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 23, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and record review, the facility failed to meet the Conditions of Participation for Patient Rights as evidenced by:


1. (2) Two patients out of (5) five patient's videotape restraint records, reviewed for appropriate restraints, revealed the restraints were placed without indication of its necessity; the patients were not at risk of harming themselves or others. Patient #5 and #11 are seen in an area with no other patients and are not involved in self-injurious behaviors. The staff are seen initiating the approaches to the patients and creating the need for the restraints. The restraints placed the patients at an increased risk of injury.

(Patients #5 and 11) (Refer to A154)


2. (2) Two Patient's restraints had been applied incorrectly, placing the patients at risk for injury. Patients #7, a 55-year-old-female, her wrists were held by a staff member, contrary to the facility policy. Patient #11, a 9-year-old female, was held by her underarms by two male staff, when the patient bent her knees refusing to walk, the staffs dragged her across the floor for approximately 5 feet. A nurse was observed pushing Patient #11 back into a chair when the patient attempted to stand up. The staff's actions placed both patients at risk for injury.

(Refer to A145)


3. The Facility's Risk Management & Safety Program ineffectively monitored and evaluated proper restraint use. Patients #5 and 11's incidents were not identified as being inappropriate and unwarranted. According to the facility policies and practices, if the patient is not at risk of harming self or others they should not be restrained as this puts them at an increased risk of injury.

(Cross Refer A0283 Quality Improvement Activities)


4. Dirty linens were being stored on the floor, creating an unsanitary environment in (4) four out of (5) five inpatient units observed for cleanliness.

(refer to A144 Care in a Safe Environment)


5. Failing to ensure patient belongings/valuables had been returned to 1 of 1 patients reviewed [Patient #3], thus failing to ensure the right to reasonable protection and security of personal property for each patient

(refer to A0144)


6. No documented evidence that 1 of 1 patients reviewed [Patient #3] was made aware of the information in the facility's patient bill of rights, either upon admission or prior to the patient's discharge

(refer to A0117)


7. Failure to secure informed consent for each patient receiving psychoactive medication, thus ensuring each patient's right to be counseled regarding medication, including intended effects and potential side effects of the medication, for 1 of 1 patients reviewed [Patient #3]

(refer to A0131)


8. Failure to ensure grievances were investigated and resolved appropriately [patient #9]

(refer to A0123)


9. Failure to ensure patient's representatives had the right to make informed decisions regarding their care [patient #9]

(refer to A0131)


10. Failure to address medical issues for 2 of 2 patients [patients #2 and #9]

(refer to A0144).
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on observation, a review of facility documentation, and staff interview, the facility failed to ensure that each patient received and was made aware of the information in the facility's patient bill of rights for 1 of 1 patients [Patient #3] reviewed.

Findings were:

Facility policy # 35 entitled "Patient Services," last approved 01/2018, included the following:

"It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form, as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms ...
Procedure ...

3. When the individual receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably by a family member, legal guardian or friend (if available) or by another staff member ...

6. Within the first 24 hours following inpatient admission a nursing staff member will review the patient's right with the patient again and obtain a second signature to confirm understanding of the rights ..."


A review of the patient record of Patient #3 revealed she was brought into El Paso Behavioral Health on an emergency detention order on 3/22/18. On that date, a Patient's Bill of Rights form included the typed statements, "I received a copy of this document (patient's bill of rights) prior to admission," and "Someone on the staff explained to me what this document says in a language I understand." The admissions staff person had written "Pt on EDO (emergency detention order). Pt unable to sign due to AMS (altered mental status)." It was signed by the admissions staff person, but the form included no additional witness. The form also included the typed statement, "Sometime during the first 24 hours after I was admitted , someone on staff explained to me what this document says in a language I understand." This statement was also not initialed or signed by the patient. The record contained no documented evidence of additional attempts to explain the information in the patient bill of rights to Patient #3.


The above findings were confirmed in an interview with Staff #6, Director of Admissions, on the afternoon of 5/23/18.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a review of facility documents and staff interview, the facility failed to ensure the hospital investigated a grievance and notified the patient's representative of its resolution.

Findings included:

Facility policy titled "Section 504 Grievance Procedure" stated in part, "The Section 504 Coordinator, or his/her designee, shall conduct an investigation of the complaint. The investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint ..."


Patient/Family Grievance Form dated 5/2/18 at 9:30 am stated in part, "Did you speak to a staff member about your complaint? Yes/No ... Did the staff member make an attempt to address your complaint? No

Grievance/Complaint: CPS [Child Protective Services] not advised of child's discharge or included in discharge planning. Child was discharge w/ broken knuckles. Child is being required to undergo surgery due to improper medical care.
How can this be resolved? CPS needs to be included at patient discharge. Medical injuries which occur under hospital admission, should be properly followed up w/ prior to discharging patient. CPS should be allowed immediate access to paperwork for serious medical incidents ...

Date/Time Received by Patient Advocate: 5/2/18/1030 am

Steps taken by Patient Advocate on behalf of the patient to investigate: Met with CPS in lobby to address concerns. Informed CPS I will follow up with UR [utilization review] about contacting CPS. Also will follow up with medical records. Will talk to staff about keeping CPS up to date with all medical issues or anything else about patient. Notify CPS and Family about Incidents! Keep CPS up to date with discharge plan.
Result/Disposition of Grievance: Informed leadership and they would look into it."

