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 Sept. 9, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of the clinical records and facility documentation, and facility staff interview, the facility failed to protect the right of patient #1 (child/adolescent with reported history of sexual abuse) to receive care in a safe setting. Identified in 1 of 9 patient records reviewed.

Findings were:

Review of the clinical record for patient #1 revealed that patient #1 was admitted to the child/adolescent unit at EPBH (El Paso Behavioral Health) on 1-27-15 at approximately 11:40 pm on a voluntary basis. The patient reported a "history of abuse" (later described in the psychiatric evaluation as physical and sexual abuse).

Telephone orders for admission were obtained from the admitting psychiatrist at 1:45 am on 1-28-15. Admitting diagnoses state "Mood d/o nos; PTSD (hx of both physical & sexual trauma)."

Patient #1 was noted to be 4'5" (53") tall and weighed 78 pounds.

A review of the Initial Treatment Plan for patient #1 revealed no mention of his history of sexual abuse.

On 1-28-15 at approximately 11:20 am, the psychiatric evaluation was conducted, which stated, in part: "Additionally the patient does have a history of sexual abuse and physical abuse, has been diagnosed with PTSD in the past and is currently still being treated for PTSD."

On 1-28-15 at approximately 5:30 pm, patient #2 was admitted to the child/adolescent unit and was assigned to the same room as patient #1. His psychiatric evaluation notes the reason for admission to be, in part, "...increased verbal aggression and threatening behavior at home ..." Admission orders state that patient #2 was 5' 6 " (66.5") tall and weighed 200 pounds.

A review of Multidisciplinary Progress Notes for patient #1 revealed the following:
1-29-15 at 2040 (8:40 pm) - "Staff member reported seeing pt door closed and opened the door and turned the light on and reported pt was near roommates (sic) bed (# ) [patient #2] and both pt and roommate were in their underwear. Upon opening the door, pt ran back to his bed and hid underneath his covers. Pt was questioned what had occurred (sic) and why he and roommate (# ) [patient #2] were in underwear. Pt responded 'it got hot in here' and proceded (sic) to hide under the covers. Pt was asked if any sexual misconduct had occred (sic) by staff, pt responded 'nothing happened.' Pt was then placed in dayroom and assigned a new room."
1-29-15 at 2125 (9:25 pm) - "Pt was found throwing chairs in dayroom, and was asked to sit down and speak with staff. Pt was asked again if sexual misconduct had occurred (sic) and pt responded tearfully 'he asked me to take my clothes off, and to come near his bed. He then touched me down there in the front and my butt. I was scared.' Pt also verbalized 'no one wants me anymore, and not even my family wants to talk to me.' Pt informed that parent was going to be contacted and pt begged 'please don't call my mom' and pt became tearful again. Pt informed that he will have a room change and pt verbalized understanding. Will continue to monitor while on unit."
1-29-15 at 2150 (9:50 pm) - "Dr (name illegible) physician on call notified, and Administrator and manager also notified."
1-29-15 at 2220 (10:20 pm) - "Pt mother contacted to inform on pt status. Pt mother became angry with staff, and verbalized 'how can I know that my son is safe?' Staff responded by informing mother that pt was sleeping in dayroom and had a room change and was being closely monitored by staff. Pt mother verbalized understanding and verbalized 'I still don't understand why the door was closed,' staff informed mother of understanding of (illegible). Pt (sic) mother asked if she had any further questions and pt (sic) mother verbalized 'No, I don't' and ended the phone call. Will continue to monitor pt on unit."
All above notes were labeled as "nursing" in the column indicating discipline.

Facility policy titled "Admission Process" stated, in part:
"POLICY:
To ensure individuals served are admitted in a safe and appropriate manner.
...
Individuals are admitted , (either voluntary or involuntary status) in the most expeditious manner, ensuring the patient's rights are protected and that the patient is treated with respect and dignity.
...
1. Unit assignment and room placement will be determined by the CNO, Nurse Manager and Admitting or Attending Physician to assure the safety, privacy and comfort of the individuals served."

A review of the clinical record for patient #2 revealed no documentation that room placement (for patient #2) had been determined by the Chief Nursing Officer, the Nurse Manager or the Admitting/Attending physician in order to assure the safety of the individuals served.

Facility policy titled "Sexually Acting Out and Sexual Victim Prevention" states, in part:
"POLICY:
University Behavioral Health of El Paso shall implement a policy for patient/residents for protective measures the facility shall take for those who are vulnerable to sexual victimization by other patients/residents ...Patients/residents shall not have sexual contact with one another. Patients/residents are assessed for risk of sexual acting out behavior or of being sexually victimized.

PURPOSE:
Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents.

