Wyoming Behavioral Institute's "Systems Failures" Led to Condition-Level Violations, CMS Finds

In April 2010, the Centers for Medicare and Medicaid Services (CMS) determined Wyoming Behavioral Institute had violated several conditions of Medicare participation and risked termination of its Medicare provider agreement.

CMS found the facility failed to protect and promote patient rights after finding that care plans were not modified to reflect restraint use, restraints were ordered on a PRN  or “as needed” basis and face-to-face evaluations were not performed as required. One six year old patient was given an order for PRN or “as needed” papoose board restraint upon admission to the facility. Pursuant to federal law, orders for the use of restraint may never be written on an as needed basis. CMS also found failures in protecting medical record confidentiality and found that “The cumulative effect of these systems failures resulted in the inability of the facility to ensure patient rights to confidentiality and being free from abuse, and that use of seclusion and restraint interventions were implemented appropriately.”

Wyoming Behavioral Institute also violated the Medicare conditions of participation related to the provisions on nursing services. In support of the violation, CMS described a case in which a physician waited for ten days before ordering Plavix medication for a patient at risk of stroke. The patient also missed finger stick blood sugar tests on five days. At the end of this ten day period medical records showed,

Review of the 10/20/09 occupational therapy (OT) notes showed the patient was observed with his/her head lowered and had stopped the activity s/he was performing. At the time it was noted the patient was slurring his/her words and was unable to communicate with the occupational therapist. Review of the same note revealed the patient was unable to get his/her left side to cooperate. Review of the OT notes showed the nurse on duty was notified of this episode.

Review of the 10/21/09 OT notes showed the occupational therapist observed the patient was again not using the left side of the body. The patient said the activity hurt his/her head. The occupational therapist observed the patient was unable to use both sides of the body and required assistance.

Review of the nursing notes showed neither of these episodes were assessed or monitored by nursing staff.

CMS also cited the Wyoming Behavioral Institute for violating the condition of Medicare participation related to patient discharge planning. One young patient with “aggressive and violent behaviors” was discharged seven days early “due to the patient’s deterioration in the hospital environment.” CMS found that the facility was deficient in preparing both the patient’s school and the patient’s mother for this early discharge, such that the school did not have a one-on-one teacher available for the patient and the mother did not receive counseling on how to continue the child’s post-hospital care and respond to his/her continuing behaviors.

As a result of these violations, the facility was required to submit a plan of correction to address the cited deficiencies and deficient policies and procedures.