In an interview with the patient advocate on the morning of 5/22/18, they stated, "I talked with CPS that day and referred it to leadership."

In an interview with staff #5 on the afternoon of 2/23/18, when asked who investigated this grievance, they were unsure. They brought an "investigation" that consisted of copies of restraint documentation and nursing notes from the patient's medical record. There was no investigation completed.

In an interview with staff #2 on the afternoon of 2/23/18, when asked what happened to this grievance, staff #2 stated, "It looks like that's the resolution [referring to the grievance form]."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, a review of facility documentation, and staff interviews, the facility failed to secure informed consent for each patient receiving psychoactive medication, thus ensuring each patient's right to be counseled regarding medication, including intended effects and potential side effects for 1 of 1 patient [Patient #3] reviewed.

Findings were:

Facility policy # 45 entitled "Patient Rights and Organizational Ethics," last approved 01/2018, included the following:

"The right to be informed of proposed treatments or procedures and to be given the opportunity to withhold their consent ..."


A review of a document entitled "Basic Rights for All Patients," of El Paso Behavioral Health included the following:

"29. You have the right to not be given medication you don't need or to be given too much medication ...However, you may be given appropriate medication without your consent if:

o Your condition or behavior places you or others in immediate danger; or

o You have been admitted by the court and your doctor determines that medication is required for your treatment and judicial order authorizing administration of the medication has been obtained ..."


Facility policy # 72 entitled "Informed Consent for Medication Administration," last approved 01/2018, included the following:

"Informed Consent:

Informed Consent for the administration of psychoactive medication shall be required for all patients, voluntary or involuntary. Such consent must be written and made a part of the medical record ...Informed consent must be given by the legally authorized representative of a patient under the age of 18 admitted under the voluntary, emergency or OPC provisions of Texas statues, or by the patient himself if he meets the following criteria: ...

2. Receipt of Information - The person giving the consent has been informed of the nature, purpose, risks, and benefits of treatment with psychoactive medication, as well as generally accepted alternatives to such treatment, if any;

3. Voluntariness - The consent has been given voluntarily ...

Documentation of Informed Consent:

Informed consent for the administration of psychoactive medication will be evidence by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient admitted under the voluntary, emergency, or OPC provisions of Texas statues or his legal authorized representative ...

Patient admitted Under Texas Statues:

Psychoactive medications may not be administered to a patient admitted under the voluntary, emergency, or Order of Protective Custody provisions of Texas statues without informed consent, except in an emergency or a situation which, in the opinion of the treating physician, indicates the possible of immediate physical or mental deterioration of the patient, or indicated the possibility of immediate physical injury or death of the patient or other persons in the hospital ..."

A review of the patient record of Patient #3 revealed three (3) Consents to Treatment with Psychoactive Medication included in the patient record for: oral Zyprexa (an anti-psychotic also used to treat bipolar disorder and depression), oral Trileptal (an anti-seizure, used off-label to treat bipolar disorder) and oral Seroquel (an anti-psychotic). The consents for Zyprexa and Trileptal were not signed by the patient. On the line for patient signature was written "NA." On the patient signature line for the consent for Seroquel was written "Verbal Consent." The form did include two staff witnesses to the consent. Thus, Patient #3 consented only to receiving Seroquel on 3/30/18 at 9:00 p.m., and no other psychoactive medications.

The patient received doses of Trileptal and Seroquel on 3/30/18 and 3/31/18 at 9:00 p.m. She also received Trileptal at 9:00 a.m. and 9:00 p.m. along with Seroquel at 9:00 p.m. on 4/1/18 and 4/2/18. These medications were administered to the patient without the facility's having a consent to treatment with psychoactive medication signed by her for these doses.

She was not court-ordered to receive psychoactive medication until 4/3/18, thus the psychoactive medications noted above were administered to her prior to her giving informed consent to receive the medications - consent which included intended effects, possible side effects and other information required by the patient to fully understand what she was taking.

These findings were confirmed in an interview with Staff #30, Assistant Director of Nursing, on the afternoon of 5/22/18 in the facility conference room. She agreed that the patient had received psychoactive medication for which she had not provided consent.



Based on a review of facility documents, a review of medical records and staff interview, the facility failed to ensure patient's representatives had the right to make informed decisions regarding their care.

Findings included:

Texas Administrative Code chapter 404 subchapter E titled "Rights of persons receiving mental health services" stated in part, " ...(8) The right to explanations of the care, procedures, and treatment to be provided ... This right extends to the parent or conservator of a minor, the legal guardian of the person, when applicable ...

(14) The right to participate actively in the development of a discharge plan addressing aftercare issues which include the individual's mental health, physical health, and social needs. This right extends to a parent or conservator of a minor, or the legal guardian of the person, when applicable ... Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate."

Review of the medical record for patient #9, a [AGE]-year-old patient, revealed they were admitted on [DATE] for suicidal ideation. A multidisciplinary note by patient #9's program therapist dated 4/17/18 stated in part, "CPS [child protective services] caseworker presented herself to notify of the need to be involved in treatment due to having conservatorship over [patient #9] ..."

