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 79902 | Jan. 24, 2017 |
| VIOLATION: TRANSFER OR REFERRAL | Tag No: A0837 | |
| Based on review of documentation and interviews with facility staff, the facility failed to complete Memorandum of Transfer forms as required by facility policy in 3 of 20 cases reviewed where a hospitalized patient developed a medical condition requiring transfer to an acute care hospital. In another 8 cases where a patient was transferred to an acute care hospital, the Memorandum of Transfer was not signed by a physician. This resulted in missing documentation required by facility policy when a patient was transferred which included a physician's certification which includes a summary of risks and benefits of transfer. The findings were: The facility policy entitled "Medical Emergencies" dated 7/16 reflected in part "Policy: El Paso Behavioral Health System will provide triage, basic first aid, basic life support, and notification to emergency services in the event of an unexpected illness or injury of a patient, visitor, staff member, applicant, prospective patient or passerby to the extent the equipment and expertise allow on site at the time of the event. Procedure ...4. Nursing, and/or medical staff, will determine the nature of the medical emergency and, if a patient of the hospital, contact the internal medicine group, the attending physician and/or the on call physician for medical orders. 5. If a life-threatening emergency exists, basic life support measures will be initiated and a 911 call placed to activate the Emergency Medical System ...B. A patient status report will be called to the Emergency Department of the receiving hospital. Once the medical emergency has been addressed, a Memorandum of Transfer will be prepared and forwarded at the first available opportunity." The Transfer Agreement between Tenet Hospitals d/b/a Providence Memorial Hospital, Sierra Medical Center, and Sierra Providence East Medical Center and University Behavioral Health of El Paso dated 5/3/13 reflected in part "2. Responsibilities of the Transferring Facility. The Transferring Facility shall be responsible for performing or ensuring performance of the following ...p. Complete, execute, and forward a memorandum of transfer form, incorporated herein as Attachment 'A,' to the Receiving Facility for every patient who is transferred." The facility policy entitled "Memorandum of Transfer" dated 7/16 reflected in part "Memorandum of Transfer: A Memorandum of Transfer must be completed for every patient transferred and must contain the following information ...a Certification signed by the transferring physician who includes a summary of the risks and medical benefits reasonably expected as a result of transfer (Document on the Memorandum of Transfer form)." A sample of twenty patient records were reviewed where the patient was transferred to an acute care hospital. The patient records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form. The medical record of patient # F1 contained a nurse's note dated 11/30/16 at 0605 that reflected in part "patient pacing on hallway, suddenly pt (patient) stopped screaming & fainting, falling down face to floor. Noted having a seizure lasting about 10 seconds. Pt unconscious, code blue team present. VS (vital signs) 130/80 - 89 - 90% RA (oxygen saturation 90% on room air), ventimask applied. Dr., staff # F11 with patient at this moment 911 is called PRN." At 0640 " Report is given to Alex RN to SMC (Sierra Medical Center) ER. " The patient record of patient # F7 contained a nurse's note dated 10/25/16 at 2250 that reflected in part "Pt c/o (complained of) severe pain and swelling in his L (left) foot d/t (due to) gout attack. Pt was observed to have 1+ pitting edema @ L ankle w/discoloration. Pt requested to be taken WBAMC (William Beaumont Army Medical Center) ER for prednisone injection. Dr., staff # P12 contacted. Nursing supervisor contacted. Pt MOT to Sierra MC." The patient record of patient # F17 contained a nurse's note dated 11/21/16 at 0546 that reflected in part "He did not attend groups because he slept all day due to stomach pain and vomiting. He was medication compliant with no adverse effects today. He was sent out via EMS life ambulance at 0140 for severe abdominal pain, severe emesis/nausea, weakness, hypoactive bowel sound, and the patient stating 'I can't take it anymore, I feel like I'm dying.' Report was previously called to Sierra Medical Center where patient was sent." At 11/21/16 0600 the nurse's note reflected in part "Sierra Medical Center informed me via phone that the patient will be admitted ...he had fluid in his abdomen from a draining abscess." The medical records of patients # F6, F9, F10, F11, F15, F16, F20, and F22 who had been transferred to acute care hospitals contained Memorandum of Transfer forms where a physician had not signed the Physician Certification which reflected "Based upon the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of transfer to the patient and in the case of labor, the unborn child." In an interview with the risk management director, staff # F2 on 1/24/17 at approximately 4:00 pm, staff # F2 agreed that the medical records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form and that the Memorandum of Transfer forms for patients # F6, F9, F10, F11, F15, F16, F20, and F22 were incomplete. