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 Nov. 29, 2017
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of documentation and interview it was determined that the facility failed to ensure that medical records were complete.
Findings were:

Medical records were not complete. A review of the medical record for patient #6 revealed that the Multidisciplinary Treatment Plan dated 9/22/2017 had not been signed by the parent or guardian of patient #6. The patient, a minor had signed instead. The area directly under the patient's signature stated: "Patient/Parent of minor/Legal Guardian Signature." Underneath the signature area were two additional signature blanks with the comment: "If verbally reviewed with parent/legal guardian, must have two licensed employee signatures to verify." Next to this area was a space for the review date and time as well as the printed name of the parent/legal guardian. These areas were all blank with no signatures from two licensed staff, no date/time and no printed name of the parent or legal guardian.

Review of facility Policy Stat ID 40, Documentation in the Patient's Medical Record stated on page that the purpose was to: "Standardize the procedures for routine documentation in the patient record." Also found on page one was: "Policy: It is the policy of El Paso Behavioral Health System (EPBHS) to establish standards for routine documentation within the patient medical record. These standards are outlined in the following table and shall be followed by all EPBHS employees and members of the Medical Staff when documenting in the patient's medical record." Page two stated: "Forms" "All blanks on forms should be completed (ie., unknown, negative, not obtained, N/A,)." Page three stated: "Using all Lines" "Never leave blank areas in the medical record. Begin current documentation immediately following the last entry. If lines are inadvertently left blank a line should be immediately marked through these unused lines to indicate no entry will be made."

In an interview on the afternoon of 11/27/2017 with facility staff #3 the above findings were confirmed. In a separate interview with the facility staff #20 on the afternoon of 11/28/2017 the above findings were confirmed.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interviews and record review the facility failed to meet the Condition of Participation for patient rights as evidenced by:

a) The facility administered psychoactive medications to and developed a treatment plan for an incapacitated Patient without the legally appointed Guardian's consent or input, resulting in the Guardian's inability to participate in the effective care and treatment plans. (Patient #9). (refer to A0130)

b) One-to-one level of patient observation was initiated without an order from a physician for Patient #6. (refer to A0143)

c) Failing to assess or examine 1 of 1 patients (Patient #4) after his making an allegation of sexual assault by another patient. In addition, testing and examinations required by facility policy were not performed after the allegation was made. Also, the facility could provide no documented evidence of a nurse having assessed Patient #4 at all for a 24-hour period 2 days after the alleged assault. (refer to A0144)

d) The facility placed (3) of (3) patients in restraints with no evidence of having attempted positive behavioral interventions or modifications to the treatment plans, resulting in continued risk of safety to self and others. (Patients #4, 9 and 13). (refer to A0144)

e) Failing to ensure each patient was free from all forms of abuse or harassment as allegations of sexual abuse or exploitation against 1 of 1 facility employees (Staff #5) were not adequately addressed or documented by the facility. In addition, the allegations were not reported to appropriate regulatory agencies as required by facility policy and regulatory standards. (refer to A0145)

e) Failing to document systematic attempts to treat Patients #4, 9 and 13 in the least restrictive manner prior to the initiation of a restraint, resulting in continued adverse behaviors and self injuries. (refer to A0166)

The cumulative effect of these systematic deficient practices resulted in noncompliance with the Condition of Participation 482.13 Patient Rights.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on review of documentation and interview it was determined that the facility failed to honor the legal guardian's right to participate in the implementation of treatment plans for Patients #6, a minor and #9, an incapacitated patient.

Findings were:


A review of the medical record for patient #6 revealed that the Multidisciplinary Treatment Plan dated 9/22/2017 had not been signed by the parent or guardian of patient #6. The patient, a minor had signed instead. The area directly under the patient's signature stated: "Patient/Parent of minor/Legal Guardian Signature." Underneath the signature area were two additional signature blanks with the comment: "If verbally reviewed with parent/legal guardian, must have two licensed employee signatures to verify." Next to this area was a space for the review date and time as well as the printed name of the parent/legal guardian. These areas were all blank with no signatures from two licensed staff, no date/time and no printed name of the parent or legal guardian.

Review of Patient #9's Certificate of Medical Examination revealed a 21- year- old female admitted on [DATE] under an Emergency Detention Order with a diagnosis of Schizoaffective Disorder Bipolar type."

Review of Patient #9's Letters of Guardianship dated 7/17/17 reflected "Guardianship of ... (Patient #9), An Incapacitated Person .... Letter Expires 3/16/2018 ...".

Review of Patient #9's Treatment Plan reflected the guardian did not sign the Treatment Plan and the treatment plan was not reviewed with the guardian.

Review of facility Policy Stat ID 40, Documentation in the Patient's Medical Record stated on page that the purpose was to: "Standardize the procedures for routine documentation in the patient record." Also found on page one was: "Policy: It is the policy of El Paso Behavioral Health System (EPBHS) to establish standards for routine documentation within the patient medical record. These standards are outlined in the following table and shall be followed by all EPBHS employees and members of the Medical Staff when documenting in the patient's medical record." Page two stated: "Forms" "All blanks on forms should be completed (ie., unknown, negative, not obtained, N/A,)." Page three stated: "Using all Lines" "Never leave blank areas in the medical record. Begin current documentation immediately following the last entry. If lines are inadvertently left blank a line should be immediately marked through these unused lines to indicate no entry will be made."