In an interview with staff #34, on the afternoon of 5/23/18 in the facility conference room, they were asked how CPS was involved in the treatment and discharge planning of this patient. Staff #34 stated, "CPS was already involved with this case when the patient was admitted . [They] had a caseworker. She came in and requested to speak with a therapist ... Our utilization review [UR] handles all the aftercare ... I didn't contact CPS about the incidents with the patient's hand because that was a medical issue. Nursing should have notified CPS. Our UR is [employee name]. [They do] all the follow-up care when a patient is discharged . CPS should have been involved in the discharge planning."

In an interview with staff #35, Utilization Review Assistant, on the afternoon of 5/23/18 in the facility conference room, they stated, "I handle scheduling follow-up appointments. The therapist got hold of the patient's grandmother ... We usually coordinate together at discharge. The therapist would usually be talking to CPS at discharge ... The RNs will usually convey to me the need for a medical appointment ... I just make sure they have follow-up appointments, that they're going to the right place and that transportation is arranged ... It looks like maybe the family didn't know they needed to follow up with their PCP [primary care provider]." When asked who made that appointment, staff #35 stated, "It's not an appointment. It was probably the nurse."

In an interview with staff #2 on the afternoon of 5/23/18, they stated, "Therapy is really the liaison between the patient and the family [and/or guardian]. Therapy can inform CPS of medical issues and can refer them [the family and/or guardian] to nursing if they need more information."

CPS had conservatorship over patient #9 and had the right to be involved in their care including treatment planning, medical needs and discharge planning. The facility failed to ensure CPS was able to make informed decisions about patient #9's care.

The above was confirmed in an interview with staff #2 on the afternoon of 5/23/18 in the facility conference room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, a review of facility documentation, and staff interviews, the facility failed to ensure the right to reasonable protection and security of personal property, and to implement its own policy regarding this issue, for 1 of 1 patients [Patient #3].

Findings were:

Facility policy entitled "Patient Belongings," issued 2/2017, included the following:

" ...Returning Valuables/Belongings: ...

5. The staff member will indicate each item(s) to the patient are being returned upon discharge by staff's signature and date along with the patient's signature and date.

6. A copy of the form will go to the patient and a copy in the patient's chart ..."


A review of the patient record of Patient #3 revealed a document entitled Patient Property & Inventory Sheet. The form listed a number of items which were brought into the facility by Patient #3, including valuables listed as: 1 bracelet, 1 ring, 1 necklace, 1 wallet. A box on the form entitled Discharge Valuables Disposition was left completely blank. It included the typed statement "I (patient) acknowledge that I have received all items listed on the patient property and inventory sheet." The form included a place for the patient to sign, the employee to sign and a date/time line to show when the patient received the items back upon discharge. All were blank.


In an interview with Staff #6, Director of Admissions, on the afternoon of 5/23/18 in the hallway outside the conference room, she stated, "The discharge process requires a mental health technician to come down with the patient to admissions. The patient completes and signs the form indicating that they got their belongings back. If a patient refuses to sign the form, we would need to document that. And if they're saying they're missing belongings and that's why they're not signing the form, then we would get our patient advocate involved to initiate the grievance process ..."






Based on observation, interview and record review the facility failed to provide care in a safe setting when

a.) Three patients were restrained inappropriately, placing them at risk for injury, the facility did not identify Patient #5 and #11's restraints as being applied incorrectly and did not correct the staff's actions to prevent further incidents. (Patients #5, 7 and 11)

b.) Dirty linens were stored on the floor, creating an unsanitary environment.

Findings Include:

a.) Review of Patient #5's medical record reflected a [AGE]-year-old male admitted on [DATE] with a diagnosis of Paranoid schizophrenia.

On 5/22/18, a review of the facility provided video tape from the evening of 3/3/18 at 4:17 pm revealed, Patient #5 standing in the empty hall way outside his room. Two large male staff members, Staff #10 and Staff #11, MHTs, were several feet away from the patient, they are seen coming toward the patient. Patient #5 raised his hands up in the air above his head. The staff continued to approach the patient and were standing side by side, less than an arms width in front of Patient #5; Staff #10, MHT is at least a foot taller than Patient #5 and weighed approximately 250 pounds. Patient #5 backed up against the wall and lowered his hands, the staff are seen taking him by the arms and lowering him to the floor. Staff #10, MHT was observed laying across Patient #5's legs from 4:19 pm to 4:31 pm. The restraint lasted 14 minutes. Patient #5 was slow to rise, requiring assistance from staff to stand, and was unsteady on his feet.


Review of the Patient #5's facility provided incident report for the incident dated 3/3/18 reflected, "pt was seen being aggressive and verbally abusive to MHT and posturing and threatening to hit staff." The report was written by the nurse and does not reflect the information leading up to why the staff were approaching and standing close to the patient.


Review of Patient #7's medical records reflected a 55-year-old-female admitted on [DATE] with a diagnosis of Schizoaffective disorder and generalized anxiety disorder.