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on observation, interview, and record review, the facility failed to ensure a safe patient environment. The air conditioner cover plates in patient rooms were left unlocked and the patients had access to sharp edges and corners increasing the risk for self-harm. Findings Include: An observation on the morning of 1/23/17 of Patient Rooms #237, 236, 235, 201, 203, and 204 revealed the patient room's air conditioner thermostat covers had sharp edges and were accessible to patients. The covers were being left open in the rooms and some were closed but not locked. Staff E13, COO(Chief Executive Officer) confirmed the edges were sharp and were a risk to a patient wanting to harm themselves. During an interview on the morning of 1/23/17 on the women's unit Staff E5, MHT(Mental Health Technician) when asked how can the patient adjust the temperature in their rooms stated, " ...the thermostat covers are locked ...the nurse has to open and close the covers, the MHTs don't have a key...." During an interview on the morning of 1/23/17 on the women's unit, Staff E6, Unit Nurse Manager stated, "...I don't know where the key is located...." During an interview on the morning of 1/23/17 Staff E4, Director of Environmental Services stated, "The medication nurse has the key...We have 93 rooms, all the rooms are set up the same....patients are able to control their own room temperatures...." During an interview on the morning of 1/23/17 on the Adult unit Staff E11, RN when asked who has keys to the locked thermostat covers stated, "The nurses have the key, they are supposed to be locked...some can't be locked...." During an interview on the morning of 1/23/17 in the facility's board room, when asked for a policy on locking the air conditioner doors Staff E14, Chief Executive officer stated, "We don't have a policy....We have already been discussing the air conditioning covers ....The locks get bent..." When asked had the facility identified the safety risk due to the sharp edges Staff E14 stated, "No." When asked who does the environmental rounds Staff E14 stated, "...We all do environmental rounds...we would not have been able to tell the covers were unlocked unless we had pulled on them...we would have to make a more closer round...me missed the training component...." Review of the facility's SAFETY/PATIENT SAFETY meeting minutes (dated August 31, 2016) reflected "...The project to replace the air conditioning screens is still pending...." Further review of the Safety meetings reflected no further mention of the air conditioning screens. Review of the facility's Basic Rights for All Patients (undated) reflected "...3. You have the right to a clean and humane environment in which you are protected from harm..." Review of the facility's Risk Management Program (undated) reflected "PHILOSOPHY: ... shall endeavor to ensure patient safety through a well-planned and organized risk management program to minimize for patients, visitors and personnel those risks which are unavoidable. It is believed that identification of the general clinical areas which represent actual or potential sources of patient injury, together with resolution of those clinical problems, will promote the delivery of safe, quality patient care...." |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on a review of documentation and staff interview, the facility failed to ensure adequate nursing sestaff 24 hours a day. 1. The facility failed to have an adequate number of nursing staff to provide patient care on January 1, 2017 thru January 15, 2017 and on January 24, 2017 per their facility staffing grid. The lack of adequate nursing staff to provide patient puts the patient at risk for sub-standard nursing care and poor outcomes for patient health. 2. The facility failed to complete and initiate patient Treatment Plans in 3 of 9 patient Treatment Plans reviewed. 3 of 9 Treatment Plans did not contain goals and interventions for all of the assessed problems. This practice prevents the patient from obtaining all the treatment they need. 1 of 9 patients was not notified of the date and time of their Treatment Plan Meeting which prevented the patient from participating in the development of their care. Cross refer to: A0392 A0396 |
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| VIOLATION: STAFFING AND DELIVERY OF CARE | Tag No: A0392 | |
