Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave, the staff person must write it down for you.
2. You have the right to be discharged from the hospital within four (4) hours of requesting discharged . There are only three (3) reasons why you would not be allowed to go:
? First, if you change your mind and want to stay at the hospital, you can sign a paper that says you do not wish to leave, or you can tell a staff member that you don ' t want to leave, and the staff member has to write it down for you.
? Second, if you are under [AGE] years old ...
? Third, you may be detained longer than four (4) hours if your doctor has reason to believe that you might meet the criteria for court-ordered mental health services or emergency detention because:
o You are likely to cause serious harm to yourself;
o You are likely to cause serious harm to others;
Or
Your condition will continue to deteriorate and you are unable to make an informed decision as to whether or not to stay for treatment.
If your doctor things you may meet the criteria for court-ordered mental health services or emergency detention, he/she must examine you in person within 24 hours of your filing the discharge request. You must be allowed to leave the hospital upon completion of the in-person examination unless your doctor confirmed that you meet the criteria for court-ordered mental health services and files an application for court-ordered mental health services and files an application for court-ordered services. The application asks a judge to issue a court order requiring you to stay at the facility for services. The order will only be issued if the judge decides that either:
? You are likely to cause serious harm to yourself;
? You are likely to cause serious harm to others; or
? Your condition will continue to deteriorate and you are unable to make an informed decision as to whether or not to stay for treatment.
Even if an application for court-ordered services is filed, you cannot be detained at the hospital beyond 4:00 pm of the first business day following the in-person examination unless the court-order for services is obtained."

No other court-ordered or emergency detention documentation was found in the record, other than the initial emergency detention dated 12/8/12.

Facility policy entitled "Request for Discharge", reviewed by the surveyor on 1/8/13, stated the following in part on page 1 of 2:
"When a staff member of UBH El Paso is informed that a voluntary patient or patient's parent of legal guardian desires to leave the hospital or requests that the patient be discharged , the hospital shall adhere to the following procedures:
1. Inform the patient or the patient's parent or legal guardian that the request must be in writing and signed, timed, and dated by the requestor on the Request for Discharge form ...."
The same policy stated the following in part on page 2 of 2:
"(g) If the patient or parent/legal guardian decides he/she no longer withes to be discharged at any point in this process the patient will withdraw his/her request for discharge by making a written statement to withdraw the request for discharge and sign, date and time that request on the appropriate section of the Request for Discharge form. Staff may assist the patient in writing this statement if necessary and have the patient sign, date and time the request on the appropriate section of the Request for Discharge form."

During an interview with the Chief Operating Officer on 1/8/13, she confirmed that the above findings were present in patient #1's medical record.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on a review of clinical records and staff interviews, the facility failed to ensure that treatment plans were followed by nursing staff as there was no documented evidence of actions taken in patient medical records, and there was no documented evidence that patient belongings were returned to patients on discharge.

Findings were:

Review of the clinical record for Patient #2 revealed that she was admitted with a diagnosis of Enuresis (nocturnal bed wetting) on 11/9/12, which was also documented in the Physician Progress notes, Clinical Assessment, and the Treatment Plan. The treatment plan included Short Term Goals with target date of 11/20/12 which stated, " [Patient #2] will be encourage (sic) to not drink anything after 9:00 pm " and " [Patient #2] ...will go to the bathroom to urinate immediately before going to bed " and " [Patient #2] ...will have a dry bed 3 days consecutively. " Nursing Intervention included " Nurse will encourage pt to limit drinking liquids 1 hr before bed. " There was no documented evidence in the nursing notes or the mental health technician ' s notes to indicate whether Patient #2 did or did not have any episodes of enuresis during her length of stay. There was also no documented evidence in the nursing notes or the mental health technician ' s notes related to the fluid intake for Patient #2 after 9:00 pm, or whether Patient #2 was encouraged to limit fluids after 9:00 pm, or that Patient #2 was prompted or actually urinated immediately before going to bed.

Review of clinical records for patients with " Property Inventory Sheets " revealed that 6 of 7 forms were not completed to indicate that the patient received their personal property when discharged (Patients # 2, 3, 4, 6, 9, and 10).

The Clinical Assessment for Patient #2 dated 11/9/12 stated, in part, Visual Problems: ' I wear glasses to see far but they are broken. " The Nursing Shift Assessment and Progress Note stated, " 11/15/12 2055 ...All belongings given to mother upon discharged (sic). " However, there were Property Inventory Lists in the patient ' s record, which included an entry in the list dated 11/12/12 which stated, " eye glasses - 1. " The form was signed by the patient indicating the property was received while still a patient at the hospital; however the form was left blank and not completed for " Released listed items to discharged patient on ___________ (Date). " The " Patient Signature " space was blank; the " Admission Staff Signature " was blank; and the " Witness Signature " was blank. There was no documented evidence on the itemized form indicating the patient received each of the items, including the eyeglasses at discharge on 11/15/12.

The above was confirmed in an interview with Staff # 1 and 2 the afternoon of 1/8/13 in the conference room.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on record review and interview, it was determined that the facility failed to follow its policies concerning informed medication consent for 2 of 20 patient records reviewed.

Findings were:

Review of the clinical record for patient #2 revealed that Consent forms for Risperdal and Depakote ER had a handwritten note that stated, " ok per Mom " dated 11/10/12 and timed 1000. The patient had a legally authorized guardian that was not her mother; there was no documented evidence in the medical record that the guardian consented to the medications Risperdal and Depakote ER. The patient received Risperdal and Depakote ER on 11/10/12, 11/11/12, 11/12/12, 11/13/12, and 11/14/12.

Review of the clinical record for patient #4 revealed that the patient was prescribed and administered Ambien on 12/7/12 at 0430; there was no documented evidence that the patient or legally authorized representative provided consent for this psychoactive medication.

The above was confirmed in an interview with Staff # 1 and 2 the afternoon of 1/8/13 in the conference room.