Review of the facility provided video tape from the evening of 3/4/18 at 10:55 pm, revealed Patient #7 pacing back and forth in front of the nurse's station. Staff are observed trying to calm the patient down. Patient #7 becomes agitated, striking at the staff. Staff #10, MHT is observed holding Patient #7's wrists in front of the patient at chest level. The patient made several attempts to release her wrists; Staff #10 continues to hold her wrists until the patient kicks at a staff member. The patient is then brought to the floor and restraints are applied according to the facility's policy.


Review of Patient #11's medical records reflected a 9-year-old-female admitted on [DATE] with a diagnosis of Suicidal Ideation.


Review of the video tape from the evening of 4/24/18 at 7:18 pm reflected Patient #11 sitting on the floor in an empty hallway. The patient is observed getting up and crossing the hall. Three staff were observed leading her to the opposite wall where she tries to sit down. Staff #28, RN is in the hallway observing. Two male staff members are observed grabbing Patient #11 under each arm and directing her to the next room; the patient bent her knees during the transfer and was dragged approximately five feet by the staff. The patient is seen sitting down in a chair with staff standing around her talking to her, the patient attempts to stand up Staff #28, RN is observed pushing her back into a chair as she tried to get up out of the chair. Staff #28, RN is observed closely following the patient around the unit, touching her on the arm and shoulder multiple times, causing the patient to move away from the staff member each time.


During an interview on the afternoon of 5/23/18, in the facility conference room, Staff #5, Director Risk when asked if the dragging of Patient #11 was a concern, after consulting with HR stated, "They determined it was an escort, it wasn't a concern."


During an interview on the morning of 5/23/18, Staff #30, RN ADON reviewed the video and confirmed the moving of the patient by dragging her and pushing her into a chair are not Handle with Care techniques. Staff #30 stated, "Rarely should you ever have to move a patient from where they are being held, you just deal with it right there. ...I'm constantly telling them don't pick up, don't pick up the kids ...I'm familiar with Patient #11 ...if you let her cry it out she calms down.... I usually sit in on flash, we talk about the restraint and if it was done correctly or if the staff need retraining...we talk with HR. HR sets the training. HR will let us know if they've been retrained. Usually, we get an email to make sure ...HR tells us it's been completed.... I have talked to Staff #28, RN several times." Staff #30 confirmed she was present for the Patient #11 video review but did not remember seeing the patient being dragged.


During an interview on the morning of 5/22/18, in the conference room, Staff #33, Human Resources Director stated, "We review all restraints at the flash meetings daily and on Monday for the weekend ...there were two incidents for Patient #5, one on 3/3/18 and another on 3/5/18. Patient #5 was restrained because he was clenching his fists and the staff thought he was going to punch them.... Staff #3 (Performance Improvement Director) and I discussed it, we decided Staff #11 was following Staff #10's lead. Staff #10 was written up for the 3/5/18 incident. He didn't use the proper Handle with Care. I told him what was expected but I didn't give him a time frame to get it done ..." When asked if the required retraining was communicated to the Nursing department and was the staff member allowed to be placed on the schedule prior to completion of the training. Staff #33 stated, "...I honestly don't recall, she (DON) should have been....We've since had a discussion. I should handle personnel; she'll handle the clinical part ...." When asked did the facility have a communication form or system between the HR and the other departments, so the Department heads knew what was expected in order for the staff to return to work, Staff #33 stated, "No, I don't document the discussion.... the process is broken."


Staff #33 confirmed, the Risk manager and the Performance Improvement (PI) were part of the team responsible for reviewing the videos for proper restraint holds and that he as Human Resources Director reviewed the videos with the staff members involved. Staff #33 also confirmed that he, the Risk Manager and the PI Director had not completed the 'Handle with Care' training and did not have clinical backgrounds.


During an interview on the morning of 5/23/18, Staff #32, RN, after being informed of the staff's interactions with Patients #5, 10 and 11, stated, "I teach the Handle with Care, I'm the lead trainer...the patient should be held from behind; for the safety of the patient and the staff.... The escort is considered a restraint, we teach to only put 'hands on' if the patient is a danger to self or others.... there should be no form of intimidation, they should get on the level of the patient, standing over them can be intimidating...they need to give the patient space.... once the patient is no longer a risk to self or others, the staff need to step back... When we take the staff off the floor they can't come back until we have completed the investigation and if they have completed any required training. Debriefing is done after each restraint to evaluate whether we could have done it better, the goal is not to get to a restraint."


On 5/23/18, review of Staff #28's, RN's employee files did not reflect discussions or counseling for the use of and the supervision of proper restraints.


Review of Employee Staff #10, MHT's, employee file dated 3/27/8 reflected A Corrective Action, "...Final Written Warning: Restraint was not EPBH mandated, Handle with Care, which lasted 5 minutes, during which time MHT Staff #10 did de-escalate the patient until an LVN could take over using an alternative method.

Briefly state what employee must do to improve: MHT Staff #10 has been through Handle with Care training on multiple occasions. He is well aware of the EPBHs-mandated method of restraint when it is needed. He will be retrained on Handle with Care and is reminded that this method must be observed in all future patient restraints."

Staff #10's employment file did not reflect completion of the Handle with Care retraining. Staff #10 had returned to work after a two-week suspension. HR confirmed the required training was not completed.