| Based on a review of documentation, nursing service did not have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. Findings were: On 1-24-17, a review of staffing assignment sheets was conducted for the 7am to 7pm shift (for the dates of 1-1-17 through 1-15-17 and 1-24-17). Numbers and types of staff present were compared to numbers and types of staff required by the facility's staffing grid. The facility's staffing grid was dated and signed for authentication by staff A17 on 1-24-17. Staff shortages were as follows: 1/1/17: PICU (psychiatric intensive care unit) overflow unit 1 RN (registered nurse) short (leaving no RNs on the unit) PICU 1 RN and 1 LVN (licensed vocational nurse) short Adult 1 RN short Rehab(rehabilitation) 1 RN short Gero (geriatric) 1 LVN short Military 1 RN short 1/2/17: Gero 1 RN and 1 LVN short Child/Adolescent 1 RN short PICU overflow 1 LVN PICU 1 RN, 1 LVN Adult 1 RN Rehab 1 RN Military 1 RN 1/3/17 Child/Adolescent 1 RN PICU overflow 1 RN (leaving no RNs on the unit) PICU 1 RN, 1 LVN Adult 1 RN Military 1 RN Missing staffing schedules for Gero, Rehab and Women's 1/4/17 Adult 1 RN Child/Adolescent 1 RN Rehab 1 RN PICU 1 RN, 1 LVN Gero 1 RN 1/5/17 Child/Adolescent 2 RNs Adult 1 RN Gero 1 RN Women 1 LVN Missing staffing schedule for PICU 1/6/17 Child/Adolescent 2 RN, 1 LVN PICU 1 RN, 1 LVN Women 1 RN Adult 1 RN (leaving no RN on the unit) Missing staffing schedule for Gero 1/7/17 Gero 1 LVN Child/Adolescent 1 RN, 1 LVN Missing staffing schedules for Women and Adult 1/8/17 Child/Adolescent 1 RN, 1 LVN Gero 1 RN Women 1 RN Missing staffing schedules for Adult and PICU 1/9/17 Adult 1 RN Child/Adolescent 1 RN, 1 LVN PICU 2 RN Missing staffing schedules for Gero and Rehab 1/10/17 Adult 1 RN Child/Adolescent 1 RN, 1 LVN PICU 1 RN, 1 LVN Military 1 RN Women 1 RN Missing staffing schedule for Gero and Rehab 1/11/17 Child/Adolescent 2 RN PICU 1 RN, 1 LVN Military 1 LVN Women 1 RN, 1 MHT Missing staffing schedule for Rehab, Adult and Gero 1/12/17 Child/Adolescent 1 LVN Military 1 RN Women 1 RN Missing staffing schedule for Rehab, Adult, Gero and PICU 1/13/17 PICU 1 RN, 1 LVN Child/Adolescent 1 RN 1/14/17 Child/Adolescent 1 LVN Adult 1 LVN Women 1 RN Military 1 RN Missing staffing schedules for Rehab and PICU 1/15/17 Gero 1 LVN Military 1 RN Rehab 1 RN PICU 2 LVN, 1 MHT Women 1 RN Missing staffing schedules for Adult and Child/Adolescent 1/24/17 Adult 1 RN Military 1 RN PICU 1 RN, 1 LVN Rehab 1 RN Women 1 RN Child/Adolescent 1 RN, 1 LVN Adolescent girls 1 RN The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 1-24-17. |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate treatment plans for the assessed needs of (3) of (9) patient's treatment plans reviewed. (Patients E6, E7 and E8) Findings Include: Review of Patient E6's medical records revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Bi-Polar and Substance Abuse. Review of the physician's assessment dated [DATE] reflected "...flight of ideas..." Review of Patient E6's Treatment Plan reflected Admitting Diagnosis Bi-Polar, Problem #1 Substance Abuse; the Bi-Polar did not have interventions and goals in place. During an interview on the morning of 7/24/17 on the facility's senior unit Patient E6, when asked if she had attended her treatment plan stated, "No, I didn't know about it." During an interview on the morning of 7/24/17 on the facility's senior unit, when asked if Patient E6 had been invited to her treatment plan meeting Staff E6, Nurse Manager stated, "...we were told we don't have to...." Staff E8, Program Manager stated, "I took it in to her and explained it to her...I had her sign it..." Review of Patient E8's medical records revealed HISTORY OF PRESENT ILLNESS: This 23 female ...jumped out of a moving vehicle that was going 40 miles per hour. Consequently, she has lacerations to her right arm, left elbow, hip, and left side of her face .... MEDICAL HISTORY: The patient has lacerations, two of them to the back of her head with 13 staples. She has lacerations and abrasions to her right hand, left hip, and left elbow. Review of Patient E8's INPATIENT PHYSICIAN ADMITTING ORDERS dated 1/15/17 reflected " ...Right hand redress daily and PRN (as needed)...wound care per protocol..." Review of Patient E8's Treatment plan reflected Wound Care as a problem; the wound care did not have interventions and goals in place. Review of Patient E7's medical records revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Bi-Polar and Substance Abuse. Review of the physician's assessment dated [DATE] reflected "...flight of ideas..." Review of Patient E7's Treatment Plan reflected Admitting Diagnosis Bi-Polar, Problem #1 Substance Abuse; the Bi-Polar did not have interventions and goals in place. Review of the facility provided document TREATMENT PLANS (dated 7/16) reflected, "Purpose To establish guidelines for the coordinated care of the patient while hospitalized .... Each patient's care will be guided by a multidisciplinary treatment plan. Procedure 1. Following the Nursing Admission Assessment, the RN will add any medical problems to be addressed to the treatment plan, and discuss this with the patient/family.... 