In an interview on the afternoon of 11/27/2017 with facility staff #3 the above findings were confirmed. In a separate interview with the facility staff #20 on the afternoon of 11/28/2017 the above findings were confirmed.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on review of documentation and interview it was determined that the facility failed to ensure that 1:1 orders were obtained.

Findings were:
1:1 orders were not obtained for patient #6.
Review of the medical record for patient #6 revealed that the Patient Observation/Rounds Form 1:1 sheet had for 9/22/2017 had a hand written comment: "Placed on 1:1" written beside the time 21:15. A review of the physician order section of the medical record revealed no 1:1 physician order for this date or time. The Patient Observation/Rounds Form 1:1 sheet had for 9/23/2017 had a hand written comment: "Placed on 1:1" written beside the time 20:45. A review of the physician order section of the medical record revealed no 1:1 physician order for this date or time.

Review of facility policy entitled: "Special Precautions Guidelines and Patient Observation" with a revised date of 9/2017 stated under the Procedure section: "2.0 An order for the appropriate level of supervision should be documented in the physician's order section of the medical record, and the appropriate Observation should be initiated by the charge nurse or designee. When special precautions are initiated by nursing order, the nurse will contact the physician as soon as possible and notify him/her of the need for the precaution. Initiation of precautions should be documented in the physician orders specifying date, time and level of observation. Any special precautions that impinge on the Patient's rights such as an increase to 1:1 level of observation must have clinical justification. The physician should be contacted within 1 hour to obtain verbal order for special precaution. A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted per facility policies and procedures."

In an interview with factility staff #3 on the morning of 11/28/2017 it was confirmed that there was no 1:1 order found in the medical record of patient #6 for the above referenced dates.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documentation and staff interviews, the facility failed to assess or examine 1 of 1 patients (Patient #4) after his making an allegation of sexual assault by another patient. In addition, testing and examinations required by facility policy were not performed after the allegation was made. Also, the facility could provide no documented evidence of a nurse having assessed the Patient #4 at all for a 24-hour period 2 days after the alleged assault.

Findings were:

Facility policy entitled "Sexually Acting Out/Sexual Victim Prevention Early Identification, and Observation/Precautions, Interventions and Response & Notification," last revised 04/2016, included the following:
"A. Early Identification: The Admissions Clinical shall assess patients/residents both for variables for sexual behavior groups: At risk for sexually acting out and those at risk for sexual victimization ...

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 contact between patients ...
c. Evaluation or ER visit; STD/HIV, Hepatitis B, Hepatitis, C, rape kit, pregnancy testing, and Plan B (emergency contraceptive) reviewed/offered as appropriate ...
d. Incident location and evidence, such as clothing, bed sheets, etc. are secured, (victim does not shower until examined)
e. Complete a Healthcare Peer Review (incident) report and forward the report to Risk Management within 24 hours.

E. Response:
1. Investigation:
a. Any allegations of sexual contact are investigated for reasons including, most importantly, the protection of patient rights. In addition, investigations are conducted to assure safety, to find causes, to prevent similar occurrences and to protect the company interests.
b. Components to the Risk Manager's investigation include:
Securing a copy of the video of the alleged event at the direction of the assigned Corporate Risk Manager.
Obtaining copies of external reports, (ER record, police report), as applicable ...
3. Documentation: ...
f. Document contact made to physicians, parents and guardians ..."

Facility policy entitled "Protection of Evidence Resulting from Assault," last revised 7/2016, included the following:
"2.0 Procedure
2.1 Immediately upon receiving any information concerning a possible assault, the nurse will immediately ensure the patient's safety ...
2.3 If a patient reports a sexual assault, the unit RN will arrange to transfer patient to Sierra Medical Center as per Police Department Protocol.
2.4 The victim of sexual assault should be requested to refrain from any personal hygiene including oral hygiene until examined by the physician...
2.7 Notify the local police department and advise them that a patient needs to be transferred to Sierra Medical Center for a sexual assault examination ..."

Facility policy entitled "Patient Assessment Nursing Flow Sheet," last revised 07/2016, included the following:
"POLICY
The Patient Assessment/Nursing Flow Sheet are utilized on all patients as a method of documentation and reassessment of the patient in order to communicate treatment provided and its results.
PURPOSE:
To ensure an accurate and concise assessment and record of the patient's needs and treatment every shift. RN assessment will be completed every 12 hours ..."