Review of employee Staff #11's employee file reflected no discussions or additional training on the use of physical restraints.

Review of the facility provided policy Use of Physical restraints (Dated 1/2018) reflected, "...Physical restraint: The application of physical body pressure by another person to the body of a patient in such a way as to limit or control the physical activity... The use of physical body pressure or physical assistance in escorting a patient is considered a physical restraint.... Each and every restraint episode requires a physician's order....based on the patient's authorization, the family/significant other is notified of the restraint incident...Assessment includes as appropriate: signs of injury...CNO or designee Investigate all unusual patterns of restraint use...."

Review of the facility provided policy Philosophy on the Use of Seclusion and Physical Restraint (dated 1/2/18) reflected "El Paso Behavioral Health System is a mechanical restraint free facility. The facility is committed to: ...Limit the use of physical restraint and seclusion to emergencies in which there is an imminent risk of an individual physically harming himself or herself or others....The hospital does not permit the use of physical restraint or seclusion for any other purpose such as coercion, discipline, convenience, or retaliation by staff...."


Review of the facility provided document The Primary Restraint Technique (PRT)

Step 1 The PRIMARY RESTRAINT TECHNIQUE is applied

Step 2 Initiate the Takedown, taking a long step back lowers A's center of gravity, drawing the resident off balance. A's palms are against the resident's back to support his weight The Count: Deep Step Back

Step 3: A lowers his knee to the floor, slowly staging the resident's descent to a sitting position

Step 4: "drop the other knee. Settle bringing the client to a sitting position...."


Review of the facility provide Risk Management & Safety Program (dated 2017) reflected, "...Risk Identification is essential in order to identify potential risk exposures faced by the facility, and to provide direction for the facility to prevent, mitigate, and eliminate risk generating practices.... Risk Manager is notified of all...Incident Report...trends are reviewed for incident frequency, reoccurrence, etc., and appropriate actions taken to reverse trends...."

a.) Observations of the following facility's dirty linen closets, on the morning of 5/22/18 revealed:

PICU- (1) one cloth bag of soiled linens sitting on the floor.

Geri Unit- (2) two cloth bags of soiled linen sitting on the floor and (1) one bag of trash on the floor.

Women's Unit- (1) one cloth bag of soiled linen on the floor and (2) two trash bags and trash on the floor.

Military Unit- (2) Two cloth bags of soiled linens sitting on the floor.


During an interview on the Military Unit, Staff #8, MHT when asked if the linens are wet stated, "...sometimes they are wet...."


During an interview on the PICU, Staff #9, MHT stated, "When we don't have a cart we put it on the floor in the utility room, so it won't drip into the halls...."


During an interview on the facility's patient inpatient units Staff #5, Risk Manager confirmed the findings.


During an interview on the morning of 5/22/18, in the conference room, when asked if dirty linens are stored on the floor, Staff #26, EVS (Environmental Services) Director stated, "...The dirty linen has to be on the linen carts.... not on the floor."


Review of the facility provided policy Soiled Linen (dated 1/2018) reflected, "All employees will utilize Standard Precautions when handling soiled linen ....7. Dirty linen carts will be located on each patient care unit in easily accessible areas. 8. Non-infectious linens will be placed directly inside the dirty linen carts ...."







Based on a review of facility documents, a review of medical records, and staff interview, the facility failed to ensure patients received care in a safe setting.

Findings included:

A review of a document entitled "Basic Rights for All Patients," of El Paso Behavioral Health included the following, "16. You have the right to receive treatment of any physical problems which affect your treatment. You also have the right to receive treatment of any physical problem that develops while you are in the hospital. If your physician believes treatment of any physical problem is not required for your health, safety, or mental condition, you have the right to seek treatment outside the hospital at your own expense ..."


Review of the medical record for patient #2 revealed they were admitted early on the morning of 11/2/18 for suicide ideation. Nursing admission assessment dated [DATE] at 8:40 am stated in part, "Review of systems: ...Neurological: other: Migraines
...Pain Assessment: Patient's Current Pain Rating: 8; migraine headache ..."

Clinical Assessment 2 stated in part, "Assessment attempts:

1. 11/3/17/1100 ... Reason: pt in bed w/ migraine

2. 11/3/17/1500 ... Reason: pt in bed w/ migraine

3. 11/3/17/1700 ... Reason: pt declined to meet with therapist ..."


The patient was complaining of migraines since admission. There was no evidence the patient was given medications for migraines until 11/3/17 at 8:51 pm. The patient complained of migraine pain for over 37 hours before medication was provided.


Patient #2 received the following PRN [as needed] medications with no documentation if they were effective or steps taken if they were not effective:

-Fioricet [for migraine pain]:

*11/3/17 at 8:51 pm

*11/4/17 at 8:00 am

*11/6/17 at 12:48 pm

*11/7/17 at 6:45 am and 10:20 pm

*11/8/17 at 7:40 am and 12:42 pm both documented as (-) [negative] with 9/10 pain and no follow-up or alternatives attempted for unrelieved symptoms


-Proventil [for asthma]:

*11/7/17 at 4:30 am, 3:00 pm and 10:40 pm

*11/8/17 at 11:45 pm

*11/8/17 at 7:30 am


In an interview with staff #30 on the morning of 5/23/18, they stated, "They [the nurses] should be noting if it [the medication] was effective or not."