4. The treatment plan will be reviewed and/or updated weekly at Treatment Team meetings and will reflect changes in the patient's course of treatment...." During interview on the morning of 1/24/17 in the facility conference room Staff E10, Director of Clinical Services after reviewing the patient's medical records confirmed the Bi-Polar needed to have been included on the treatment sheet for both Patient E6 and Patient E7 and confirmed the findings for Patient E8. When asked if she was aware that the facility needed to notify patients of the date and time of their care plan conference, so the patient can be an active participant, Staff E10 stated, "No." |
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| VIOLATION: CONTENT OF RECORD | Tag No: A0449 | |
| Based on observation, interview, and record review, the facility failed to evaluate, document, and clarify treatment orders for a patient admitted with multiple abrasions to her right hand. (Patient E8) Findings include: Observation on the morning of 1/23/17 on the women' unit revealed Patient E8 with multiple abrasion wounds to the top of her right hand knuckles. The wounds were each approximately 1cm x 2 cm and were a white color with skin discoloration around the wounds. Review of Patient E8's medical records revealed HISTORY OF PRESENT ILLNESS: This 23 female ...jumped out of a moving vehicle that was going 40 miles per hour. Consequently, she has lacerations to her right arm, left elbow, hip, and left side of her face.... MEDICAL HISTORY: The patient has lacerations, two of them to the back of her head with 13 staples. She has lacerations and abrasions to her right hand, left hip, and left elbow. Review of Patient E8's INPATIENT PHYSICIAN ADMITTING ORDERS dated 1/15/17 reflected "...Right hand redress daily and PRN (as needed)...wound care per protocol..." Review of Patient E8's Wound Care orders dated 1/15/17 at 9:00 a.m. reflected Daily wound care to Right hand, Use hydrogen peroxide/Normal Saline 50:50 daily for cleansing x ___days. The order was written by an LVN. Review of the Medical Consultant's Orders dated 1/16/17 reflected the treatment to the scalp wound but did not include the treatment for the open hand wounds. Review of the facility provided document Assessment of Patients (dated 10/2016) reflected "...4.... A comprehensive nursing assessment is performed by a Registered Nurse within eight (8) hours of admission. Following review of the previous assessment and validation of information with the patient, the nursing assessment will include the following information:... 2. Physical Status Database - information regarding medical/surgical history... self-care deficits, and body identification...." Review of Patient E8's Physical Skin Assessment reflected "...bruises laceration to the right wrist...." The abrasions to the knuckles were not recorded on the nursing assessment. During an interview on the afternoon of 1/23/17 on the Adult unit when asked how did the LVN know how to treat the wound and if the facility has a wound protocol Staff E7, Director of Performance Improvement stated "...we don't have a wound protocol..." Staff E7 confirmed the wounds had not been measured and the treatment orders had not been clarified. |
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| VIOLATION: ORGANIZATION | Tag No: A0619 | |
| Based on observation, interview, and record review, the facility failed to provide an organized and sanitary dietary services. Findings include: Observation made during a tour of the facility's dietary services on the morning of 1/23/17 revealed: - The reach-in refrigerator had an internal temperature of 45 degrees Fahrenheit and an outside digital temperature of 43 degrees Fahrenheit. The refrigerator contained food items to be served to the patients. - The refrigerated cold plate had 14 individual milk cartons sitting on portions of the non-refrigerated cold plate at room temperature. -The permanent plastic wrap cutter container had dried food debris on the container and blade. -The can opener had dried food debris on the blade and the holster. -The Liquid butter and seasoning salt container were not dated when opened and multiple spice jars had dried food on the lids and down the side of the containers. - The dietary back door had an approximate quarter inch gap in the back door with daylight shining through allowing access to insects. - (2) Cracked eggs were in the walk-in refrigerator and accessible for patient use. - A large pan of chili and a large pan of beans were outdate and accessible for patient use. - The waste grease receptacle had old discarded grease and trash around the can creating an unsanitary environment. Review of the facility's SANITATION & SAFETY (dated April 1, 2016) reflected...11. All work surfaces, utensils and equipment shall be thoroughly cleansed and sanitized after... 