CMS finds condition-level deficiencies at Timberlawn 2 months following termination warning

During an unannounced follow-up survey conducted by the Centers for Medicare and Medicaid Services (CMS), Timberlawn Mental Health System was again cited for condition-level violations related to patient rights and nursing services. Timberlawn had previously been cited for violating the conditions of the Medicare program in May 2015 and was sent a letter demanding the facility correct the deficiencies, or risk losing federal funding read more here.

On July 2, 2015, the last day surveyors were onsite, CMS presented the CEO and other hospital delegated personnel with the preliminary findings of the unannounced survey. Once again, CMS found that Timberlawn was not meeting Conditions of Participation for patient rights and nursing services. CMS wrote, “The deficient practices found posed an immediate jeopardy to the health and safety of patients.”

The inspectors noted 5 instances where the facility had failed to ensure a safe environment for 19 of 19 patients. The instances included: (page 2-3)

1. Patient #7, a 15 year old adolescent patient was transferred to another hospital after ingesting a piece of metal off of a domino box found on the adolescent boy’s unit on 6/17/15.
2. Patient rounds records for 6 of 6 patients were not kept current and failed to document the location and behavior of patients.
3. Two rooms on the adolescent girls’ unit had loose covers over the light fixtures enabling access to glass light bulbs and/or electric wiring.
4. A registered nurse was not immediately available for the bedside care of 2 patients in the Apprehension by Peace Officer without Warrant (APOWW) area.
5. The bathroom sinks on the adolescent girls and boys units had faucets that were not ligature resistant and posed a potential risk for 9 patients who were all on suicide precautions.

In one instance, a 15 year old adolescent patient was identified as a high risk patient with suicidal/self-harm ideation with a history of ingesting objects. On 6/17/15, the patient was seen throwing up and told nurse that he swallowed a piece of metal off the lid to a domino box. A staff member retrieved the domino box and sent the lid with emergency personnel and the patient to a local hospital. Personnel #36 logged all of the appropriate nursing notes related to the incident before clocking out and going home. She stated that she was contacted by Personnel #7 who instructed her to return to work and re-write her note to exclude information regarding the domino box. When asked about the revisions, Personnel #7 told CMS surveyors that it was “because of the recent safety issues identified by The State.”

In another instance, observation rounds were conducted on the Geriatric Unit on 6/29/15 but the records were incomplete for 5 patients. The records did not record the patients’ behavior or location. The inspector flagged the records to Personnel #6 who was then observed filling in patient behavior/location as she was walking back to the nursing station. The inspector asked Personnel #6 why she filled in the documents when they were left incomplete initially but she offered no response.

Lastly, inspectors found that 3 rooms in the boy’s adolescent unit and 5 rooms on the girls’ adolescent unit had bathroom sink faucets that were not ligature resistant. The clinical records for the 9 patients in the rooms indicated that all the patients were on suicide precautions. Personnel #1 stated she did not think that the faucets posed a safety risk and could be used to hang self. The inspector demonstrated with an article of clothing that it is possible. (pg. 12) Personnel #2 indicated that the faucets have been an “ongoing project since May 2014” when a risk assessment was completed. However, CMS interviewed Personnel #20, a Safety Specialist, who stated that “no one had discussed the faucets as being a safety risk with her” and no education was provided. (pg. 13)

In conjunction with this inspection, an unannounced Psychiatric Hospital Recertification Follow-up survey was conducted. During that inspection, surveyors cited the facility for deficiencies related to discharge planning for seven patients and found that the “facility failed to ensure that the Psychosocial Assessments provided a description of the specific and individualized role of the social work staff in treatment and discharge planning for these patients. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patient’s discharge plan for reentry into the community.”  CMS also found that the facility’s director of social services failed to adequately monitor and evaluate the quality and appropriateness of social services furnished, due to the deficiencies mentioned above

The facility was also cited for treatment plan violations, CMS found that “the facility failed to ensure that the Master Treatment Plan (MTP) interventions by physicians and nursing staff addressed specific treatment needs for eight patients.” CMS also found that the facility’s Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility, due to the treatment plan deficiencies mentioned above.

The facility was required to submit a plan of correction.