Nursing narrative progress notes for Patient #4 included the following:
9/17/17 at 8:15 p.m.: " ...The MHT (mental health technician) staff informed the nurse staff that pt reported that he was sexually abused by another pt [Patient #5] yesterday. Pt asked ...MHT staff for another pt name while talking on the phone. On asking why pt needed the name, pt reported the sexual allegation and stated that pt [Patient #5] touched his private part yesterday. The was off [sic] the phone and pt was interviewed by the nurse staff and the MHT staff. Pt reported that pt ...[Patient #5] dragged him into his room and closed the door and touched his private part yesterday after smoke breaks. Pt was unable to specify the ...actual time. Pt reported that he was talking to his aunt over the phone about the incident and that she wanted to know the other Pt [Patient #5] name. Pt reported that the "whole incident was no more than 2 minutes." Pt was asked why he did not report the incident yesterday, pt stated that he was too afraid to report the incident. The house supervisor was notified. Pt separated from pt [Patient #5] and moved to opposite hall way. Pt was informed of need to feel safe at all time while in the facility. Pt informed to notify staff of any feeling of frustration and any sexual abuse propagated against pt. Pt heard talking to his family member over the phone while making preparation to separate pt from pt [Patient #5]. On call Dr. notified. Will continue to monitor Q15 mins for safety ..."
9/18/17 at 6:00 p.m.: "Pt gave information about the incident on Saturday night. Pt stated that on Saturday night he was waiting in the hallway for his meds at 2000. He then decided to go to his room to use the restroom. Pt. stated that that is when the other pt went into the restroom with him. Pt stated that the other pt took off both of their clothes. Pt stated that the other pt. put his private parts into "his mouth" and "through the back." Pt stated that lasted for about an hour. Pt stated that the other pt then pulled him to his room and repeated the same thing. Pt stated that lasted for 2 hours. Pt. stated he said yes to all that so the other pt. could leave. Pt stated this happened on Saturday night from "8 to 10" at night."

The facility could provide no documented evidence that Patient #4 was assessed or examined by nursing staff after making the above allegation. There was no evidence of nursing evaluation or offer of ER visit; no evidence that testing for STD/HIV, Hepatitis B, or Hepatitis C was offered or performed, nor that a rape kit was offered. There was no evidence provided by the facility that the incident location and evidence, such as clothing, bed sheets, etc. were secured, or that the alleged victim did not shower until examined.

A review of Nursing Flowsheets for Patient #4 included those for 9/16/17 through 9/19/17. The flowsheets are the nursing assessments performed on a patient each shift. It was pointed out to the facility Risk Manager that the flowsheets for 9/17/17 and 9/18/17 were not in the patient record. Thus, there was no documented evidence of the patient having been assessed by nursing staff for 4 shifts - or a 48-hour period. Just prior to exiting the survey which spanned three days, the Risk Manager stated she had the flowsheet for 9/17/17 and brought it to this surveyor. It was a copy of an original and the Risk Manager stated she did not know where the original form was. No nursing flowsheet was provided for 9/18/17. The sheet covered a 24-hour time period 2 days after Patient #4 made an allegation against Patient #5 of sexual assault.

In an interview with Staff #29, RN, House Supervisor, on the afternoon of 11/28/17 in the facility conference room, he stated, "I never knew about this allegation. There's a whole protocol and sexual abuse sheet we have to fill out and follow ...It would be reported on the House Supervisor sheet. We'd follow our sexual assault policy whether it looked like it happened or not."

In an interview with Staff #28, RN, evening shift PICU (psychiatric intensive care unit), on the morning of 11/29/17 in the facility conference room, she stated, "When an allegation of sexual assault is made, we'll talk to both parties and immediately notify the CNO and upper management. We'd absolutely follow our policy and our procedure for an allegation of sexual assault no matter whether it appeared to have happened or not. If the patient was saying it happened, it happened."






Based on interview and record review the facility failed to protect vulnerable patients when the (3) of (3) patient's treatment plans reviewed for violent behaviors were not modified to prevent further harm towards self and others. (Patients #4, 9 and 13)

Findings include:

Review of Patient #4's Treatment Plan reflected a [AGE]-year-old male admitted with a diagnosis of Schizoaffective disorder and a Violence Risk was initiated on 9/7/17.

Review of Patient #4's Restraint/Emergency Medication Order/Records reflected:
- On 9/6/17 at 10:44 p.m. "Pt agitated." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 9/11/17 at 5:20 p.m. "Pt agitated. Attempting to tear phone off wall. Throwing objects at staff across Nurse's Station towards peers." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 9/18/17 at 2:00 p.m. Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.

Review of Patient #9's Initial Treatment Plans reflected "Danger to self...Self-injurious....Anxiety."

Review of Patient #9's Restraint/Emergency Medication Order/Records:
- On 10/29/17 at 10:00 a.m. reflected "...Self injuring. Pt had metal screws. Refuse to give them to staff. Destroying property. Pulling fire alarm...self-inflicted superficial scratches about 10-12 on left forearm from screws removed from wall- clean dressing applied...." Treatment Plan modification indicated: was not checked for a no or a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had not been marked yes or no, and reason why.
- On 10/30/17 at 6:15 p.m. reflected, "Pt striking head on the wall. Pt attached LVN...." 1. Treatment Plan modification indicated: was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 11/1/17 at 7:05 a.m. "...aggressive agitated towards MHTs....Pt hitting techs as they were doing their round MHTs and nursing staff witnessed pt [sic] also hitting window, attempting to scratch face and pulling shower curtain to try to hurt self. Pt was placed in 'handle with care' not to exceed 15 minutes....1. Treatment Plan modification indicated: was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 11/6/17 at 8:50 a.m. reflected, "...Self-inflicted old scratches reopened by patient left temporal area...1. Treatment Plan modification indicated: was checked with a yes response. there were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.