18. The Dietary Department will be operated in compliance with all applicable federal, state and local sanitation and safety laws and regulations.24. Garbage is held, transferred and disposed of in a manner that does not create a nuisance or a breeding place for insects, rodents and vermin or otherwise permit the transmission of disease.... Proper sanitizing techniques will be used according to items being sanitized. Review of the facility's SANITATION & SAFETY (dated April 1, 2016) reflected "...EQUIPMENT & UTENSIL CLEANING AND SANITIZING Policy:...2. Kitchenware and food-contact surfaces of equipment shall be washed, rinsed and sanitized after each use...." Review of the TEXAS FOOD ESTABLISHMENT RULES (updated 2015) revealed: Food Temperature/Time Requirements/Potentially Hazardous Foods (PHF) ...Cold Hold (41F) a. PHF's must be stored at or below 41F. During the tour of the dietary services on the morning of 1/23/17 the Dietary Director confirmed the findings. |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on observation, interview, and record review, the facility failed to ensure the safety of patients; sharp metal edges were left exposed and accessible in all of the (6) out of (6) patient rooms. Refer to A0701 Maintenance of Physical Plant Based on observation, review of documentation, and interviews with facility staff, the facility failed to conduct emergency medical equipment checks in accordance with the facility daily checklist on a total of 5 days on two of seven units toured. This potentially could have resulted in emergency equipment not being ready in an emergency situation. Refer to A0724 Facilities, Supplies and Equipment Maintenance Based on observation, review of documentation, and interviews with facility staff, the facility failed to perform annual fire extinguisher inspections on 3 of 3 fire extinguishers in the northeast outpatient clinic in accordance with facility policy. This potentially could have resulted in a fire extinguisher malfunction in an emergency situation. Refer to A0710 Life Safety From Fire |
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| VIOLATION: LIFE SAFETY FROM FIRE | Tag No: A0710 | |
| Based on observation, review of documentation, and interviews with facility staff, the facility failed to perform annual fire extinguisher inspections on 3 of 3 fire extinguishers in the northeast outpatient clinic in accordance with facility policy. This potentially could have resulted in a fire extinguisher malfunction in an emergency situation. The findings were: The facility policy entitled "Fire Extinguishers" reflected in part "Annual Fire Extinguisher Inspections: The following procedure will apply for this inspection once annually ...Annual Inspection - at least annually all Fire Extinguishers and Exit Lighting will be inspected by trained personnel, licensed to perform such work." During a tour of the northeast outpatient clinic on the afternoon of 1/24/17 in the company of the outpatient director, staff # F9, the fire extinguishers were noted to have tags attached with inspection dates punched by the fire extinguisher company as follows. 1. The fire extinguisher located in the hall leading to the adolescent area: the tag was dated 4/15. 2. The fire extinguisher located near the nurse's office: the tag was dated 3/15. 3. The fire extinguisher located in the adolescent group room: the tag was dated 5/15. In an interview with staff # F9 during the tour on 1/24/17 at approximately 3:40 pm, staff # F9 agreed that the fire extinguisher tags were dated as noted above. |
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| VIOLATION: MAINTENANCE OF PHYSICAL PLANT | Tag No: A0701 | |
| Based on observation, interview, and record review, the facility failed to provide a safe environment; the air conditioner cover plates were left unlocked and the patients had access to sharp edges and corners increasing the risk for self-harm. Findings Include: An observation on the morning of 1/23/17 of Patient Rooms #237, 236, 235, 201, 203, and 204 revealed the patient room's air conditioner thermostat covers had sharp edges and were accessible to patients. The covers were being left open in the rooms and some were closed but not locked. Staff E13, COO(Chief Executive Officer) confirmed the edges were sharp and were a risk to a patient wanting to harm themselves. During an interview on the morning of 1/23/17 on the women's unit Staff E5, MHT(Mental Health Technician) when asked how can the patient adjust the temperature in their rooms