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 July 2, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on medical record review, policy review, and staff interview, the facility failed to document in the medical record that patients on an emergency medical detention were provided a copy of their patient rights.

Findings were:

Review of medical records for patient #2 and #11 on 7/1/14 and 7/2/14 revealed the facility did not document that the patient was given a copy of the document titled Patient Bill of Rights or that someone on staff explained the document to the patient in a language the patient could understand. The Patient Bill of Rights document in the medical record for patients #2 and #11 had the wording "Pt on EDO" (EDO - emergency detention order) documented in the space that was intended for the patient's initial and signature.

Facility policy titled "Patient Rights and Responsibilities" states, in part "All patients served will receive a statement as well as an oral explanation of those rights..."

Interview with staff #8 on 7/1/14 revealed the standard process for a patient that is on emergency detention order is to write "Pt on EDO" on their Patient Bill of Rights form. She stated she was sure the patient received a copy of the bill of rights but could provide no documentation that the patient signed for their rights form, or refused to sign for the form, or that they had been explained their rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of documentation and interview the facility failed to ensure the right of patients to receive care in a safe setting.

Findings were:

Review of the medical record for Patient #3 revealed diagnosis of "Alzheimer's, Dementia by hx (history)". Documentation in the medical record noted that Patient # 3 had a high risk factor of "dx with dementia".

According to the "Group Therapy Progress Notes" on 4/29/14 the patient attended group therapy from 9:15 AM until 12:00 PM

The "Consent for Treatment-Outpatient" signed by Patient # 3 on 4/29/14, stated in part, "I understand the Hospital will not be responsible for the safety or care of the patient if the patient leaves the premises and will indemnify the Hospital for any loss or injury which may occur as a result of leaving against medical advice."

Facility based policy entitled, Incident Reporting stated in part, "The Incident Report is a mechanism, for informing Administration of the occurrences of circumstances surrounding individual problematic events. An "Incident" is defined as any happening that is not consistent with the normal or usual operation of the hospital and/or department. Injury does not have to have occurred.

Procedure ...

5. All occurrences involving patients should be charted in the patient's medical record; no mention of the occurrence report should be made in the medical record."

Review of the medical record, revealed that patient # 3 attended outpatient therapy programming at the facility on 4/29/14. In an interview on 7/2/14, Staff member # 12 confirmed that Patient # 3 was picked up on the morning of 4/29/14 in a facility provided van and was transferred to the facility to attend outpatient therapy. According to Staff member # 12, Patient # 3 did not return home via facility based transportation on 4/29/14. The patient's family contacted the facility and Staff member # 12 on 4/29/14 in the afternoon to inform them that Patient # 3 did not return home as planned after therapy.

In an interview on 7/2/14, staff member # 12 was asked why no one was aware Patient # 3 did not get on the van to return home. Staff member # 12 replied, "Because they're all voluntary. A lot of patients we don't take home or pick up. They might take a bus in or drive. Might have spouse or kids pick up for whatever reason ...
This gentleman did not leave in middle of group which would be a concern. He stayed for the whole treatment day. If they don't get in the van, it's their right if they don't get in. It's not a daycare or child care facility here."

A type written statement (provided to the surveyor on 7/2/14) by Staff member # 12 stated, "On April 9th at approximately 5:30 pm I received a call from the daughter of patient [# 3] stating that he had not returned home from treatment. This was patient's first day of outpatient treatment and daughter was concerned regarding patient's cognitive ability to return home on his [sic].I contacted our transportation coordinator, [name], and he stated that we picked the patient up for treatment but did not transport him home. Patient stayed for the entire treatment day and left.

Shortly after contacting our transportation coordinator, I called the police. When they were on route to the hospital I sent out 2 transportation vans looking for the patient in the vicinity of the hospital. I also spoke to daughter of the patient who informed me of his most frequent locations, which the driver' [sic] went by although did not find the patient.

The patient's daughter and police arrive shortly after and I spent about 2 hours with them, giving them a full description of the patient. They stated that they currently were filing a silver report sending patrol officers to look for patient.

At about 9pm that evening, I received a call from patient's daughter on my cell phone. She stated that her father walked to urgent care center nearby the hospital. According to his daughter, the urgent care asked the patient if he needed help as they were closing and subsequently called family to inform patient of his whereabouts."

Review of the medical record for Patient # 3 revealed no documentation of the patient leaving the facility on his own or not taking facility provided transportation home. There was no documentation of the patient's daughter reporting the patient had not returned home, the facility contacting the police, issuing a "silver report", or the eventual location of the patient.