The above was confirmed in an interview with staff #30 on the morning of 5/23/18.


Review of the medical record for patient #9 revealed a nursing note dated 4/19/18 at 5:45 pm that stated in part, "Pt [patient] requested to speak to [their] mother. Became upset when told [they were] not able to speak to mother. Pt went into restroom and punched wall several times. Pt able to calm down on [their] own with 1:1 [one-to-one] processing. [Doctor] notified and ordered a STAT X-ray 2 views to Right hand ..."

X-ray dated 4/19/18 results stated in part, "Acute right hand fracture ..." The patient was transferred to the emergency room for medical care and came back to the facility that evening.

Physician order dated 4/20/18 at 8:00 am stated in part, " ...rept [repeat] X-ray in 3 days: R hand ..." Follow up x-ray was not found. There was no evidence a physician monitored the patient's hand throughout their inpatient stay. Patient #9 was discharged on [DATE] without aftercare for the right hand fracture.

In an interview with staff #35 on the afternoon of 5/23/18, when asked about aftercare, staff #34 stated, "[Patient #9] didn't break [their] hand, it was just swollen ... Oh, I didn't know that. If I had, I would have made an appointment for [them]."
Grievance form regarding patient #9 dated 5/2/18 stated in part, " ...Child was discharge w/ [with] broken knuckles. Child is being required to undergo surgery due to improper medical care."

Patient #9 broke their hand while inpatient at the facility on 4/19/18. They were able to get medical attention that evening but received no care for the hand when returned back to the facility and throughout their stay until their discharge on 4/25/18. There was no inpatient or follow-up care for patient #9's hand.

The above was verified in an interview on the afternoon of 5/23/18 with staff #2 in the facility conference room.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on observation, interview and record review the facility failed to prevent Patients from abuse when two patients were restrained without cause. (Patients #5 and 11)

Findings Include:

Review of Patient #5's medical record reflected a [AGE]-year-old male admitted on [DATE] with a diagnosis of Paranoid schizophrenia.

On 5/22/18, a review of the facility provided video tape from the evening of 3/3/18 at 4:17 pm revealed Patient #5 standing in the empty hall way outside his room. Two large male staff members, Staff #10 and Staff #11, MHTs, were several feet away from the patient, they are seen coming toward the patient. Patient #5 raised his hands up in the air above his head. The staff continued to approach the patient and were standing side by side, less than an arms width in front of Patient #5; Staff #10, MHT is at least a foot taller than Patient #5 and weighed approximately 250 pounds. Patient #5 backed up against the wall and lowered his hands, the staff are seen taking him by the arms and lowering him to the floor.

Review of Patient #11's medical records reflected a 9-year-old-female admitted on [DATE] with a diagnosis of Suicidal Ideation.

Review of the video tape from the evening of 4/24/18 at 7:18 pm reflected Patient #11 sitting on the floor in an empty hallway. The patient is observed getting up and crossing the hall, there are no other patients in the area and Patient #11 is not threatening to harm self or staff. Three staff were observed leading her to the opposite wall where she tries to sit down. Staff #28, RN is in the hallway observing. Two male staff members are observed grabbing Patient #11 under each arm and directing her to the next room; the patient bent her knees during the transfer and was dragged approximately five feet by the staff. The patient is seen sitting down in a chair, with staff standing around her talking to her, the patient attempted to stand up. Staff #28, RN is observed pushing her back into a chair as she tried to get up out of the chair.

During an interview on the afternoon of 5/23/18, in the facility conference room, Staff #5, Director Risk when asked if the dragging of Patient #11 was a concern, after consulting with HR stated, "They determined it was an escort, it was not a concern."

During an interview on the morning of 5/23/18, Staff #32, RN, after being informed of the staff's interactions with Patients #5, 10 and 11, stated, "I teach the Handle with Care, I'm the lead trainer ...the patient should be held from behind; for the safety of the patient and the staff .... The escort is considered a restraint, we teach to only put 'hands on' if the patient is a danger to self or others ...there should be no form of intimidation, they should get on the level of the patient, standing over them can be intimidating ...they need to give the patient space .... once the patient is no longer a risk to self or others, the staff need to step back ...."

During an interview on the morning of 5/23/18, Staff #30, RN ADON reviewed the video and confirmed the moving of the patient by dragging her and pushing her into a chair are not Handle with Care techniques. Staff #30 stated, "Rarely should you ever have to move a patient from where they are being held, you just deal with it right there. ...I'm constantly telling them don't pick up, don't pick up the kids...I'm familiar with Patient #11...if you let her cry it out she calms down...."

Review of the facility provided policy Use of Physical restraints (Dated 1/2018) reflected, "...Physical restraint: The application of physical body pressure by another person to the body of a patient in such a way as to limit or control the physical activity ...The use of physical body pressure or physical assistance in escorting a patient is considered a physical restraint....Each and every restraint episode requires a physician's order...based on the patient's authorization, the family/significant other is notified of the restraint incident...Assessment includes as appropriate: signs of injury...CNO or designee Investigate all unusual patterns of restraint use...."

