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EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX 79902 Feb. 7, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of documentation and interview, the facility failed to ensure that patient care was provided in a safe setting as evidence by failing to ensure that patients on "chaperone" monitoring were efficiently monitored by a sufficient number of staff according to the review of staffing assignment sheets.

Findings included:

In an interview on 02/06/17, staff member #11 stated that the nurses on each unit complete the assignment sheets as they see fit. Staff member # 11 was asked if there was a report they could run to see what beds patients were in, they were unsure. When asked how a chaperone would watch multiple patients at one time, they stated, "Can I draw you a picture?" They drew two rooms next to each other with two beds in each room and stated, "See if they sit here in the hall, outside the room, they can watch all four kids at one time." This staff member was asked how the facility was able to identify room assignments for patients for these dates. They stated that nursing staff on the unit could usually tell you what the room assignments were in real time, but was unable to explain how the facility could trace back room assignment for patients on the dates of 01/15/18 through 01/25/18. They were not able to provide any documentation of room assignments for the patients on these dates.

Tour of the Child and Adolescent Unit on 02/07/18 revealed several rooms that cannot be monitored by the same chaperone simultaneous due to distance and/or obstacles obstructing view of the patients such a seclusion room located between rooms and a double door way.

Several child and adolescent patients (#7, 8, 9, and 10) were on chaperone status on 01/15/18 through 01/29/18 due to sexual predator or victimization behavior. Review of the Child and Adolescent Unit staffing assignment sheets for 01/16/18 through 01/29/18 revealed the following:
* From 01/15/18 through 01/25/18 the Patient Care Assignment sheets were not completed with consistent information. Some sheets indicated which staff members were assigned to 1:1's or "chaperone" status, others did not. These assignment sheets also did not include room number assignments for the patients on the unit.
* On 01/20/18 Patients #7, 9, and 10 remained on "chaperone" at night status. The Assignment Sheets for 7P-7A listed these three as "1:1 QHS". The assignment sheet listed Patients #7 and 9 alone, but Patient #10 had another patient's name (Patient #12) listed beside her indicating they were a roommate. Patients # 9 and 10 were monitored by the same staff member. Patient #7 was monitored by a different staff member. Due to not knowing the patient room assignments/roommate status/location it cannot be established that one staff member could adequately visualize and monitor Patients # 9 and 10, especially since Patient # 10 appears to have a roommate based on the assignment sheet.
* On 01/21/18 #7, 9, and 10 remained on "chaperone" at night status. The Assignment sheet for 7P-7A only listed Patient #7 as the only patient with a "chaperone". Patients # 9 and 10 were monitored by the same staff member. Patient #7 was monitored by a different staff member. Due to not knowing the patient room assignments/roommate status/location it cannot be established that one staff member could adequately visualize and monitor Patients # 9 and 10 simultaneously.
* On 01/22/18 #7, 9, and 10 remained on "chaperone" at night status. The Assignment sheet only listed Patient #7 as the only patient with a "chaperone". Patients # 9 and 10 were monitored by the same staff member. Patient #7 was monitored by a different staff member. Due to not knowing the patient room assignments/roommate status/location it cannot be established that one staff member could adequately visualize and monitor Patients # 9 and 10 simultaneously.
* On 01/24/18 #7, 9, and 10 remained on "chaperone" at night status. The Assignment sheet listed these patients as "1:1 QHS", it also listed Patient #9 and 10 side by side like roommates. Patient # 7 also had another patient's name (#13) listed by his name as a roommate. All three patients were monitored by the same staff member. Due to not knowing the patient room assignments/roommate status/location it cannot be established that one staff member could adequately visualize and monitor all three patients on chaperon status and their roommates simultaneously.
* From 01/15/18 through 01/29/18, the "Patient Observation/Rounds Form Continuous chaperone observation when in room with roommate" form was appropriately completed for these patients, all q 15 minute checks were documented.
* From 01/25/18 through 01/29/18 room numbers were included for all patients so it could be determined if patient's had roommates and where their room was located on the unit. In an interview on 02/07/18, Staff member #3 stated that addition of the room numbers to the assignment sheet was at the recommendation of nurses in the nurse staffing committee.
* Review of the assignment sheets on 02/06/18 revealed that room assignments, chaperone status, and staff assigned as chaperones were all documented. Review of the "Patient Observation/Rounds Form Continuous chaperone observation when in room with roommate" forms revealed that the patients were adequately monitored with different staff member assigned as chaperones for any rooms with obstacles between or in different areas of the unit.

On the dates of 01/20/18, 01/21/18, 01/22/18, and 01/24/18 patient room assignments/roommate status/location could not be determined and therefore it cannot be established if these patients on "chaperone" monitoring were effectively monitored by the appropriate amount of staff. Room assignments and configuration directly impacts how many patients one staff member could safely visualize and monitor. From 01/25/18 onwards room numbers were included on assignment sheets make it possible to determine how many staff were needed to monitor patients on "chaperone" monitoring.

The above findings were confirmed in an interview with staff members #1, 2, 3, and 11 on 02/07/18.