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||April 30, 2019|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on observation, interview and record review the facility failed to provide a safe patient environment when dirty linens, soiled toilet tissue and wet tissue was left in the patient's bathroom floors creating an unsanitary environment.
Observations on the afternoon of 4/29/19 at 2:00 pm, of the patient units, revealed the following:
Room 216- Wet soiled toilet tissue was noted on the bathroom floor and a piece of toilet tissue with a brown substance was sitting inside to tissue holder. There were two wet towels noted on the floor.
Room 217- Wet toilet paper and two dirty towels were noted on the patient's bathroom floor.
During an interview on the afternoon of 4/29/19, on the inpatient unit, Staff #4, ADON confirmed the findings.
Review of the facility provided policy (undated) reflected, "Q-15's OBSERVATION ROUND GUIDELINES AND STAFF DUTIES ... Immediately remove any linens from the floor, and take to appropriate soiled linen bag, this is an infection control issue ...."
|VIOLATION: ORGANIZATION OF NURSING SERVICES||Tag No: A0386|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide medically indicated treatment when the Dietitian had recommended nutritional supplements, to manager Patient #4's elevated blood sugars, was not ordered and initiated.
Review of Patient#4's medical records reflected a 54- year female admitted with a history of Diabetes mellitus, uncontrolled, Hypertension, [DIAGNOSES REDACTED] and a danger to self and danger of deterioration.
Review of the Physician's Progress note dated 2/13/19 "She continues to be fairly erratic here on the unit, asking for food all the time when really what she wants are donuts. Because of her diabetes and the brittleness of her diabetes, we are trying to restrain her from having .... The patient is seen today in the dayroom. She is putting her head on the table, saying "I want food, I want food...."
On 2/18/19 at 5:05 am, the nursing note reflected, " ... Blood sugar taken (422). Pt. was offered 10 units' regular insulin, per sliding scale protocol, however Pt. refused.
At 7:18 am, "Dr. ... is reached and informed of current situation with Pt. Dr.'s orders were: 1. Recheck BS, follow slidescale [sic] protocol, and if elevated still call me 2. If pt. refuses BS, MOT Pt ...."
At 7:20 am, "BS is 467 ...."
Review of Dietitian Consultation record dated 2/01/19 reflected Triggered for Nutrition Screen, Diabetic and low BMI (body mass index). History: 54 yoF [sic] triggered for low body weight and uncontrolled diabetes .... Pt will benefit from Glucerna shakes (Designed to help minimize blood sugar spikes in people with diabetes compared to high-glycemic carbohydrates) .... Recommendations: 1. Diabetic Diet 2. Glucerna TID 3. Feeding assistance and encouragement ...."
During a telephone interview on the afternoon of 4/29/19, in the facility conference room, Staff #7, RD stated, " ...The way I work, once I get the consult I talk to the staff, they are more aware of the patient's eating .... I tell the nurses my recommendations ... I don't have ordering privileges at this facility .... I don't follow-up to see if the order was implemented unless there is an issue ...Some nurses are really good at letting me know if a patient is not eating ...."
During an interview on the morning of 4/29/19, in the facility conference room, when asked about the Dietitian's recommendation not being ordered Staff #6, MD stated, "I didn't see the recommendations ... The nurse is the one who initiated the consult. If I didn't order the consult, I wouldn't know to look for it ...."
Review of the facility provided policy Patient Rights and Responsibilities (dated 6/2018) reflected, " ...Patients have a right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ....
A. Access to Care: Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated ...
S. Refusal of Treatment: The patient has the right to refuse particular treatments without prejudice to participation in other programs, or without compromising access to other treatment or services solely because of the refusal ...."