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.

Based on record review and interview, it was determined that the facility failed to maintain a central log on each individual who comes in for treatment.

Findings were:

Review of corroborating evidence from another facility on 10/16/12 revealed a psychiatric evaluation for Patient #1 dated 10/9/12, which stated that Patient #1 was initially taken to University Behavioral Health by police on 10/9/12.

In an interview with the Director of Admissions on 10/16/12 at approximately 2:20 PM, he stated that if Patient #1 was assessed by the facility his name would have been entered into the "Care Center Call Log". The Director of Admissions stated that when a person is brought in by the police they are brought into a special locked area where the assessor would see them. He stated that he was working on 10/9/12 and he did not recall the police taking in a person that day, and he stated that he would not turn them away if they came in. The Director of Admissions also said that any person that comes in signs the "Guest Sign In Sheet", or the person's representative signs in on the "Guest Sign In Sheet".

Review of the University Behavioral Health documents on 10/16/12 revealed the following:
- The "Guest Sign In Sheet" dated 10/9/12 did not have an entry from Patient #1, or anyone with the last name of Patient #1.
- The "Care Center Call Log" dated 10/9/12 did not have an entry for Patient #1.

A facility policy entitled "Emergency Assessment Process", reviewed on 10/16/12, stated the following:
"Policy: ...It is the policy of University Behavioral Health of El Paso to provide ready access to mental health inquiries and to ensure that all individuals shall have equal access to emergency treatment, stabilization, and emergency care within the capacity and capabilities of the facility. This service shall be provided to all individuals seeking an evaluation screening or assessment, 24 hours a day, 7 days a week ....When a person presents at University behavioral Health of El Paso for an evaluation, or when a potential patient is seen at an offsite location by the mobile assessment team, an appropriate assessment will be completed. The assessment as described in the integrated assessment policy will include: personal demographics, medical history/screening information, psychiatric history/mental status exam, initial diagnostic impression and Communicable Disease Questionnaire...Procedure: ...Qualified mental health professionals employed by the facility complete assessments 24 hours a day, 7 days a week. Persons may arrange for or receive assessments through a variety of mechanisms including, but not necessarily limited to the following: ...B. Walk-Ins: 1. Persons may walk into the facility and request to speak with a counselor. The receptionist will notify assessment services that will respond. If the person does not appear to be in a crisis situation, offer to perform an assessment at the earliest possible time when there are other crisis assessments being performed. Otherwise, the assessment will be performed immediately. The waiting time for assessments should be less than 30 minutes ...C. Involuntary Commitment: 1. Emergency detentions are usually brought in by Police Department or ambulance and have been approved for involuntary commitment ...III. A/R staff or Nursing Supervisor responds immediately if the person is a walk-in by: A. Greeting the person in the lobby. B. gathering preliminary information on a Triage Medical History Screening Form and a triage priority level is assigned. C. Assess the needs of each person when two or more persons arrive at the facility simultaneously and will follow the established triage system procedure."