Review of Patient #9's Treatment Plans did not reflect any changes or additional interventions following the incidents on 10/29, 11/30, 11/1 and 11/6/17 and the restraint forms indications to modify the treatment plans.

Review of Patient #13's Treatment Plan dated 9/13 and 9/24/17 reflected a [AGE]-year-old female admitted with a diagnosis of Schizoaffective disorder and a Violence Risk.

Review of Patient #13's Restraint/Emergency Medication Order/Records reflected:
- On 9/15/17 at 7:00 p.m. "Pt charged at staff, tried to bite staff, screaming at staff..." Treatment Plan modification indicated was not checked for a no or a yes response.
- On 9/16/17 at 7:00 p.m. "Verbally aggressive, pulling off room numbers from wall, attempting to hit staff..." Treatment Plan modification indicated: was checked no, the why was not filled out.
- On 9/19/17 at 6:35 p.m. "...kicked door and hid keys in vagina." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 9/21/17 at 6:25 p.m. "Pt charged a peer and began punching and pulling her hair" Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 9/29/17 at 6:00 p.m. "Pt physical attacked another patient, grabbing her by the pair, punching and kicking her." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 10/1/17 at 9:45 p.m. "Patient was grabbing another patient in a head lock and refused to let go..." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 10/1/17 at 10:07 p.m. "Pt was attempting to hit....MHT" Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 10/1/17 at 11:40 p.m. "Pt had another patient in headlock" Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.
- On 10/2/17 at 10:45 p.m. "...breaking plastic soap dispensers..." Treatment Plan modification indicated was checked with a yes response. There were no changes to interventions in the treatment plan after the indications to modify the treatment plans had been marked yes.

During an interview on 11/28/17, in the administration conference room, Staff#19, Director of Performance Improvement when asked if the charts are checked to see if the treatment plans are working, Staff #19 stated, "We review the treatment plans, we check for updates and that all the signatures are present..."

During an interview on the morning of 11/29/17, in the facility conference room, Staff #25, Program Manager stated, "We are not present when the nurse fills out the restraint form....usually if there is a repeat in the restraint I do go into the chart....When it comes to the restraints we do not have any place to write on the form." When asked about the question on the incident report that recommends treatment plan be modified, Staff #25 stated, "I've never seen the incident reports....We do, sometimes, discuss what happened ....Me, as a therapist, I do need to write more....We do need to add a little more of what were are doing in the treatment plan....If there is an incident we do discuss it, but we don't add it until the 7-day update in the treatment plan ...." When asked, 'What does update the treatment plan mean to you? Staff #25, while looking at the treatment plan, stated, "... I just don't see the different interventions. I think that is something that we need to work on."

During an interview on the morning of 11/28/17, in the administration conference room, Staff #20, Clinical Services Director stated, "The therapist is the scribe for the treatment plans...the nurses will tell up if there is a change in the patient...The restraints are discussed in the Pre-flash and the flash meeting. The therapist is there for the Pre-flash, when the discharges and the census is discussed. The restraints are discussed during the Flash meetings; the therapists do not attend, that's when they are in treatments. We only find out about the restraints if the nurse tells us or we happen to be on the unit when the restraint is applied...if a treatment plan needs to be modified the treatment team wouldn't be aware...."
When asked how the MHTs find out about the care and changes made to the treatment plans, Staff #25 stated, "through word of mouth, whether they have knowledge is not very likely..."

Review of the facility provided policy Treatment Planning (dated 2/2017) reflected, "3. Social Services will complete problem sheets for each active psychiatric problem identified....Each psychiatric problem sheet will include behavioral manifestations, triggers and duration for/or of the identified problem ...the MTP will be reviewed and updated at a minimum of every seven days from the date of the completion of the initial MTP or prior update completion. MTP reviews can be done before seven days, if need be, to address changes to the patient's condition that may impact the patient's safety, treatment, and discharge planning. An example of this can include, but is not limited to, a patient that has had two or more restraints, is on a one to one level of care, or actively has become a danger to self or other while in the inpatient setting."

Review of the facility provided Plan of Care Policy (undated) reflected "...10.2 Master Treatment Plan...The treatment plan is a reflection of our philosophy of treatment and reflects the interdisciplinary input and collaboration of all team members. It includes the following: Identification of physical, psychological and social problems the patient is experiencing...Therapeutic approaches (interventions) used by each discipline to assist the patient in meeting the treatment goals...The nursing staff and case manager...are responsible for noting the treatment method, as well as decisions and revisions of the treatment plan by the treatment team, both at meeting and on an on-going basis.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient was free from all forms of abuse or harassment as allegations of sexual abuse or exploitation against 1 of 1 facility employees (Staff #5) were not adequately addressed or documented by the facility. In addition, the allegations were not reported to appropriate regulatory agencies as required by facility policy and regulatory standards.