stated, " ...the thermostat covers are locked ...the nurse has to open and close the covers, the MHTs don't have a key...." During an interview on the morning of 1/23/17 on the women's unit, Staff E6, Unit Nurse Manager stated, "...I don't know where the key is located...." During an interview on the morning of 1/23/17 Staff E4, Director of Environmental Services stated, "The medication nurse has the key...We have 93 rooms, all the rooms are set up the same....patients are able to control their own room temperatures...." During an interview on the morning of 1/23/17 on the Adult unit Staff E11, RN when asked who has keys to the locked thermostat covers stated, "The nurses have the key, they are supposed to be locked...some can't be locked...." During an interview on the morning of 1/23/17 in the facility's board room, when asked for a policy on locking the air conditioner doors Staff E14, Chief Executive officer stated, "We don't have a policy....We have already been discussing the air conditioning covers ....The locks get bent..." When asked had the facility identified the safety risk due to the sharp edges Staff E14 stated, "No." When asked who does the environmental rounds Staff E14 stated, "...We all do environmental rounds...we would not have been able to tell the covers were unlocked unless we had pulled on them...we would have to make a more closer round...me missed the training component...." Review of the facility's SAFETY/PATIENT SAFETY meeting minutes (Dated August 31, 2016) reflected "...The project to replace the air conditioning screens is still pending...." Further review of the Safety meetings reflected no further mention of the air conditioning screens. Review of the facility's Basic Rights for All Patients (undated) reflected, "...3. You have the right to a clean and humane environment in which you are protected from harm..." Review of the facility's Risk Management Program (undated) reflected, "PHILOSOPHY: ... shall endeavor to ensure patient safety through a well-planned and organized risk management program to minimize for patients, visitors and personnel those risks which are unavoidable. It is believed that identification of the general clinical areas which represent actual or potential sources of patient injury, together with resolution of those clinical problems, will promote the delivery of safe, quality patient care...." |
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| VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE | Tag No: A0724 | |
| Based on observation, review of documentation, and interviews with facility staff, the facility failed to conduct emergency medical equipment checks in accordance with the facility daily checklist on a total of 5 days on two of seven units toured. This potentially could have resulted in emergency equipment not being ready in an emergency situation. The findings were: The facility form entitled "Emergency Medical Equipment Daily Checklist" reflected in part "Emergency Supplies: Initials indicate that all Emergency Supplies and medications are present, tear away locks are intact, no rips and tears are noted to emergency supply packaging and expiration dates are checked and in date ...Emergency Equipment: AED (Check each element as indicated and check if test is positive and enter initials when complete) ...Oxygen Tank (Enter Oxygen level in spaces provided and enter initials when complete)." During a tour of the facility on the morning of 1/23/17 in the company of the infection control nurse, staff # F1, the missed checks on the emergency medical equipment daily checklist were noted on the following dates. 1. Child/Adolescent Unit, October 2016, the check boxes for 10/28/16, 10/29/16, and 10/30/16 were blank. 2. Child/Adolescent Unit, November 2016, the check boxes for 11/27/16 were blank. 3. Rehab Unit, January 2017, the check boxes for 1/14/17 were blank. In an interview with staff # F1 during the tour on 1/23/17 at approximately 12:15 pm, staff # F1 agreed the emergency medical daily checklist had missed documentation as noted above. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation, a review of facility documentation, and staff interview, the facility failed to maintain a sanitary physical environment in 2 of 2 patient rooms inspected. This deficient practice placed all hospital inpatients at risk for infections and communicable diseases. Findings were: Facility policy entitled Routine Cleaning of patient Rooms, last revised 11/2016, included the following: "It is the policy of El Paso Behavioral Health Systems that all patient rooms be routinely cleaned when patients are discharged or transferred to another room or area... Environment of Care Staff:... 