During an unannounced complaint investigation survey conducted by the Centers for Medicare and Medicaid Services (CMS) in April 2015, Timberlawn Mental Health System was cited for condition level deficiencies around patient rights, quality assurance and performance improvement (QAPI), and nursing services.
During the April investigation survey, CMS found that Timberlawn had once again violated the conditions of Medicare program participation around patient rights and quality assurance and performance improvement (QAPI). Just two months earlier in February 2015, CMS cited Timberlawn for failing to uphold patient rights because it did not provide a safe environment for patients. The facility was also cited in February for failing to maintain a QAPI program that addressed current and previously identified patient safety risks. CMS determined that the deficient practices identified during the February survey “posed an immediate jeopardy to the health and safety of patients.”
During the April 2015 survey inspection, CMS surveyors determined that Timberlawn continued to be deficient in upholding patients rights by failing to ensure a safe environment for 10 of 20 patients. CMS referenced an incident in which a 10-year old pediatric patient was assaulted by two teen patients, resulting in a head injury that needed medical attention from an acute care hospital.
CMS also found other examples of violations of patient’s rights to a safe environment, including: incomplete rounds records which inaccurately documented 8 patients’ behavior/location. CMS referenced an example where 4 patients’ rounds records were left incomplete because one mental health technician was in charge of 16 patients, including a patient who was on every five-minute (high level observation) checks. A [confidential] CMS interview with a staff member revealed that “the unit did not have enough staff.”
Other examples of safety risks found by CMS included an empty oxygen tank inaccurately documented as “full,” which would result in the unavailability of oxygen in cases of emergency. CMS also found that safety risk items were in close proximity and easily accessible to patients. CMS observed that the hospital’s dining room was near an unlocked staff dining room, which contained unsafe items such as electrical cords, a plastic trash bag, and substances that would require point control interventions if ingested (Sani Wipes).
During the April 2015 survey inspection, CMS surveyors determined that the facility continued to be deficient in its performance improvement program. Federal regulations require that “the hospital’s governing body must ensure that the [QAPI] program must …focus on indicators related to improved health outcomes and the prevention and reduction of medical errors.” However, CMS found that the hospital had failed to track adverse events for four patients. In one incident, two adolescents assaulted a pediatric patient. The survey report noted:
“Patient #14’s Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, ‘Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she (Patient #14) stood up the female with another female peer jumped her (Patient #14) and hit her on the floor…neuro checks started…called Dr…send to ER (emergency room) for medical clearance of any injuries… Social Worker guardian called and notified…stated he will press charges for assault…”
Even though the assault incident occurred on 3/22/15 CMS interviews with facility personnel approximately one month later revealed that the incident had not been investigated. These interviews also revealed that at the time of the incident, “there was only one technician for 14 patients.” In another incident, a patient threw a lit cigarette at a fellow patient, but an investigation was not initiated or completed either.
A CMS review of the hospital’s performance improvement documentation found that “every second hospital incident in 02/2015 was documented as a physical confrontation.” Yet when CMS asked how the hospital was addressing the problem, a facility personnel member only stated that “a PI [performance improvement] team is being developed.”
During the April 2015 survey inspection, CMS surveyors also determined that the facility violated the conditions of Medicare program participation around nursing services. Specifically, CMS found that the hospital failed to ensure that its nursing services met patient’s care needs.
CMS found that the facility’s nurses failed to assess and reassess patient’s medical needs. CMS referenced an incident in which a pediatric patient was sent to a medical hospital for an injury, but was not assessed upon return to the facility. No neuro checks, vital signs, and/or reassessment was documented for this child, even though the acute care hospital’s discharge instructions informed the facility to perform these assessments in order to monitor whether the child’s mild head injury would develop into a more serious problem.
CMS also found that a patient fell on his wrist/hand and no assessment was completed after the event was reported, and the patient did not receive treatment for a fracture until four days following the incident. (p18) CMS also cited the facility for discharge planning deficiencies related to this incident and noted that the patient’s discharge plan failed to include discharge planning/instructions addressing the wrist fracture.
CMS also determined that nursing staffing on the adolescent and adult units “were not adequate to ensure patient safety and care provision. CMS noted that:
“A pediatric patient was assaulted by a 14 and 16 year old adolescent patients. One technician was in charge of the 14 patients. The adult psychiatric unit had a total of 16 patients with one technician. One of the sixteen patients was on (HLO) hightened level of observation every five minute checks and the technician was responsible for all 16 patients observation rounds.”
In the adolescent unit (where children and adolescents are housed together), only one mental health technician was assigned to all 14 patients. However, all 14 patients required some form of close observation precautions. All 14 patients were placed on 15 minute check observations, seven patients were on assault precautions, two patients were on sexually acting out precautions, and six patients were on suicide precautions. A CMS interview with a staff member revealed that “staffing [on the adolescent/children unit] is unsafe.”
Low levels of staffing were also present In the adult psychiatric unit, with one mental health technician in charge of 16 patients. Many of the patients on this unit were required to be on observation precautions, including one patient needing observation checks every 5 minutes. However, once again, a staff member told CMS surveyors that “the unit did not have enough staff,” even though the hospital’s own policy states that staffing assignments must be based on the programmatic and patient acuity needs.
The facility submitted a plan of correction on May 1, 2015 to address the cited deficiencies from the April 2015 survey. However, CMS’ subsequent review of surveys (such as those from February 2015, April 2015, and May 2015) found that the facility remained out of compliance with the following Medicare conditions of participation:
- Patient Rights
- Nursing Services
- Special Medical Record Requirements for Psych Hospital
- Special Staff Requirements for Psych Hospitals
As a result of this continued noncompliance, CMS notified Timberlawn on May 29, 2015 that it had until June to correct its deficiencies, otherwise its Medicare Agreement and associated federal funding would terminate on July 13, 2015.