Findings were:

Facility policy entitled "Reporting Suspected Abuse," last revised 10/2016, included the following:
"Definitions:
A. Patient Abuse
1. Class I Abuse

Any act or failure to act done knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused major physical injury to a patient. Sexual activity between an employee and patient will be considered Class 1 Abuse ...
Actions to Take
A. The staff member receiving information regarding the possibility of abuse/neglect of a person meeting the above criteria shall:
1. Any staff person having reason to believe that a child, adolescent, disabled adult, adult, or geriatric patient's physical health, mental health, or welfare has been affected by abuse or neglect shall immediately report this concern to the patient's physician and treatment team. After determining that the report should be made, the "outcry witness" (the staff person who was told about the abuse) should make a report to the appropriate authority ...If the report is related to suspected abuse/neglect by a staff member, an incident report must be made immediately, with the Director of Risk Management, Director of Performance Improvement, and the Director of Clinical Services to be notified. The call to the authorities is to be made by either the Director of Risk Management or Director of Performance Improvement.
2. A report shall then be made to the Texas Department of Protective and Regulatory Services within 48 hours of awareness to 1-800-252-5400 or online at [no site noted in policy] ...
4. All activity, conversation, responses and results of action taken on suspected abuse and neglect cases are to be documented in the medical record, with date and time of occurrence ..."

Facility policy entitled "Patient Abuse and Neglect Policy In-House Patients," last revised 11/2016, included the following:
"PROCEDURE:
1. Any hospital employee, agent, or affiliate who observes or suspects or becomes aware of a situation at anytime after the fact of patient abuse shall report the suspicion immediately to their immediate supervisor and risk director within the hour of allegation and report to respective authorities. Written documentation of the report shall be made within two (2) hours via the hospital's Incident Report ...
5. In all instances of suspected patient abuse, Administration shall notify the Texas Department of State Health Services (DSHS) by telephone ..."

Facility policy entitled "Reporting Unethical, Illegal, Unprofessional Conduct," last revised 10/2016, included the following:
"Procedure: ...
3. Reporting is required when a person reasonably believes or knows of information that would reasonably cause a person to believe that the facility or an employee or health care professional associated with the hospital has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the hospital or services provided in the hospital.
4. Reports should be made to the Texas Department of State Health Services at (888) 963-7111 regarding services provided by the hospital ...
14. Reporting of sexual exploitation is required if an employee has reasonable cause to suspect that a patient has been the victim of sexual exploitation by a mental health services provider during the course of treatment, or if a patient alleges sexual exploitation by a mental health services provider during the course of treatment, the mental health services provider or the employer shall report the alleged conduct not later than the thirtieth (30*) day after the date the person became aware of the allegations to the prosecuting attorney in the count in which the alleged sexual exploitation occurred, the state licensing board that has responsibility for the mental health services provider's licensing and the Texas Department of Health ..."

A review of the personnel record for Staff #5, Mental Health Technician, revealed an Employee Corrective Action Report with correction action listed of "Counseling Event - Verbal Counseling's [sic] regarding Therapeutic Boundaries" dated "On or about 3/15/16, 1/25/2017, 7/24/2017." A line for employee signature entitled "Counseling Event" was signed by Staff #5 on 8/18/17.

The section entitled "Recent Incident(s)" of the report read as follows:
"Briefly state facts or events leading to the filing of the report: [Staff #5] has been informed on multiple occasions regarding complaints made against [Staff #5] by patients involving boundary violations. [Staff #5] was instructed on January 25, 2017 by [former Staff Name], HRD (Human Resources Director) and [Staff #3], Director of Risk Mgmt, that he is expected to report any personal conversations/interactions with patients that were not reported to the treatment team and report them to the nurse on the unit.

On July 24, 2017 a patient complaint to the nurse about [Staff #5] touching him inappropriately. On August 10, 2017 another patient complaint about inappropriate communication [Staff #5] and the patient stated that [Staff #5] gave the patient his personal phone number and offered to have the patient stay over at [Staff #5's] apartment if the patient he did not have a place to stay.

This behavior is in direct violation of the Therapeutic Boundaries training the [Staff #5] has received. [Staff #5] has been informed that he must report any personal conversations/interactions that may arise to avoid these types of allegations against [Staff #5]. In addition [Staff #5] was also instructed to ensure that he must always t [sic] maintain therapeutic boundaries at all times.

Due to the repeated complaints made against [Staff #5] for lack of appropriate therapeutic boundaries [Staff #5] will be receiving a final written warning. If problems continue, the next disciplinary action will be taken up to and including termination..."

The form was signed by the former Director of Human Resources, on 8/18/17 and the former nurse supervisor on 8/18/17. The line entitled "Executive Signature" was not signed.

[Staff #5's] personnel file contained no other documentation related to allegations of sexual misconduct. He had been on the state nurse aide registry since 1993.

