Old Vineyard Cited for Understaffing, Governance, and Emergency Care Deficiencies

Old Vineyard Behavioral Health was cited by the Centers for Medicare and Medicaid Services (CMS) for violating the conditions of Medicare participation for its governing body and quality improvement processes. CMS found that the facility’s governing body failed to oversee and ensure the hospital maintained an effective Quality Improvement program and an organized Dietary Services department. An interview with the Director of Nursing revealed, “We do not do any quality monitoring of contracted services.” The facility submitted a plan of correction to address these deficiencies. Old Vineyard’s condition-level violation citation was also related to failure to meet the emergency needs of patients under EMTALA. As a hospital providing emergency services, Old Vineyard was required to provide medical screening exams to patients presenting with potential emergencies, including psychiatric emergencies. The facility failed to provide such exams to two patients. In one case, a patient had been involuntarily committed due to danger to self, but an infection control nurse determined that the patient was “too medically acute for admission to the hospital,” and the patient was sent back to the outpatient clinic that referred him. In another case, a patient was turned away without a medical screening exam because there were no beds available. Old Vineyard was also cited by CMS because the facility failed to provide each unit with a separately functioning staff. Review of staffing assignment sheets and interviews revealed that instead of providing one licensed nurse for each unit, one nurse sometimes covered duties on two units at once, switching places with an MHT when she moved between them. Additionally, the facility was found to have failed to maintain comfortable room temperatures. Fifteen (15) patients complained about cold temperatures in their bedrooms on the female adolescent unit between September 15 and October 18, with some mentioning that there were no extra blankets available. Some patients told staff they were unable to sleep because of the temperature and were less able to concentrate and participate in programming during the day. Each time patients complained, staff referred the issue to facility maintenance for investigation. Risk management staff were not aware of what actions maintenance staff took to investigate or resolve the problem, but had marked the patient complaints as “resolved.” When CMS inspected the facility, they found that “no changes had been made to resolve the cold temperatures in the acute female adolescent unit.”