6. Damp wipes all ledges, fixtures, and furniture below shoulder height..." A review of the facility Infection Control and Prevention Plan 2016 revealed the following: "Goal...Environment of Care Will ensure evidence-based methods and best practices for environmental cleaning in the facility are used..." During a tour of the psychiatric intensive care unit (PICU) on the afternoon of 1/23/17 with the facility CEO and COO, rooms #201 and 208 were inspected. In each room, a heating/air conditioning unit below the window included an opening in which the thermostat adjustment knob was accessible. The opening also included visible access to water pipes, another section of the heating/air conditioning unit, and an area behind the wall. This allowed access to patient rooms for pests and insects. In addition, the areas around the thermostat control knob included large amounts of visible dirt and sticky residue. In an interview with the hospital CEO during the tour, he stated, "This is how it is in all the rooms. I agree, it's really dirty in there -- no question." In an interview with the facility Director of Infection Control on the afternoon of 1/23/17 in the office of the chief operating officer, she stated she performed environment of care rounding to identifty potential infection control issues. She stated, "These just got missed." These findings were again confirmed in an interview with the CEO and other administrative staff on the afternoon of 1/24/17 in the facility conference room. Based on review of facility policies and procedures, observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients. Findings were: "OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner." Facility policy titled "Cleaning of Hospital Equipment (low level disinfection)" stated in part "In an effort to provide a safe and sanitary environment for our patients, it is the policy of El Paso Behavioral Health Systems to prohibit the spread of infection by ensuring that all hospital equipment is disinfected between sessions of use ... Procedure: 9. All refrigerators: ...b. All refrigerators will be maintained in a safe and sanitary condition to prevent the spread of food-borne illnesses." Facility policy titled "Cleaning of Recreational Equipment" stated in part "Policy: Exercise Equipment will be maintained in a manner that reduces the risk of spreading infection. Procedure: 1. The IC NURSE or designee is responsible for training all staff regarding this section of the IC Program Manual. 2. Anyone using the fitness equipment must place a clean towel on the seat or bench of the fitness equipment where it must remain while the person exercise on that piece of equipment. 3. Clean towels are kept readily available and issued by patient care staff to all participants in the fitness room. Patient care staff will replace towels as necessary when cleaning the recreational area ... 5. Equipment is disinfected between each patient use. General Exercise Equipment: 1. Wet paper towels with hospital approved disinfecting wipe and wipe all surfaces that contacted the person i.e., seat or bench." The following was observed on a tour of the facility the afternoon of 1/23/17: Two paper scrub bottoms, inside out, on the floor of the pool women's restroom Hardware on the bathroom stall doors and benches were discolored making it impossible to clean in the women's restroom of the pool Dirt build-up on the ground of the adolescent nutrition room Dirt build-up in the patient refrigerator of the adolescent nutrition room Baseboards peeling in hallway and group room of adolescent unit The above was verified in an interview with staff B1 and B11 on the tour on 1/23/17. On a tour of the gym on 1/23/17, patients were using gym equipment, when staff #B9 was asked how they clean the equipment between patients, they were unable to answer. There were no disinfecting wipes, sprays or towels, noted. In an interview with staff B8, the infection control nurse, on the afternoon of 1/24/17, when asked if staff were trained on how and when to clean equipment and for documentation, she stated, "I did not train them." On a tour of the pool area on 1/23/17, there were three porous foam noodles. When asked how these could be disinfected in an interview with staff B8, the infection control nurse, on the afternoon of 1/24/17, she stated she did not know. The above was verified with the CEO and other administrative staff in the exit conference on the afternoon of 1/24/17. |
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| VIOLATION: TRANSFER OR REFERRAL | Tag No: A0837 | |