PROCEDURE:
A. Early Identification: The Admissions Clinician shall assess patients/residents both for variables for sexual behavior groups: At risk for sexually acting out and those at risk for sexual victimization.
...
Patients will be assessed for any potential for sexual victimization. The assessment process will consider individual circumstances of patient/residents including age, physical size, having a history of being sexually abused, being developmentally disabled, speech and language problems, physical status/medical conditions that may compromise the patient's ability to defend self (i.e. disorientation, bed-ridden), having sexually provocative/hypersexual behaviors, current sexual activities, or a person receiving ECT treatments.
...
F. Notification:
1. Contact the immediate Nursing Supervisor and Clinical Director.
2. Contact the attending psychiatrist.
3. In the event of sexual abuse notify the local Child Protective Services."

Although the clinical record for patient #1 reveals knowledge of patient #1's history as a victim of sexual abuse prior to the admission of patient #2, patient #2 was placed in a room with patient #1 despite the fact that patient #2 was much larger in physical size (patient #1 weighed 78 lbs, patient #2 weighed 200 lbs) and was 2 years older than patient #1.

Facility policy titled "Abuse/Neglect Identification" states, in part:
"SEXUAL ABUSE
Sexual abuse is defined as inappropriate sexual contact with a child. This may be nonviolent as in fondling, caressing or indecent exposure ..."

Facility policy titled "Patient Rights and Responsibilities" states, in part:
"1.0 Policy
University Behavioral Health of El Paso's policy is to preserve the patient's basic human rights during hospitalization , and that the patient's behavior, their relatives, and friends are reasonable and responsible. Patients have the right to be free from mental, physical sexual and verbal abuse, neglect and exploitation. All patients served will receive a statement as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms prior to admission.
...
5.0 Procedures
5.1 RIGHTS:
I. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned."

On 1-29-15 at 9:25 pm, patient #1 stated to staff that he had been sexually abused by his roommate (patient #2).

Facility document titled "Children's Bill of Rights" states, in part:
"You have the right to be safe."

Because all facility policies and documents listed the facility name as "University Behavioral Health of El Paso", the surveyor requested and was furnished with a clarifying document dated 9-9-15 (and signed by staff #3) that stated "All policies and procedures containing language referencing University Behavioral Health of El Paso apply to El Paso Behavioral Health System. University Behavioral Health of El Paso LLC is doing business as El Paso Behavioral Health System."

The above was confirmed in an interview with the the Human Resources Director, the Chief Financial Officer/Interim Chief Executive Officer, the Chief Nursing Officer and the PI/Risk Management Director on the afternoon of 9-9-15.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on a review of the clinical records and facility documentation, and facility staff interview, the facility failed to protect 1 of 9 patients right (patient #1) to be free from all forms of abuse or harassment.

Findings were:

Review of the clinical record for patient #1 revealed that patient #1 was admitted to the child/adolescent unit at EPBH (El Paso Behavioral Health) on 1-27-15 at approximately 11:40 pm on a voluntary basis. The patient reported a "history of abuse" (later described in the psychiatric evaluation as physical and sexual abuse).

Telephone orders for admission were obtained from the admitting psychiatrist at 1:45 am on 1-28-15. Admitting diagnoses state "Mood d/o nos; PTSD (hx of both physical & sexual trauma)."

Patient #1 was noted to be 4'5" (53") tall and weighed 78 pounds.

On 1-28-15 at approximately 11:20 am, the psychiatric evaluation was conducted, which stated, in part: "Additionally the patient does have a history of sexual abuse and physical abuse, has been diagnosed with PTSD in the past and is currently still being treated for PTSD."

On 1-28-15 at approximately 5:30 pm, patient #2 was admitted to the child/adolescent unit and was assigned to the same room as patient #1. His psychiatric evaluation notes the reason for admission to be, in part, "...increased verbal aggression and threatening behavior at home ..." Admission orders state that patient #2 was 5' 6 " (66.5") tall and weighed 200 pounds.

A review of Multidisciplinary Progress Notes for patient #1 revealed the following:
1-29-15 at 2040 (8:40 pm) - "Staff member reported seeing pt door closed and opened the door and turned the light on and reported pt was near roommates (sic) bed (# ) [patient #2] and both pt and roommate were in their underwear. Upon opening the door, pt ran back to his bed and hid underneath his covers. Pt was questioned what had occurred (sic) and why he and roommate (# ) [patient #2] were in underwear. Pt responded 'it got hot in here' and proceded (sic) to hide under the covers. Pt was asked if any sexual misconduct had occred (sic) by staff, pt responded 'nothing happened.' Pt was then placed in dayroom and assigned a new room."
1-29-15 at 2125 (9:25 pm) - "Pt was found throwing chairs in dayroom, and was asked to sit down and speak with staff. Pt was asked again if sexual misconduct had occurred (sic) and pt responded tearfully 'he asked me to take my clothes off, and to come near his bed. He then touched me down there in the front and my butt. I was scared.' Pt also verbalized 'no one wants me anymore, and not even my family wants to talk to me.' Pt informed that parent was going to be contacted and pt begged 'please don't call my mom' and pt became tearful again. Pt informed that he will have a room change and pt verbalized understanding. Will continue to monitor while on unit."
1-29-15 at 2150 (9:50 pm) - "Dr (name illegible) physician on call notified, and Administrator and manager also notified."
1-29-15 at 2220 (10:20 pm) - "Pt mother contacted to inform on pt status. Pt mother became angry with staff, and verbalized 'how can I know that my son is safe?' Staff responded by informing mother that pt was sleeping in dayroom and had a room change and was being closely monitored by staff. Pt mother verbalized understanding and verbalized 'I still don't understand why the door was closed,' staff informed mother of understanding of (illegible). Pt (sic) mother asked if she had any further questions and pt (sic) mother verbalized 'No, I don't' and ended the phone call. Will continue to monitor pt on unit."
All above notes were labeled as "nursing" in the column indicating discipline.

