Timberlawn poses "immediate jeopardy" to health and safety of patients; "hospital plant anomalies" attributed to patient suicide

In February 2015, the Centers for Medicare and Medicaid services (CMS) cited Timberlawn Mental Health System for deficient practices that “posed an immediate jeopardy to the health and safety of patients, and resulted in actual harm to Patient #1.” Specifically, facility inspectors found that the hospital failed to ensure that patients received care in a safe setting because suicidal patients were not give appropriate levels of supervision and ligature risks within the hospital  were not removed. Facility inspectors found that the hospital’s deficient practices were serious enough to violate the conditions of Medicare program participation around patient rights, as well as quality assurance and performance improvement (QAPI). Facility inspectors found that the hospital failed to uphold patient rights because it did not ensure that a safe environment was provided for 2 patients. In one case, a patient committed suicide in December 2014  from hanging herself on a closet door knob in the Trauma Unit.  Despite the facility’s knowledge of the patient’s history of attempted suicides and the patient’s placement on assault/suicide precautions and 15-minute observation, this event occurred due to the hospital’s failures in correcting its “hospital plant anomalies.” CMS found an internal facility document titled “Hospital Plant Anomalies” from May 2014 (7 months prior to the patient suicide) which identified, “Trauma unit…patient door handles and closet door handles could be a ligature risk…” A CMS interview with a staff member revealed that the hospital came up with a list of hospital plant anomalies which identified closet and patient room door knobs as ligature risks. The staff member further revealed that no action was taken to remove the risks until after the suicide event, and that patients continued to be admitted to the rooms with the existing doorknobs even after the patient suicide event. Two months following the patient suicide, a CMS facility inspection was conducted, which
“Revealed the continued presence of unsafe items accessible to psychiatric patients for potential harm which included, plastic liners in trash cans, electrical cords and phone cords.”
In another case, CMS inspectors found that a patient with suicidal thoughts was not continuously monitored.The patient’s “every fifteen minute observation round record”  was left incomplete and omitted the patient’s location and behavior. Facility inspectors also found that the hospital violated the conditions of Medicare program participation around demonstrating evidence of and maintaining a quality assurance and performance improvement (QAPI). Specifically, inspectors found that,
“The hospital quality improvement and performance program failed to ensure current and previously identified patient safety risks were addressed from 05/2014 through 02/18/15/ Safety measures were not implemented for 2 of 12 patients…”
Due to the seriousness of the aforementioned violations, CMS determined that,
“Timberlawn Mental Health System no longer meets the requirements for participation in the Medicare program because of deficiencies that represent immediate jeopardy to patient health and safety.” CMS notified the facility that “unless the  immediate jeopardy to patient health and safety is removed, the Medicare agreement will be terminated no March 28th, 2015…termination can only be averted by correction of deficiencies through submission of acceptable plans of correction…and verification of compliance…”
Subsequent surveys conducted by CMS (including a hospital survey and psychiatric hospital survey conducted on April 22, 2015, and a May 13, 2015 survey) , found that the facility remained out of compliance with the following Medicare conditions of participation:
  • Patient Rights
  • QAPI
  • 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.