CMS: Poor Patient Safety, Infection Control Could Cost Dallas Mental Health Hospital Millions

The Timberlawn Mental Health System will have its federal funding revoked on July 13 unless it implements a litany of corrective practices to bolster patient safety and improve infection control measures.

The Centers for Medicare and Medicaid Services OK’d a lengthy corrective plan last week that will help the East Dallas behavioral health facility emerge with federal dollars intact if it follows through. Region 9 of CMS, which includes Dallas, didn’t have the exact amount of money the hospital will lose and Timberlawn did not return messages requesting comment.

But according to figures via the American Hospital Directory, a Kentucky-based company that aggregates CMS funding administered to hospitals, Timberlawn received about $20.8 million from the agency last year. That amounts to roughly a third of its total patient revenue, which sat at about $64.8 million.

The hospital, located in the shadow of Interstate 30 on Samuell Boulevard in East Dallas, has been under federal scrutiny since December following the suicide of 37-year-old Brittany Bennetts. The psychiatric patient tore a bed sheet and used it to hang herself from a closet doorknob, despite an alert that the hospital received months prior about the risk of those specific knobs being used for suicide attempts.

The corrective plan approved by CMS shows many cases beyond this one. In April, CMS launched an investigation into the hospital and found that it failed to provide a “safe environment” for 10 of 20 patients they interviewed. The 42-page document details alleged failures to ensure a clean and sanitary environment in four of of its units, including geriatric and trauma.

CMS staffers found urine specimens for patients who had been discharged and others that had not been submitted to the lab for “timely analysis.” The report says the hospital “placed patients at risk of acquiring infections,” then goes on to mention soiled and dusty floors in the trauma unit’s dining room and wet and soiled paper towels in an exam room.

Meanwhile, there were additional alleged incidences of unsafe conditions:

  • A 14-year-old patient and a 16-year-old patient attacked a 10-year-old girl, who was knocked to the floor and hit her head on a door on her way down. The two teens then continued to attack the girl while she was on the ground. She was taken to a nearby emergency room for treatment for the “minor injury to head” and returned with Ibuprofen.
  • A staffer later told CMS that there was just one technician for 14 patients. Too, the patient record indicated that the girl was present at Timberlawn when she was in fact receiving care at the emergency room. CMS also says the fight was never properly investigated.
  • The status of a patient who said he “wanted to kill himself” and had “anger problems” was not recorded every 15 minutes as required. For about three hours, nurses did not fill out the rounds records.
  • Rounds records were left blank for a patient who was previously exhibiting violent behavior with neighbors and “stated he wanted to die … would make police kill him.”
  • One technician was in charge of 16 patients, including one high-risk man who was required to be checked once every five minutes. About a half dozen others were on 15-minute checks for suicide and the technician lagged behind the 15-minute requirement.
  • A patient was allowed to reenter a unit’s common area after having a bowel movement without washing her hands.

And some of the approved, associated fixes:

  • Two of the patient units were divided into four units, which will each be staffed with at least one registered nurse and mental health technician, with more added depending on census and acuity.
  • To address the 10-year-old being attacked, the hospital will now hold beds in the adolescent unit in case a patient comes in with APOWW certification, which means Apprehended by a Peace Officer Without Warrant.
  • The RNs must assess and evaluate patients at least once a shift. They are required to do so again if the patient’s condition changes, such as if they receive care at a separate hospital.
  • Each occurrence (i.e. a fight) must be clearly reported. The supervisor and risk manager must be informed, and the details of which are marked in each patient’s electronic health record.
  • Hospital CEO Shelah Adams and the Director of Nursing will compare the nursing reports with the occurrence reports each day.
  • Instituting a slew of new training regimens, including risk and condition assessment for RNs, rounds and documenting processes for MHTs, and individual training sessions with the Infection Control Preventionist on, well, infection control.
  • Those urine specimens weren’t picked up because a computer was down and could not print out the proper paper requisition. If this happens again, the requisition will be filled out by hand and the specimen will be placed in a plastic bag for transfer to the lab.
  • Safety specialists are now in charge of cleanliness of the unit, proper storage of linen, proper storage of paper scrubs, nutrition stations, treatment rooms, patient storage rooms, exam rooms, as well as the “timely” pickup of specimens.

Federal investigators will be on-site sometime before July 13 to verify that Timberlawn kept up its end of the bargain. The facility offers inpatient and outpatient services for adults and adolescents, including psychiatric care and substance abuse programs. Its website touts its “continuum of care” as “one of the most complete in the United States, and is one of the reasons Timberlawn is consistently considered among the best psychiatric treatment centers in the country.”


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