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 Aug. 15, 2017
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, review of medical records and interview, the facility failed to ensure all records documented discharge summaries with outcomes of hospitalization s, dispositions of care and provisions for follow-up care.

Eight of ten outpatient adolescent medical records reviewed had no discharge summary documented.

Findings included:

Medical Staff Rules and Regulations stated in part, "5.4 Discharge Summary: Members must complete the discharge summary within 30 days of discharge ...
...5.4.3 The final diagnosis shall be provided by the attending Member on or before the time of the patient discharge ... Discharge diagnoses are to be written in the medical records prior to discharge."


Patient #1 was discharged in May 2017. There was no documented discharge summary.

Patient #3 was discharged on [DATE]. There was no documented discharge summary.

Patient #5 was discharged on [DATE]. There was no documented discharge summary.

Patient #6 was discharged on [DATE]. There was no documented discharge summary.

Patient #8 was discharged on [DATE]. There was no documented discharge summary.

Patient #9 was discharged on [DATE]. There was no documented discharge summary.

Patient #10 was discharged on [DATE]. There was no documented discharge summary.

Patient #11 was discharged on [DATE]. There was no documented discharge summary.

The above was confirmed in an interview with staff #10 on the afternoon of 8/15/17.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, review of medical records and interview, the facility failed to ensure all records contained the final diagnosis and were complete within 30 days following discharge.

Eight of ten outpatient adolescent medical records reviewed were not complete within 30 days following discharge.

Findings included:

Medical Staff Rules and Regulations stated in part, "5.4 Discharge Summary: Members must complete the discharge summary within 30 days of discharge ...
...5.4.3 The final diagnosis shall be provided by the attending Member on or before the time of the patient discharge ... Discharge diagnoses are to be written in the medical records prior to discharge."


The following medical records were reviewed on 8/15/17 and were not complete:

Patient #1 was discharged in May 2017. There was no documented discharge summary.

Patient #3 was discharged on [DATE]. There was no documented discharge summary.

Patient #5 was discharged on [DATE] to inpatient services. There was no documented discharge summary or progress notes related to the incident that caused the admission to inpatient status.

Patient #6 was discharged on [DATE]. There was no documented discharge summary or progress notes related to the incident that caused the discharge from the facility.

Patient #8 was discharged on [DATE]. There was no documented discharge summary.

Patient #9 was discharged on [DATE]. There was no documented discharge summary.

Patient #10 was discharged on [DATE]. There was no documented discharge summary.

Patient #11 was discharged on [DATE]. There was no documented discharge summary.

The above was confirmed in an interview with staff #10 on the afternoon of 8/15/17. Staff #10 stated the records were placed in a separate cabinet for risk management and "fell through the cracks."
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and interview, the facility failed to ensure medical records contained information to describe the patient's progress and response to services.

Findings included:

Patient #5 was discharged on [DATE] to inpatient services. There was no documented discharge summary or progress notes related to the incident that caused the admission to inpatient status.

Patient #6 was discharged on [DATE]. There was no documented discharge summary or progress notes related to the incident that caused the discharge from the facility.

The above was verified in an interview with staff #10 on the afternoon of 8/15/17.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of records and staff interviews, the facility failed to ensure the safe transport of patients to and from their residence for outpatient services at El Paso Behavioral Health facility. Up to fourteen patients are transported at a time and the only staff person is the driver of the vehicle.
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Findings include:
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Facility document entitled "Risk Management Plan", states in part,
"Philosophy: El Paso Behavioral Health System 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."

Surveyor asked staff #10 for the outpatient services policy twice, but policy was never brought to the surveyor for review.

In an interview with staff #2 when asked what is the highest number of patients he has driven on his own and if he felt that it was safe, he stated, "14/13 patients. I don't think that's safe at all. 2 or 3 years ago, we had a tech in the back and it worked well ... we would concentrate on driving and they could focus on the patients. Especially with kids, they love to take off their seatbelt and we have to pull over and ask them to put it back on. I know other patients try to hit each other but I always try to pull over and calm that down."

Review of the facility transportation record revealed five to seven transportation driver were used to transport patient to and from their residence to the facility outpatient service daily.


The above findings were confirmed in an interview the afternoon of 8/15/17 with Staff #10 in the facility conference room.