How many things can a hospital do wrong before losing funding?

Life safety volations, a patient death, inhumane patient restraints... and taxpayer money still flows

A May 3, 2016, Patriot Ledger article by reporter Chris Burrell describes events surrounding psychiatric facility Pembroke Hospital:

“State health inspectors made six surprise visits to the 120-bed psychiatric facility in Pembroke during a 5-week period in March and April and flagged violations related to understaffing, simultaneously restraining and isolating a patient and unclear criteria for evaluating a patient’s risk for aggressive behavior.”

The surprise visits occurred, perhaps, once a week? State Health inspectors knew about these violations for months on end, yet allowed this facility to remain open, and accept and treat patients?

The state uncovered “urgent patient care and life safety violations,” Chris Burrell writes of the Arbour-owned Pembroke Hospital along with four other Arbour-owned facilities: Quincy (18 beds), Westwood (136 beds) and Jamaica Plain (136 beds).

I wonder what is meant by “life safety violations” - is it about the patients, the staff, or both?

State inspectors also cited the hospital for violating regulations on restraining patients: “The physician ordered mechanical restraint and locked door seclusion to be done simultaneously,” adding that both methods cannot be combined.


Was this a psychiatric physician who ordered this inhumane treatment? Why would anyone order that and how long has that been being done to the mentally ill? Was this abuse reported? If so, why wasn’t it stopped?

The current multi-agency probe goes back to last fall, when 20-year-old patient Amber Mace was found dead in her room August 30, 2015; it was determined that Mace had been dead for at least two hours before any staff took action. According to reports by the State Department of Mental Health, Pembroke Hospital staff did not properly perform 15-minute safety checks by failing to physically enter her room and check for signs of breathing.  Department of Mental Health licensing director Janet Ross wrote that the “failed safety checks constituted a dangerous condition, which may have delayed treatment for a medical condition beyond the point where intervention could be effective.”
Pembroke Hospital told the State that it “disciplined staff involved in Mace’s treatment and also retrained its nursing and mental health staff last fall.”

Pembroke failed in their night-time checks of this patient, and a State inspection agency concluded it created a dangerous and inhumane condition for this young woman, possibly contributing to her death.

The Centers for Medicare and Medicaid also found the hospital failed to meet standards for patient safety and the administration of drugs, “but the failures were not severe enough to jeopardize the hospitals provider agreement for accepting Medicare and Medicaid tax-payer funded health insurance,” according to reporter Chris Burrell.

All this time Pembroke hospital remains open, treating – or not treating – patients, and receiving taxpayer-funded monies.

I just don’t get it.

Sheila Wilson, RN BSN MPH
President stophealthcareviolence
www.stophealthcareviolence.org

Source:
Patriot Ledger
WCVB