In April 2015, the Centers for Medicare and Medicaid Services (CMS) conducted an unannounced, facility inspection at Timberlawn Mental Health System to assess regulatory compliance with the Conditions of Medicare participation for hospitals (through an A-tag survey) and for psychiatric hospitals (through a B-tag survey). The A tag survey found that the facility was noncompliant with the conditions of of Medicare program participation around upholding patient’s rights, maintaining an effective quality assurance and improvement program, and ensuring adequate nursing services.
The B-tag survey found that Timberlawn also violated the Condition of Medicare participation around special medical record requirements and special staffing requirements for psychiatric hospitals.
Special Medical Record Requirements
Failure to provide adequate treatment
CMS surveyors found that the facility failed to provide master treatment and alternative interventions for patients. CMS noted that :
“Although the treatment plan for each patient included multiple group therapies, both patients were not cognitively capable at times of attending the groups listed on their unit’s schedules. The patients regularly and repeatedly did not attend the groups. Both patients spent many hours without any structured activities in his/her rooms or wandering around the units. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients’ treatment goals and objectives, potentially delaying their improvement.”
Failure to provide adequate boarding
CMS also found that the facility failed to secure proper unit placements for patients. CMS found that the facility’s adolescent unit serves the dual role of housing mentally ill patients, while also providing care to individuals apprehended by police officers without a warrant (APOWW), some of whom may be adults.
Most of the adolescent APOWWs may not require hospitalization and staff has estimated that about half are sent out of the facility after an initial evaluation. CMS found that
“Throughout the day seriously mentally ill persons may be sharing meals, groups etc. with persons not seen as mentally ill. The potential for harm to the acutely ill patients is therefore quite high.”
CMS also noted that:
“There may also occur APOWW persons who are adults. Administrator estimates that 10% to 20% of these persons are assessed as not requiring acute care hospitalization yet are present throughout their stay with acutely mentally ill patients. There is a likelihood that other patients may be victimized by these persons who are not patients.”
CMS also found that the facility has a research program that assesses patient responses to double blind medication interventions. The patients are typically hospitalized on the Lewis 1 Unit amid acutely ill mental patients, but may be placed on the Bloss Unit (Adult Intensive Care). CMS notes that:
“Nursing staff and pharmacy staff do not know who is or is not receiving medications aimed at lessening their symptomatology. The potential for assaults, property destruction, and other behavioral issues is present and there is a likelihood of victimization of patients not in this research program.”
The facility’s administrator was interviewed concerning these placements of acutely mentally ill patients with persons who do not warrant hospitalization or are not receiving medications that might benefit them. She acknowledged that these situations are occurring.
Special Staffing Requirements
CMS found that Timberlawn violated special staffing requirements for psychiatric hospitals by failing to provide adequate numbers of registered nurses and mental health workers on the Dual/Psychiatric Adult units “to create and maintain a therapeutic milieu.” CMS found that the facility’s “Dual Psychiatric Adult Unit,” which had a nursing station and two locked units located on either side of the station, was considered one unit, even though the two sides operated as separate units. Despite this, CMS found that
“The total number of staff assigned to these units was split between the two sides, creating an inadequate number to meet all patients’ needs…This inadequate staffing results in the likelihood of unsafe patient care and failure of the professional nurses to adequately provide direction and supervision of non-professional personnel (Licensed practical nurses and mental health workers) in the provision of patient care.”
For example, CMS found that 7 of the 8 day shifts and 2 of 8 night shifts only had 1 RN (registered nurse) and 1 LVN (licensed vocational nurse) on duty. When this staffing level is scheduled, one unit does not have a professional nurse and the one RN has to cover both sides in providing treatment or documentation. Even when a slightly higher level of staffing is scheduled for a shift, such as 2 RNs and 2 MHT (mental health techs), in actuality only 1 RN and 1 MHT are assigned to care for 16-17 patients in each unit.
CMS interviews revealed that one facility nurse felt that the 1 RN and 1 LPN staffing level for both units made it difficult to get all the work done for both sides, because nurses are tasked with performing nursing assessments on all patients and admitting any new patients. One MHT felt that it was difficult to perform proper patient monitoring when only one MHT is assigned to care for 16-17 patients. CMS’ interview with the MHT revealed, “‘It’s extremely difficult. Patients are very needy. They want something to drink or towels, or time for doing their laundry. We also do vital signs.’ When asked how [s/he] can do all that and keep an eye on patient E1 who required checks every 5 minutes, MHT #1 stated, ‘I try to keep patient E1 in the dayroom so [s/he]’s in line of sight at all times.’ However MHT #1 admitted that a technician can get busy doing things for other patients and get behind in checking the patient every 5 minutes.” The Director of Nursing was also interviewed by CMS surveyors on the shortage of staff on this unit and she did not dispute the finings.
Upon review of CMS surveys, (such as the ones conducted on February 25, 2015, April 22, 2015, and May 13, 2015), CMS 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.