In an interview with Staff #3, Director of Risk Management, on the morning of 11/28/17 in the office of the Chief Nursing Officer, she was asked if it would be possible to interview the nurse manager who signed the report and the Director of Human Resources who was involved in the repot. She stated, "Neither one of them is here any longer. I believe [the nurse manager] left in August, and we've been without a Director of Human Resources for a while now. I believe she left in September 2017." She was asked what she knew about the behavior of Staff #5 as well as her knowledge of the Employee Corrective Action Report. She stated, "[Staff #5] is a very openly homosexual man. The patients know this and they pick up on it. And they make comments. It kind of makes him an easy target. There's never been anything found as far as inappropriate behavior on his part. There was an old allegation that was made by a patient that he was inappropriately touched in the parking lot by Staff #5. Ultimately, I looked at the video on this. There was no evidence that he ever went into the guy's room, first of all. But he did walk the patient out when he was discharged . The techs will escort patients to the lobby when they're discharged , so that's what happened. But Staff #5 walked out of the building with the guy just to smoke a cigarette. It just happened at the same time. We have no evidence that anything happened here.

His nurse manager was trying to cover his tracks. He got into trouble for not documenting any earlier incidents there might have been. So suddenly he was writing this report to cover not documenting any earlier incidents. But I looked at the camera for this last allegation, and there was no evidence. He and this guy were not even in the same places together. The patient was a relatively low functioning individual and we know him. He (the patient) doesn't like it when his family brings him into treatment. Staff #5 had a really bright, colorful shirt on that day, so he was easily viewed on camera. We urged this patient to call the police, and he said he didn't want to call them. Then on the day of discharge, I realized they were talking to him in the parking lot.

This was really the beginning of the end for [the nurse manager]. If we thought that [Staff #5] was doing anything wrong, he'd be gone. We'd be the first to do something. It's about patient safety first and foremost. I think this may have been some kind of retaliatory thing on the part of [the nurse manager] against [Staff #5]." When it was pointed out that only the report was filed in the record of Staff #5, with no investigation or other documentation to refute the allegation, she stated, "I understand."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview the facility failed to modify Patients #4, 9 and 13's treatment plans following the use of restraints.

Findings include:

Review of Patients #4,9 and 13's treatment plans revealed multiple incidents of violent behavior resulting in the use of restraints. The treatment plans did not reflect modifications to the plan of treatment. The treatment plans were updated to reflect some of the incident dates, but a review of the interventions was not evident and the behaviors continued.

(Refer to A0144)
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on facility documentation and interviews with staff, the facility failed to develop a nurse staffing plan based on the characteristics of patients, including the intensity of the patient's emotional, mental, and medicinal needs. This could potentially result in inadequate care of patients as a result of insufficient nurse staffing on units.

Findings included:

Review of facility documents, policies and daily nurse staffing schedules did not reveal a staffing plan based on the characteristics of patients, including the intensity of the patient's emotional, mental, and medicinal needs.

Facility policy titled "Nurse Staffing" stated in part, "The following specific items are taken into consideration by the Charge Nurse on the unit when evaluating staffing needs ... 4. General acuity/activity level of unit ..."
Facility policy titled "Nurse Staffing Plan" stated in part "Operationalizing the plan:
...2. Relevant factors will be taken into consideration in the determination of appropriate staffing, and may include:
...b. Patient characteristics including ...ii. Intensity of acre needed, including admissions, discharges and transfers-this hints at acuity but may want to include the words ..."

In an interview with staff #22 on 11/28/17, they stated, "I have a concern. They need to staff by acuity. They go by the numbers on the grid."

In an interview with staff #27 on 11/29/17, they stated, "We are told to staff right at the grid." When asked about acuity, they stated, "What I have been trained, they have to be evaluated by a physician/therapist and see if they need to be on a one to one. If there is a problem, we look at separating populations for de-escalation ... There is a combination of things you have to do, no just bring in additional staff."

In an interview with staff #32 on 11/28/17, they stated, "Our acuity is high most of the time, not always... The grid doesn't always fit this unit ... The other day, I had two codes going on at the same time. I needed a code team, but I needed another one ... I feel our safety is at risk a lot of times. It can be overwhelming ... I feel like our holds will go down if we are staffed. There was a time it [the staffing ratio] was 1 to 4 or 1 to 5 [nurses per patient] now it's 1 to 12 or 1 to 15, it's excessive. It's concerning."

In an interview with staff #2 on 11/28/17, they stated, "The acuity is built into the ratio. So the staffing ratio for adolescents is 5:1; adults is 6:1; PICU is back down to 5:1; Women's should be ... yes, at 6:1 ... We have the acuity built-in based on numbers from last year of our one-to-ones."

The above was confirmed in an interview with the CNO on the afternoon of 11/29/17.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on a review of facility documentation and staff interviews, the facility failed to assess or examine 1 of 1 patients (Patient #4) after his making an allegation of sexual assault by another patient. In addition, testing and examinations required by facility policy were not performed after the allegation was made. Also, the facility could provide no documented evidence of a nurse having assessed the Patient #4 at all for a 24-hour period 2 days after the alleged assault.

