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 May 15, 2018
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of camera evidence, documentation and interview, it was determined that the facility failed to always provide a safe environment for its patients.

Findings were:

Facility policy entitled "Special Precautions Guidelines and Patient Observation" stated in part
"A Special Precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation.

It is the policy of this facility to provide a safe and secure environment for patients during their hospitalization . One of the tools used to ensure patient safety is a special precaution or an intensified level of staff awareness and observation. Observation levels, however, may infringe on the patient's right to privacy. Effective management of a patient's behavior must balance the importance of protecting the patient's rights versus the use of restrictions to protect the patient or others. The level of observation required for a patient is a matter of clinical judgment, but the basis for that clinical judgment must be well documented ...

All patients on acute inpatient units in the facility and in the Admissions Department are maintained on at least every 15-minute observation by policy. Guidelines for implementation of this level of precaution include, but are not limited to observation at least every 15-minutes and the following:
* Staff should maintain visual and verbal contact sufficient to monitor the patient's condition on a frequency level of approximately every 15 minutes.
* The patient should only be allowed off the unit under direct supervision of staff
* The patient may attend all therapies and activities conducted in secure areas of the facility with direct supervision of staff
* When clinically indicated and ordered by a Physician, 1:1 supervision is maintained whenever the patient has access to restricted contraband items (sharps, razors, etc)
* Medical consultations outside the facility may be scheduled with staff supervision as ordered by the physician
* Hand off process for shift change/breaks/emergences/codes: Off going and oncoming staff will walk/monitor the unit jointly, correlating the patient location/behaviors with the Patient Observations Rounds forms to ensure the continuity of care. Both staff will initial the Patient Observation Rounds form at change of shift to indicate the completion of the hand off process.

Medical Record documentation for all levels of observation includes:
* An Observation Record, which reflects the special precautions, level of observation, date, time, and patient's location and observed behaviors every 15 minutes, is maintained by assigned mental health technicians or nursing staff as part of the patient's medical record.
* The assigned mental health technician or nursing staff will conduct their rounds every 15 minutes and will document rounds concurrently so that rounds do not contain late, missing or early entries.
* Mental health technicians or nursing staff conducting rounds will ensure that they visualize patients while in bedrooms/bathrooms, while sleeping and confirm the rise and fall of chest and/or movement
* Mental health technicians or nursing staff conducting rounds will notify charge nurse when patient exhibits high-risk behaviors e.g.: isolating self, increased agitation, etc. and utilize chain of command to communicate patient care concerns ...

Additional Routine or Unit Precautions:
* ...Dayrooms, hallways and unit common areas should be supervised by staff during unstructured times when patients are present."

Facility policy entitled "Sexually Acting Out/Sexual Victim Prevention, Early Identification, Observation/Precautions, Interventions and Response and Notification" stated in part "El Paso Behavioral Health System shall implement a policy for patients/residents for protective measures the facility shall take for those who are vulnerable to sexual victimization by other patients/residents who are on sexual precautions and residing in the facility. Patients/residents shall not have sexual contact with one another. Patients/residents are assessed for risk of sexual acting out behavior or of being sexually victimized."

On 4/29/18, due to inappropriate supervision by hospital staff, 6 children on the adolescent unit provided each other with oral sex. When this was reported later, Patient # 1 felt he was forced/bullied into participating. One child was observed laying down on the floor while his peers kicked and hit him. The staff member who was assigned to monitor the children involved was observed to be in the nurses' station watching TV.

In interviews with the Risk Manager and Chief Operating Officer on 5/15/18, the above findings were confirmed.