In an interview on 7/2/14, Staff Member # 12 confirmed this information was not in the medical record of Patient # 3. Staff member # 12 stated there was no incident report completed to reflect this incident involving Patient # 3. Staff member #12 confirmed an incident report should have been completed per facility policy.

The facility failed to ensure the safe transport of patient with a diagnosis of dementia home via facility based transportation as pre-arranged. The facility was unaware that Patient # 3 did not get on the facility van to return home on the afternoon of 4/29/14. The facility was notified by Patient # 3's family that the patient did not come home via facility provided transportation. Patient # 3 was subsequently missing for several hours until located by the police. The patient's safety was not ensured and the patient was at risk for injury after leaving the facility.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on medical record review, policy review, and staff interview, the facility failed to follow physician orders to escort a patient to his home to retrieve his CPAP machine for treatment of his sleep apnea, or make efforts to obtain a CPAP machine for patient use during his hospital stay to treat his medical condition.

Findings were:

Review of medical record for patient # 2 on 6/30/14 and 7/1/14 revealed the following:
? Physician progress note 8/2/13: "Patient wants facility to take him to his residence to retrieve his CPAP machine as he has no one to get it for him so I told him I would put in an order for staff to take him to his residence to assist him to get his things for him."
? Physician order: 8/02/13 17:00: "Please transport patient to his residence (if there is no conflict with involuntary status) to get his CPAP machine and home medications."
? Physician progress note 8/03/13 at 14:00: "He tells me he is upset because staff is not going to be able to help him go home to get his pills or CPAP and take care of his bills because the staff cited a VA rule for not being able to do that. I told him I would try to get case manager to help him out and if possible bring his CPAP machine. Also educated him about court and the fact he may have a court hearing on Monday and he can make the same request to the judge. So that helped him calm down significantly."
? Mental Status Examination 8/03/13: "He denies active suicidal or homicidal ideas or plans."
? Plan: 8/03/13: "We will try to have the case manager help the patient with his social issues to try to get his CPAP as well as home medication if at all possible."
? Initial Treatment Plan filled out by nursing on 7/30/13 has no mention under medical problems the patient has sleep apnea and uses a CPAP machine.
? Multidisciplinary Treatment Plan initiated on 8/2/13 has under diagnoses, sleep apnea. There is no mention in the plan the need by the patient of his CPAP machine from his residence nor on the updated treatment plan from 8/7/13.

Facility policies reviewed on 6/30/14 and 7/1/14 include:
? "Escorting Patients" with a date issued of 11/2008 states, in part "University Behavioral Health of El Paso nurses must receive a physician order for a court-ordered patient to be at a location away from University Behavioral Health of El Paso ....Medical and Nursing staff will determine the number of escorts necessary to provide a proper environment for the patient. All patients away from University Behavioral Health of El Paso for authorized reasons: If not elsewhere required by this facility, Medical Staff may decide to provide an escort for the patient based on medical and/or psychiatric condition."
? "Contraband" states, in part "Decisions to restrict or allow limited access to personal property items will be made by the clinical team."
? "Patient Use of Personal Electronic Devices" states, in part "The physician writes the order for patients to use personal devices."
? "Transportation of Patients" states, in part "For inpatient transports, it is considered best practice to use 2 staff to transport patients with high risk behaviors. Patient's current level of precaution and care is considered, to include, special challenges such as risk for suicide .... The risk associated with transport is balanced by the benefit of the need for transport."

The Chief Nursing Officer was interviewed on 6/30/14 at 2:10 pm and stated she thought patient #2 was an involuntary detention and historically the VA has denied passes for the veterans. When asked what the VA rule was she stated it was not written, only verbalized by staff. She stated it was that the VA historically has not allowed patients to go to outside doctor's appointments or other activities. She stated with VA patients always have to call VA to get approval prior to patient going anywhere on pass. She stated usually the therapists or utilization management call the VA for this approval. After her own review of the medical record for patient #2 she acknowledged there was no documentation in his record to indicate the VA was contacted regarding a pass to go to his home to retrieve personal items or the reason why the patient was not escorted to his home to obtain his CPAP machine per physician's order.