Findings were:

Facility policy entitled "Sexually Acting Out/Sexual Victim Prevention Early Identification, and Observation/Precautions, Interventions and Response & Notification," last revised 04/2016, included the following:
"A. Early Identification: The Admissions Clinical shall assess patients/residents both for variables for sexual behavior groups: At risk for sexually acting out and those at risk for sexual victimization ...

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 contact between patients ...
c. Evaluation or ER visit; STD/HIV, Hepatitis B, Hepatitis, C, rape kit, pregnancy testing, and Plan B (emergency contraceptive) reviewed/offered as appropriate ...
d. Incident location and evidence, such as clothing, bed sheets, etc. are secured, (victim does not shower until examined)
e. Complete a Healthcare Peer Review (incident) report and forward the report to Risk Management within 24 hours.

E. Response:
1. Investigation:
a. Any allegations of sexual contact are investigated for reasons including, most importantly, the protection of patient rights. In addition, investigations are conducted to assure safety, to find causes, to prevent similar occurrences and to protect the company interests.
b. Components to the Risk Manager's investigation include:
Securing a copy of the video of the alleged event at the direction of the assigned Corporate Risk Manager.
Obtaining copies of external reports, (ER record, police report), as applicable ...
3. Documentation: ...
f. Document contact made to physicians, parents and guardians ..."

Facility policy entitled "Protection of Evidence Resulting from Assault," last revised 7/2016, included the following:
"2.0 Procedure
2.1 Immediately upon receiving any information concerning a possible assault, the nurse will immediately ensure the patient's safety ...
2.3 If a patient reports a sexual assault, the unit RN will arrange to transfer patient to Sierra Medical Center as per Police Department Protocol.
2.4 The victim of sexual assault should be requested to refrain from any personal hygiene including oral hygiene until examined by the physician...
2.7 Notify the local police department and advise them that a patient needs to be transferred to Sierra Medical Center for a sexual assault examination ..."

Facility policy entitled "Patient Assessment Nursing Flow Sheet," last revised 07/2016, included the following:
"POLICY
The Patient Assessment/Nursing Flow Sheet are utilized on all patients as a method of documentation and reassessment of the patient in order to communicate treatment provided and its results.
PURPOSE:
To ensure an accurate and concise assessment and record of the patient's needs and treatment every shift. RN assessment will be completed every 12 hours ..."

Nursing narrative progress notes for Patient #4 included the following:
9/17/17 at 8:15 p.m.: " ...The MHT (mental health technician) staff informed the nurse staff that pt reported that he was sexually abused by another pt [Patient #5] yesterday. Pt asked ...MHT staff for another pt name while talking on the phone. On asking why pt needed the name, pt reported the sexual allegation and stated that pt [Patient #5] touched his private part yesterday. The was off [sic] the phone and pt was interviewed by the nurse staff and the MHT staff. Pt reported that pt ...[Patient #5] dragged him into his room and closed the door and touched his private part yesterday after smoke breaks. Pt was unable to specify the ...actual time. Pt reported that he was talking to his aunt over the phone about the incident and that she wanted to know the other Pt [Patient #5] name. Pt reported that the "whole incident was no more than 2 minutes." Pt was asked why he did not report the incident yesterday, pt stated that he was too afraid to report the incident. The house supervisor was notified. Pt separated from pt [Patient #5] and moved to opposite hall way. Pt was informed of need to feel safe at all time while in the facility. Pt informed to notify staff of any feeling of frustration and any sexual abuse propagated against pt. Pt heard talking to his family member over the phone while making preparation to separate pt from pt [Patient #5]. On call Dr. notified. Will continue to monitor Q15 mins for safety ..."
9/18/17 at 6:00 p.m.: "Pt gave information about the incident on Saturday night. Pt stated that on Saturday night he was waiting in the hallway for his meds at 2000. He then decided to go to his room to use the restroom. Pt. stated that that is when the other pt went into the restroom with him. Pt stated that the other pt took off both of their clothes. Pt stated that the other pt. put his private parts into "his mouth" and "through the back." Pt stated that lasted for about an hour. Pt stated that the other pt then pulled him to his room and repeated the same thing. Pt stated that lasted for 2 hours. Pt. stated he said yes to all that so the other pt. could leave. Pt stated this happened on Saturday night from "8 to 10" at night."

The facility could provide no documented evidence that Patient #4 was assessed or examined by nursing staff after making the above allegation. There was no evidence of nursing evaluation or offer of ER visit; no evidence that testing for STD/HIV, Hepatitis B, or Hepatitis C was offered or performed, nor that a rape kit was offered. There was no evidence provided by the facility that the incident location and evidence, such as clothing, bed sheets, etc. were secured, or that the alleged victim did not shower until examined.

A review of Nursing Flowsheets for Patient #4 included those for 9/16/17 through 9/19/17. The flowsheets are the nursing assessments performed on a patient each shift. It was pointed out to the facility Risk Manager that the flowsheets for 9/17/17 and 9/18/17 were not in the patient record. Thus, there was no documented evidence of the patient having been assessed by nursing staff for 4 shifts - or a 48-hour period. Just prior to exiting the survey which spanned three days, the Risk Manager stated she had the flowsheet for 9/17/17 and brought it to this surveyor. It was a copy of an original and the Risk Manager stated she did not know where the original form was. No nursing flowsheet was provided for 9/18/17. The sheet covered a 24-hour time period 2 days after Patient #4 made an allegation against Patient #5 of sexual assault.