Review of the facility provided policy Philosophy on the Use of Seclusion and Physical Restraint (dated 1/2/18) reflected "El Paso Behavioral Health System is a mechanical restraint free facility. The facility is committed to: ...Limit the use of physical restraint and seclusion to emergencies in which there is an imminent risk of an individual physically harming himself or herself or others....The hospital does not permit the use of physical restraint or seclusion for any other purpose such as coercion, discipline, convenience, or retaliation by staff...."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to keep patients free from restraints when (2) two patients were restrained without warrant. (Patients #5 and 11)

Findings Include:

Review of Patient #5's medical record reflected a [AGE]-year-old male admitted on [DATE] with a diagnosis of Paranoid schizophrenia.

On 5/22/18 a review of the facility provided video tape from the evening of 3/3/18 at 4:17 pm revealed Patient #5 standing in the empty hall way outside his room. Two large male staff members, Staff #10 and Staff #11, MHTs, were several feet away from the patient, they are seen coming toward the patient. Patient #5 raised his hands up in the air above his head. The staff continued to approach the patient and were standing side by side, less than an arms width in front of Patient #5; Staff #10, MHT is at least a foot taller than Patient #5 and weighed approximately 250 pounds. Patient #5 backed up against the wall and lowered his hands, the staff are seen taking him by the arms and lowering him to the floor. Staff #10, MHT was observed laying across Patient #5's legs from 4:19 pm to 4:31 pm. The restraint lasted 14 minutes. Patient #5 was slow to rise, requiring assistance from staff to stand, and was unsteady on his feet.

Review of Patient #11's medical records reflected a 9-year-old-female admitted on [DATE] with a diagnosis of Suicidal Ideation.

Review of the video tape from the evening of 4/24/18 at 7:18 pm reflected Patient #11 sitting on the floor in an empty hallway. The patient is observed getting up and crossing the hall. Three staff were observed leading her to the opposite wall where she tries to sit down. Staff #28, RN is in the hallway observing. Two male staff members are observed grabbing Patient #11 under each arm and directing her to the next room; the patient bent her knees during the transfer and was dragged approximately five feet by the staff. The patient is seen sitting down in a chair with staff standing around her talking to her, the patient attempts to stand up Staff #28, RN is observed pushing her back into a chair as she tried to get up out of the chair. Staff #28 is observed closely following the patient around the unit, touching her on the arm and shoulder multiple times. Patient #11 is seen moving around the unit in an attempt to get away from Staff #28.

During an interview on the morning of 5/23/18, Staff #30, RN ADON reviewed the video and confirmed the moving of the patient by dragging her and pushing her into a chair are not Handle with Care techniques. Staff #30 stated, "Rarely should you ever have to move a patient from where they are being held, you just deal with it right there....I'm constantly telling them don't pick up, don't pick up the kids...I'm familiar with Patient #11...if you let her cry it out she calms down...."

During an interview on the morning of 5/23/18, Staff #32, RN, after being informed of the staff's interactions with Patients #5, 10 and 11, stated, "I teach the Handle with Care, I'm the lead trainer....the patient should be held from behind; for the safety of the patient and the staff.... The escort is considered a restraint, we teach to only put 'hands on' if the patient is a danger to self or others...there should be no form of intimidation, they should get on the level of the patient, standing over them can be intimidating...they need to give the patient space.... once the patient is no longer a risk to self or others, the staff need to step back...HR is called in to help make the determination...I used to sit in on the flash meetings....When we take the staff off the floor they can't come back until we have completed the investigation and if they have completed any required training. Debriefing is done after each restraint to evaluate whether we could have done it better, the goal is not to get to a restraint."

Review of the facility provided policy Philosophy on the Use of Seclusion and Physical Restraint (dated 1/2/18) reflected "El Paso Behavioral Health System is a mechanical restraint free facility. The facility is committed to: ...Limit the use of physical restraint and seclusion to emergencies in which there is an imminent risk of an individual physically harming himself or herself or others....The hospital does not permit the use of physical restraint or seclusion for any other purpose such as coercion, discipline, convenience, or retaliation by staff...."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on observation, interview, and record review, the facility's Performance Improvement Program failed to identify high-risk incidents that affect patient safety when (2) two patient were restrained without warrant and (1) one patient's restraints were not applied appropriately, placing the patients at risk of injury. (Patients #5 and 11)

Findings Include:

Review of Patient #5's medical record reflected a [AGE]-year-old male admitted on [DATE] with a diagnosis of Paranoid schizophrenia.

On 5/22/18 a review, of the facility provided video tape from the evening of 3/3/18 at 4:17 pm, revealed Patient #5 standing in the empty hall way outside his room. Two large male staff members, Staff #10 and Staff #11, MHTs, were several feet away from the patient, they are seen coming toward the patient. Patient #5 raised his hands up in the air above his head. The staff continued to approach the patient and were standing side by side, less than an arms width in front of Patient #5; Staff #10, MHT is at least a foot taller than Patient #5 and weighed approximately 250 pounds. Patient #5 backed up against the wall and lowered his hands, the staff are seen taking him by the arms and lowering him to the floor. Staff #10, MHT was observed laying across Patient #5's legs from 4:19 pm to 4:31 pm. The restraint lasted 14 minutes. Patient #5 was slow to rise, requiring assistance from staff to stand, and was unsteady on his feet.

