In a rare move, a UHS behavioral hospital in Texas has been terminated from the Medicare and Medicaid programs after federal officials determined that patients were in “immediate jeopardy” of injury or death. The Dallas Morning News broke the story on July 24, and one of the most explosive revelations was that UHS’s Timberlawn Mental Health System in Dallas had “falsified patient records to avoid scrutiny” by federal regulators. (Latest Timberlawn news here.) Unfortunately, this failure to report serious incidents has occurred at other UHS facilities as well. The following review of federal and state regulatory documents, as well as investigative reporting on UHS, reveals multiple instances where the company’s facilities have either failed to report or even covered up serious patient care problems.

Timberlawn’s Untold Story

Regulators from the Centers for Medicare and Medicaid Services (CMS) began seriously investigating Timberlawn soon after a patient committed suicide in December 2014 by hanging herself from a door handle that facility officials knew was hazardous. Beginning in February, CMS conducted a series of unannounced inspections and, according to the Dallas Morning News, “consistently found accessible items that could be used for patient self-harm, instances of improper care for suicidal patients, and inadequate training and staffing of nurses in the facility.” The Dallas Morning News also reported on CMS regulators finding at least one instance where a Timberlawn staff member had falsified a patient record. According to the Dallas Morning News:
After a patient swallowed a metal object while at Timberlawn, a supervisor asked a nurse to change her notes and exclude relevant medical information. When CMS surveyors asked why, the supervisor said it was “because of the recent safety issues identified by the state.”
A review of regulatory reports on other UHS facilities shows this is not an isolated incident.

Unreported Incidents and a Very Wrong Number

Acting on a complaint about UHS’s Brentwood Hospital in Shreveport, La., CMS officials spent six days in February 2014 reviewing documents, interviewing staff and observing operations at the facility. CMS uncovered six instances of sexual misconduct at Brentwood that had occurred in the nine weeks leading up to February 3, 2014. One of the incidents involved a boy just eight years old. None of the six sexual misconduct incidents were reported to the relevant state agency in a timely manner, and four of the six incidents were not reported at all. Even if Brentwood officials had been inclined to tell state regulators about these incidents, they might have had a tough time getting in touch. While reviewing the facility’s grievance policy, CMS found that “[t]he telephone number listed for reporting allegations of abuse/neglect to the state agency (Health Standards Section) was for a Bahamas vacation.” The sexual misconduct incidents that UHS’s Brentwood facility failed to report properly are deeply disturbing. In one case, a 13-year-old boy told CMS officials he’d been forced by his 17-year-old roommate to perform a sexual act. Video evidence showed that the two patients were alone in their room at the time of the alleged incident, even though the 17-year-old had been ordered to have 1:1 observation, which requires a staff member to stay with the patient at all times. (A summary of the CMS findings at Brentwood is on our website here.)

Living in the Shadows

Some of the most distressing incidents involving youths at UHS facilities have occurred at the company’s Foundations for Living residential treatment center in Mansfield, Ohio. The Foundations for Living website advertises “a comfortable, safe environment for youth to heal and flourish.” But a searing 2014 report by Northwestern University’s Medill Watchdog project quoted a former supervisor calling the facility “a volatile, hostile environment.” The Medill reporters also found evidence that Foundations for Living staff “are discouraged from reporting incidents.” According to the Medill story:
A September 2013 police report describes a staff member who was punched in the left side of his face telling officers “he is not permitted to call the police while working because his employer does not want media attention.” Employees had to go through an on-call administrator before contacting the police, two former staff said in separate interviews. Former supervisor [Dwayne] Price said he was told that if the situation was not an emergency he should report it to the police on his own time, after hours. This policy sometimes led to employees deciding against reporting an incident to the police, he said.

“Alteration or Falsification of Medical Records”

In 2013, conditions at a newly opened UHS facility for youths in Chicago got so bad so quickly that state regulators sent in investigators from the University of Illinois at Chicago (UIC) psychiatric department to conduct an emergency review. The UIC team found that the UHS facility, Garfield Park Hospital, “was woefully unprepared when it first opened its doors to admit patients.” The UIC review also concluded that Garfield Park officials had engaged in the “alteration or falsification of medical records” to conceal problems. One of the most egregious alleged cover-ups unearthed by the UIC team was described in a 2013 Chicago Tribune story. As the Tribune reported:
In one instance, the UIC team said, facility administrators discharged a 16-year-old female state ward on a Sunday evening in March because other girls on the unit were targeting her for violent attacks, “and hospital staff did not feel they could keep her safe until the following day.” The charge nurse on duty also wrote a similar note in the chart about the chaotic situation on the unit, according to the UIC report. The former [Garfield Park] nursing director told UIC that a top hospital official pulled those notes from the patient’s chart the next day “and had the medical director and nurse rewrite their notes to exclude any mention of the unit being volatile or unsafe,” the report said. A hospital official told the nursing director that she could not believe how “stupid” the medical director was to “put something like that in writing,” the UIC report said. “[State officials] will be all over us if they find out that we discharged a patient in the middle of the night,” another hospital official told the nursing director, according to the UIC report.

And the List Goes On…

Sadly, the incidents above represent only a fraction of the cases where UHS behavioral facilities were found to be less than forthcoming about patient care breakdowns or potential problems. A longer list of instances where UHS facilities failed to fully report problems can be found using the “Word Cloud” tool on this website, which is in the sidebar at right on this page. Click on the word “reporting” to find dozens more cases. Not every one will involve a clear-cut charge of falsification, but most of them will include instances where regulators or reporters charge that UHS facilities were less than truthful about shortcomings. If you’d like to dig even deeper into UHS, go to the “RESEARCH TOOLS” page on this website, which offers a quick but comprehensive explanation of how to access the documents about UHS we’ve compiled.