Facility policy titled "Admission Process" stated, in part:
"POLICY:
To ensure individuals served are admitted in a safe and appropriate manner.
...
Individuals are admitted , (either voluntary or involuntary status) in the most expeditious manner, ensuring the patient's rights are protected and that the patient is treated with respect and dignity.
...
1. Unit assignment and room placement will be determined by the CNO, Nurse Manager and Admitting or Attending Physician to assure the safety, privacy and comfort of the individuals served."

A review of the clinical record for patient #2 revealed no documentation that room placement (for patient #2) had been determined by the Chief Nursing Officer, the Nurse Manager or the Admitting/Attending physician in order to assure the safety of the individuals served.

Facility policy titled "Sexually Acting Out and Sexual Victim Prevention" states, in part:
"POLICY:
University Behavioral Health of El Paso shall implement a policy for patient/residents for protective measures the facility shall take for those who are vulnerable to sexual victimization by other patients/residents ...Patients/residents shall not have sexual contact with one another. Patients/residents are assessed for risk of sexual acting out behavior or of being sexually victimized.

PURPOSE:
Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents.

PROCEDURE:
A. Early Identification: The Admissions Clinician shall assess patients/residents both for variables for sexual behavior groups: At risk for sexually acting out and those at risk for sexual victimization.
...
Patients will be assessed for any potential for sexual victimization. The assessment process will consider individual circumstances of patient/residents including age, physical size, having a history of being sexually abused, being developmentally disabled, speech and language problems, physical status/medical conditions that may compromise the patient's ability to defend self (i.e. disorientation, bed-ridden), having sexually provocative/hypersexual behaviors, current sexual activities, or a person receiving ECT treatments.
...
F. Notification:
1. Contact the immediate Nursing Supervisor and Clinical Director.
2. Contact the attending psychiatrist.
3. In the event of sexual abuse notify the local Child Protective Services."

Although the clinical record for patient #1 reveals knowledge of patient #1's history as a victim of sexual abuse prior to the admission of patient #2, patient #2 was placed in a room with patient #1 despite the fact that patient #2 was much larger in physical size (patient #1 weighed 78 lbs, patient #2 weighed 200 lbs) and was 2 years older than patient #1.

Facility policy titled "Abuse/Neglect Identification" states, in part:
"SEXUAL ABUSE
Sexual abuse is defined as inappropriate sexual contact with a child. This may be nonviolent as in fondling, caressing or indecent exposure ..."

Facility policy titled "Patient Rights and Responsibilities" states, in part:
"1.0 Policy
University Behavioral Health of El Paso's policy is to preserve the patient's basic human rights during hospitalization , and that the patient's behavior, their relatives, and friends are reasonable and responsible. Patients have the right to be free from mental, physical sexual and verbal abuse, neglect and exploitation. All patients served will receive a statement as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms prior to admission.
...
5.0 Procedures
5.1 RIGHTS:
I. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned."

On 1-29-15 at 9:25 pm, patient #1 stated to staff that he had been sexually abused by his roommate (patient #2).

Facility document titled "Children's Bill of Rights" states, in part:
"You have the right to be safe."

Because all facility policies and documents listed the facility name as "University Behavioral Health of El Paso", the surveyor requested and was furnished with a clarifying document dated 9-9-15 (and signed by staff #3) that stated "All policies and procedures containing language referencing University Behavioral Health of El Paso apply to El Paso Behavioral Health System. University Behavioral Health of El Paso LLC is doing business as El Paso Behavioral Health System."

The above was confirmed in an interview with the the Human Resources Director, the Chief Financial Officer/Interim Chief Executive Officer, the Chief Nursing Officer and the PI/Risk Management Director on the afternoon of 9-9-15.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of clinical records, the facility failed to promptly maintain a completed medical record for each patient.

Findings were:

During a review of clinical records for 9 patients, the clinical records for 6 of the 9 records (patients #1, #2, #5, #6, #8 and #9) were not promptly completed and contained discharge summaries filed more than 30 days following the discharge of the patients.

The above was confirmed in an interview with the the Human Resources Director, the Chief Financial Officer/Interim Chief Executive Officer, the Chief Nursing Officer and the PI/Risk Management Director.