Review of Patient #11's medical records reflected a 9-year-old-female admitted on [DATE] with a diagnosis of Suicidal Ideation.

Review of the video tape from the evening of 4/24/18 at 7:18 pm reflected Patient #11 sitting on the floor in an empty hallway. The patient is observed getting up and crossing the hall. Three staff were observed leading her to the opposite wall where she tries to sit down. Staff #28, RN is in the hallway observing. Two male staff members are observed grabbing Patient #11 under each arm and directing her to the next room; the patient bent her knees during the transfer and was dragged approximately five feet by the staff. The patient is seen sitting down in a chair with staff standing around her talking to her, the patient attempts to stand up Staff #28, RN is observed pushing her back into a chair as she tried to get up out of the chair.

During an interview on the afternoon of 5/23/18, in the facility conference room, Staff #5, Director Risk when asked if the dragging of Patient #11 was a concern, after consulting with HR stated, "They determined it was an escort, it wasn't a concern."

The facility did not document the incident involving Patient #11's two restraints. They did not initiate an incident report to inform the Risk department of the incident, conduct a physical examination following the restraints, notify the minor patient's mother of the restraints or contact the physician to obtain restraint orders.

During an interview on the morning of 5/22/18, in the conference room, Staff #33, Human Resources Director stated, "We review all restraints at the flash meetings on Monday for the weekend... Staff #3 (Performance Improvement Director) and I discussed it, we decided Staff #11 was following Staff #10's lead.... He (Staff #10) didn't use the proper Handle with Care. I told him what was expected but I didn't give him a time frame to get it done ..." When asked if the required retraining was communicated to the Nursing department and was the staff member allowed to be placed on the schedule prior to completion of the training. Staff #33 stated, " ...I honestly don't recall, she (DON) should have been ...." When asked did the facility have a communication form or system between the HR and the other departments, so the Department heads knew what was expected in order for the staff to return to work, Staff #33 stated, "No, I don't document the discussion .... the process is broken."

During an interview on the afternoon of 5/22/18, Staff #3, PI Director stated, "Nursing is in the review to see if the restraint was performed correctly....in the meeting the CEO, CNO and COO are on the team of about 10 or 11 people watching the incident. If we have a concern the HR and Risk manager will watch the videos with the staff involved.... if you're restricting movement it's a restraint."

Staff #33 confirmed, the Risk manager and the Performance Improvement (PI) were part of the team responsible for reviewing the videos for proper restraint holds and that he as Human Resources Director reviewed the videos with the staff members involved. Staff #33 also confirmed that he, the Risk Manager and the PI Director had not completed the 'Handle with Care' training and did not have clinical backgrounds.

On 5/23/18, review of Staff #28's, RN's employee files did not reflect discussions or counseling for the use of and the supervision of proper restraints.

Review of Employee Staff #10, MHT's, employee file dated 3/27/8 reflected A Corrective Action, " ...Final Written Warning: Restraint was not EPBH mandated, Handle with Care, which lasted 5 minutes, during which time MHT Staff #10 did de-escalate the patient until an LVN could take over using an alternative method.
Briefly state what employee must do to improve: MHT Staff #10 has been through Handle with Care training on multiple occasions. He is well aware of the EPBHs-mandated method of restraint when it is needed. He will be retrained on Handle with Care and is reminded that this method must be observed in all future patient restraints." Staff #10's employment file did not reflect completion of the Handle with Care retraining. Staff #10 had returned to work after a two-week suspension, to conduct the investigatin. HR confirmed the required training was not completed.

Review of employee files for Staff #11,MHT and 28, RN reflected no discussions or additional training on the use of physical restraints.

Review of the facility provided policy Use of Physical restraints (Dated 1/2018) reflected, "...Physical restraint: The application of physical body pressure by another person to the body of a patient in such a way as to limit or control the physical activity.... The use of physical body pressure or physical assistance in escorting a patient is considered a physical restraint....Each and every restraint episode requires a physician's order.... based on the patient's authorization, the family/significant other is notified of the restraint incident.... Assessment includes as appropriate: signs of injury.... CNO or designee Investigate all unusual patterns of restraint use...."

Review of the facility provided policy Philosophy on the Use of Seclusion and Physical Restraint (dated 1/2/18) reflected "El Paso Behavioral Health System is a mechanical restraint free facility. The facility is committed to: ...Limit the use of physical restraint and seclusion to emergencies in which there is an imminent risk of an individual physically harming himself or herself or others... The hospital does not permit the use of physical restraint or seclusion for any other purpose such as coercion, discipline, convenience, or retaliation by staff...."

Review of the facility provide Risk Management & Safety Program (dated 2017) reflected, "...Risk Identification is essential in order to identify potential risk exposures faced by the facility, and to provide direction for the facility to prevent, mitigate, and eliminate risk generating practices.... Risk Manager is notified of all... Incident Report... trends are reviewed for incident frequency, reoccurrence, etc., and appropriate actions taken to reverse trends...."