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Handling of mental patients reviewed


Michael Abramowitz

Monday, September 21, 2015

The unwarranted restraint and management of behavioral health patients at Vidant Medical Center in 2014 placed the hospital in jeopardy of losing its federal funding, a July report from the agency that oversees Medicare and Medicaid services showed.

Vidant officials last week confirmed the government report and said the conditions surrounding the findings by the Centers for Medicare and Medicaid Services (CMS) were corrected. Officials said that no patients were injured. Investigators acting on behalf of CMS, a division of the U.S. Department of Health and Human Services, did not find any incidents of injury to patients, but noted that some patient handling methods they saw were unsafe.

The CMS report was based in part on an incident that occurred on May 14, 2014, when the nursing staff failed to assess and document a behavioral health patient’s condition or symptoms before asking company law enforcement officers to place the patient in restraint and move the patient out of a hallway, determined by the investigators to be excessive use of force.

The incident came to light because of a patient complaint in July to Raleigh-based Disability Rights North Carolina that led the agency to interview staff and examine Vidant’s protocols and records of the incident.

After reviewing investigative materials, Kristine Sullivan, an advocacy attorney with the federally funded nonprofit agency, said she tried unsuccessfully to cooperate with Vidant officials at improving their policies, procedures and training.

“They basically declined our invitation, saying they didn’t think they did anything wrong,” Sullivan said. “At that point we concluded they might be more responsive to ... the N.C. Division of Health Service Regulation.”

As the state’s regulatory division overseeing the safety and appropriateness of patient care at medical, mental health and adult care facilities and emergency medical services, DHSR made an unannounced onsite investigation at the hospital’s behavioral health unit from July 14-16. Their findings resulted in the federal action to place Vidant in “immediate jeopardy” of funding loss.

A hospital must protect and promote each patient’s rights to qualify for Medicaid and Medicare funds. CMS revealed that Vidant staff and administrators failed that test in regard to how they cared for behavioral health patients and documented their care activities.

The investigators’ findings were reported to CMS, which then notified Vidant’s administrators that the medical center was in “immediate jeopardy” of losing all of its Medicaid and Medicare funding as a result of the investigators’ findings.

Interviews, documents and observation of two videos that recorded the patient’s interactions with staff and law enforcement officers did not reveal any behavior by the patient that was physically aggressive, violent or threatening to the staff or the patient, CMS officials said in the report.

Examination of police reports revealed patients were not safely restrained and unapproved law enforcement maneuvers were used on behavioral health patients exhibiting and not exhibiting aggressive/violent behaviors, according to the report.

The hospital stopped training staff and law enforcement in 2013 in the appropriate techniques for restraining a violent/aggressive behavior patient, the report indicated. The chief nursing officer was not aware the training had been stopped, investigators said.

A crisis prevention intervention instructor specified during the CMS interview that she did not know what a “wrist lock” is, but she did know that it was not on a listing of methods approved by the hospital for use on patients.

The behavioral health medical director and the chair of the psychiatric department also revealed in interviews that they were “unaware” of the training provided to the staff and company law enforcement officers for restraining a behavioral health patient, even though CMS requires them to be familiar with such training.

Sullivan said the underlying problem at Vidant is characteristic of an issue faced statewide.

“We find that caregivers at many hospitals like Vidant are not extensively trained in dealing specifically with people having a mental health crisis who enter through the emergency department,” she said. “The problem is the shrinking number of accessible community behavioral health services, and those that exist have shrinking budgets. As a result crisis-level events are being presented more at emergency rooms because it’s the only place people have available. It’s not a good situation for anybody.”

Vidant administrators acknowledged that, in response to the CMS investigative division’s visit, the medical center has updated its training and educated emergency department, behavioral health and law enforcement staff. Hospital officials also developed new criteria and changed policy for behavioral health patients, they said. In addition to daily review, they have improved the documentation and implementation for the use of restraints and law enforcement.

“DHSR completed a comprehensive review our new policies, procedures, training and documentation and found no deficiencies,” Vidant Medical Center President Brian Floyd said Friday. “As a result, VMC has been in compliance with the conditions of participation with CMS since Aug. 20, 2015. We have and will continue to meet with regulatory agencies and interested advocacy groups regarding concerns with our patients.”

Vidant nurses, staff and law enforcement officers care for a complex behavioral health patient population, Floyd said.

“Patient compliance is about safety for everyone,” Floyd said. “Obviously, restraining is a question of patient rights. We always try to de-escalate a situation and treat the patient first, but there are safety systems we have to use if the situation goes in the other direction and the patient becomes combative or refuses to comply for an extended time. Our commitment to excellence at VMC keeps us on a path of continued improvement to provide quality care and a safe environment for all our patients, staff and physicians.”