| Based on review of documentation and interviews with facility staff, the facility failed to complete Memorandum of Transfer forms as required by facility policy in 3 of 20 cases reviewed where a hospitalized patient developed a medical condition requiring transfer to an acute care hospital. In another 8 cases where a patient was transferred to an acute care hospital, the Memorandum of Transfer was not signed by a physician. This resulted in missing documentation required by facility policy when a patient was transferred which included a physician's certification that included a summary of risks and benefits of transfer. The findings were: The facility policy entitled "Medical Emergencies" dated 7/16 reflected in part "Policy: El Paso Behavioral Health System will provide triage, basic first aid, basic life support, and notification to emergency services in the event of an unexpected illness or injury of a patient, visitor, staff member, applicant, prospective patient or passerby to the extent the equipment and expertise allow on site at the time of the event. Procedure ...4. Nursing, and/or medical staff, will determine the nature of the medical emergency and, if a patient of the hospital, contact the internal medicine group, the attending physician and/or the on call physician for medical orders. 5. If a life-threatening emergency exists, basic life support measures will be initiated and a 911 call placed to activate the Emergency Medical System ...B. A patient status report will be called to the Emergency Department of the receiving hospital. Once the medical emergency has been addressed, a Memorandum of Transfer will be prepared and forwarded at the first available opportunity." The Transfer Agreement between Tenet Hospitals d/b/a Providence Memorial Hospital, Sierra Medical Center, and Sierra Providence East Medical Center and University Behavioral Health of El Paso dated 5/3/13 reflected in part "2. Responsibilities of the Transferring Facility. The Transferring Facility shall be responsible for performing or ensuring performance of the following ...p. Complete, execute, and forward a memorandum of transfer form, incorporated herein as Attachment 'A,' to the Receiving Facility for every patient who is transferred." The facility policy entitled "Memorandum of Transfer" dated 7/16 reflected in part "Memorandum of Transfer: A Memorandum of Transfer must be completed for every patient transferred and must contain the following information ...a Certification signed by the transferring physician who includes a summary of the risks and medical benefits reasonably expected as a result of transfer (Document on the Memorandum of Transfer form)." A sample of twenty patient records were reviewed where the patient was transferred to an acute care hospital. The patient records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form. The medical record of patient # F1 contained a nurse's note dated 11/30/16 at 0605 that reflected in part "patient pacing on hallway, suddenly pt (patient) stopped screaming & fainting, falling down face to floor. Noted having a seizure lasting about 10 seconds. Pt unconscious, code blue team present. VS (vital signs) 130/80 - 89 - 90% RA (oxygen saturation 90% on room air), ventimask applied. Dr., staff # F11 with patient at this moment 911 is called PRN." At 0640 " Report is given to... RN to SMC (Sierra Medical Center) ER. " The patient record of patient # F7 contained a nurse's note dated 10/25/16 at 2250 that reflected in part "Pt c/o (complained of) severe pain and swelling in his L (left) foot d/t (due to) gout attack. Pt was observed to have 1+ pitting edema @ L ankle w/discoloration. Pt requested to be taken WBAMC (William Beaumont Army Medical Center) ER for prednisone injection. Dr., staff # P12 contacted. Nursing supervisor contacted. Pt MOT to Sierra MC." The patient record of patient # F17 contained a nurse's note dated 11/21/16 at 0546 that reflected in part "He did not attend groups because he slept all day due to stomach pain and vomiting. He was medication compliant with no adverse effects today. He was sent out via EMS life ambulance at 0140 for severe abdominal pain, severe emesis/nausea, weakness, hypoactive bowel sound, and the patient stating 'I can't take it anymore, I feel like I'm dying.' Report was previously called to Sierra Medical Center where patient was sent." At 11/21/16 0600 the nurse's note reflected in part "Sierra Medical Center informed me via phone that the patient will be admitted ...he had fluid in his abdomen from a draining abscess." The medical records of patients # F6, F9, F10, F11, F15, F16, F20, and F22 who had been transferred to acute care hospitals contained Memorandum of Transfer forms where a physician had not signed the Physician Certification portion of the form which reflected "Based upon the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of transfer to the patient and in the case of labor, the unborn child." In an interview with the risk management director, staff # F2 on 1/24/17 at approximately 4:00 pm, staff # F2 agreed that the medical records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form and that the Memorandum of Transfer forms for patients # F6, F9, F10, F11, F15, F16, F20, and F22 were incomplete. |
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