The PI Director/Risk Manager was interviewed on 6/30/14 at 4:40 pm and again on 7/1/14 at 11:20 am. She stated that she did not know if the VA rule was explained to patient #2. She further stated there is no documentation or policy for the process of contacting the VA to get approval for veterans to go out on passes. When asked about the physician order for transport of the patient she stated the physician would be the one to determine if the patient was safe to allow to be escorted to his home. After review of the patient medical record she stated that there was no indication in physician notes, case manager notes, counselor notes, or nursing notes that patient#2 had suicidal or homicidal ideations since his admission and was being cooperative with staff. She further stated no documentation was provided in patient #2's medical record to indicate the reason he was not transported to his home to obtain his CPAP machine as per physician order. She further stated there is nothing in the Involuntary Admission policy that would prevent patient #2 being escorted to his home per the Escorting Patients policy.

Staff #6 and #7 both stated the VA rule is not written anywhere. Staff #7 stated that the treatment plan for patient #2 did not address his sleep apnea and the need for a CPAP machine to treat his sleep apnea. Staff #6 stated there is no documentation that the VA was contacted regarding transporting patient to his home to obtain his CPAP machine. Both stated they did not attempt to obtain a CPAP machine or speak with the physician to obtain a CPAP for patient #2 even though the facility would not transport patient #2 to his home to obtain his personal CPAP machine.
VIOLATION: ABUSE (483.13(b)) Tag No: A1532
Based on a review of documentation, video, and interviews, the facility failed to ensure that patients were free from sexual abuse.

Findings were:

Facility policy titled Sexually Acting Out and Sexual Victim Prevention stated, in part, "Patient/residents shall not have sexual contact with one another ...
B. Observation: ...
g. Staff will observe the patient for such behaviors as sexually inappropriate interactions, inappropriate touching or attempts at inappropriate touching, poor boundaries, lingering near patient bedroom or bathrooms,.
h. Staff will report to the Chief Nursing Officer or designee observed or reported behaviors such as sexually inappropriate touching, poor boundaries, lingering near patient bedrooms or bathrooms ...
D. Intervention:...
2. Discovery of an Allegation: This can occur either as witnessed by staff, as reported to staff by a third party witness or by way of hear-say, or as reported to staff by one of the client's allegedly involved. Upon report or discovery of an allegation of sexual familiarity between clients:
E. Response ...
3. Documentation:
a. Any client care issue is documented in the client's medical record.
b. Allegations of sexual familiarity are documented in the client's medical record."

Patient # 1 (diagnosed with borderline intellectual functioning) was inpatient at the facility from 6/6/14 through 6/12/14.

Security camera footage of the group room on the 3rd Floor Adult Unit was reviewed by the surveyor on 6/30/14 at 1:00 PM. The video footage reviewed was from 6:00 PM until 7:30 PM on 6/8/14. The surveyor observed Patient # 1 in the group room watching TV and interacting with various other patients. At approximately 6:45 PM a male peer (Patient # 4) joined Patient # 1 in the room. The two patients talked and watched TV.
? Between 6:45 PM and 7:25 PM Patient # 1 and Patient # 4 were observed to hold hands, kiss several times (on the cheek and mouth). Patient # 4 was observed to place their hand in Patient # 1's groin area on top of Patient # 1's jeans and appeared to be making a rubbing motion, several times. Patient # 1 was observed to placed her hand in the male patient's groin area. Once Patient # 4 was observed to lean over and place their head the Patient # 1's groin area.
? At approximately 7:25 PM a staff member completing the 15 minute check appeared to have observed the two patients holding hands. The staff member motioned for the two patients to exit the room. The two patients left the group room; the staff member was observed to turn off the lights in the room and closed the door.

The medical record for Patient # 1 does not accurately reflect what occurred on the security camera video footage for 6/8/14. The discharge summary stated in part, "...A family session was held with the mother and Adult Protective Services because of the fact that her daughter had been touched by a male patient. The patient then began to relate that she had been touched in her private parts, but we have reviewed a videotape and there was no indication that she was touched in her private parts ..."A facility self-investigation of the incident dated 6/9/14, included a review of security footage, also had no indication that Patient # 1 was touched in the groin area by Patient # 4. While the facility did its own internal investigation, the investigation did not accurately reflect what this surveyor observed when reviewing the video footage.

The security video footage (for the date of 6/8/14), reviewed on 6/30/14 by the surveyor revealed that it appeared Patient # 4 placed their hand on the groin area of Patient # 1 and made a rubbing motion. This video footage was reviewed a second time on 7/2/14, by 2 surveyors with staff members # 1 and 2 present. Staff members # 1 and 2 both verbally agreed that it appeared that Patient # 4 was making a rubbing motion with their hand that appeared to be in Patient # 1's groin.

The facility failed to ensure that Patient # 1 and Patient # 4 did not engage in sexual contact per facility policy.