Hospital failed to put policies in practice for medication and military patients

The Centers for Medicare and Medicaid Services (CMS) found that the University Behavioral Health Center of El Paso violated the conditions of Medicare participation. CMS found several medication violations, including having expired medications available for patient use. CMS also found that “scheduled drugs”  (AKA controlled substances) were not properly secured or accounted for. The facility did not keep current or accurate records of the receipt and distribution of scheduled drugs, nor did its pharmacy secure patients’ personal prescriptions of these drugs. Staff members even had keys to access the personal prescription cabinet. CMS found that these practices not only violated facility policies, but “potentially could have resulted in patients receiving ineffective or unsafe medications and the misappropriation of scheduled drugs.” Additionally, CMS determined that “the Governing Body failed to ensure the facility’s bylaws, rules and regulations were implemented and enforced” in areas including handling of laboratory specimens, patient medication security, facility cleanliness. Among other housekeeping and maintenance problems, CMS found, “cracked and missing laminate was observed to counter tops in nourishment area on the Womens Unit and nurse’s station on the Military Unit, rendering the countertops unable to be properly cleaned or disinfected.” Patient toilet areas and walls with damaged sheet rock were also found to be unable to be properly cleaned. In the Military Unit, CMS found that despite policies requiring frequent contact with military clinical and command personnel, 4 out of 9 patients had “no written informed consent to contact the patient’s Commanding Officer.” In order to correct its deficiencies, University Behavioral Health of El Paso was required to submit a plan of correction.