In an interview with Staff #29, RN, House Supervisor, on the afternoon of 11/28/17 in the facility conference room, he stated, "I never knew about this allegation. There's a whole protocol and sexual abuse sheet we have to fill out and follow ...It would be reported on the House Supervisor sheet. We'd follow our sexual assault policy whether it looked like it happened or not."

In an interview with Staff #28, RN, evening shift PICU (psychiatric intensive care unit), on the morning of 11/29/17 in the facility conference room, she stated, "When an allegation of sexual assault is made, we'll talk to both parties and immediately notify the CNO and upper management. We'd absolutely follow our policy and our procedure for an allegation of sexual assault no matter whether it appeared to have happened or not. If the patient was saying it happened, it happened."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation and interview it was determined that the facility failed to ensure that medications were secure from the potential of unauthorized access.

Findings were:
Medications were found unsecured from the potential of unauthorized access.
During a tour of the Senior Unit on the early afternoon of 11/27/2017 the following was observed: The sliding glass medication distribution window was closed but not locked, the surveyor was able to open the window from the hallway (patient side) and then reach inside the window and open a drawer on the medication cart. Once the drawer on the medication cart was opened the surveyor potentially could have removed medication from the cart. Review of facility Policy Stat 42, entitled: "Floor Stock" stated under Purpose: "To assure integrity security and safe administration of drugs frequently required for immediate use, emergency drugs, frequently used over-the-counter drugs, and frequently used liquids and injectables. The Policy section stated: "Floor stock drugs shall be readily available to the patient-care staff but not accessible to patients, visitors, and unauthorized personnel." In an interview with facility staff #1 on the afternoon of 11/27/2017 the finding was confirmed facility staff #1 added that both the sliding window and the medication cart should have been locked.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on interview and record review the facility failed to document a reported incident, when Staff #26, RN (Registered Nurse) did not document Patient#9's self-inflicted injuries.

Findings include:

During an interview on the morning of 11/28/17, in the facility conference room, Staff #9, MHT when asked about Patient #9's bruising noted on 11/7/17, after discharge and a possible reason for the injuries acquired on the evening of 11/6/17 stated, " ...Patient #9 would do anything to hurt herself. She would find anything to hit herself with. I saw her hit her face with her fist and punch her-self in the stomach. On her last visit, she was banging her knees and legs up under the sink ...I informed the nurse ....He went to go check on the patient."

During an interview on the morning of 11/29/17, in the facility conference room, Staff #26, RN stated, "I do remember, the behavior started 30-40 minutes at the start of shift change .... I didn't write the incident; they do the behaviors so often that we would have to be constantly writing incident reports ....I didn't do a full skin assessment, she was wearing pants and wouldn't remove them ...I couldn't lift the legs to see her knees, that's when I found a security clip on the bottom of her left pant leg. (Staff #26 drew a picture of the security device. It was approximately 2 inches in diameter with an approximately inch thickness. The device, if separated had a metal pin in the center) Staff #26 stated, "I didn't want to remove the device because it had ink in it, if you remove it, it would ruin the pants. I was going to bring in a magnet to remove the device but she was discharged the next day."

During an interview on the morning of 11/29/17, in the facility conference room, Staff #3, Risk Manager confirmed the missing incident report and the lack of a skin assessment.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview it was determined that the facility failed to ensure that the premises were clean and maintained.

Findings were:
The physical plant was not clean and maintained.

During a tour of the children/adolescent unit on the early afternoon of 11/27/2017 the following was observed:
1.) In the dayroom area there were 13 chairs, each of the chairs had a fabric covered seating area. All of the chairs were dirty and stained in appearance. One of the chairs had a tear on the outermost edge of the horizontal seating area, the tear was approximately 12 inches long by 2 inches wide and the foam inner core was exposed. Also observed was that several of the chairs had small pieces of what appeared to trash on the sides of the cushioned seating area. When the surveyors asked how the chairs were cleaned, a member of the housekeeping staff took a broom which was used to sweep the floor and then used the same broom to sweep out the trash on the chairs. This was a potential infection control issue as it would be difficult to clean the foam inner cushion on the chair with the ripped upholstery, and using a broom which had been used to sweep the floor created a cross contamination situation.

2.) In patient room #114, there were two visible dried stains on the wall adjacent to the window, each of the stained areas had what appeared drip marks and small pieces of dark particulate matter stuck to the wall.

3.) In patient room #122, there was a wall mounted silver metal plate which was intended to cover the electrical outlets. One of the screws used to hold the metal plate in place was missing and the plate could be rotated and easily moved by the tip of the surveyor's shoe. This was a potential safety hazard as the plate could possibly be bent downward and could be potenially used to injure a patient. In interview with both faciltiy staff #1 and staff #4 on the afternoon of 11/27/2017 the above findings were confirmed.