Newly released documents from federal regulators detail how four patients at a southwest Missouri hospital endured abuse at the hands of caregivers or security guards, leading hospital officials to dismiss 12 employees over the summer.
In one case, staffers knocked a patient’s head against concrete. In another, nurses forced an 18-year-old patient to swallow medication, according to a 105-page report from the Centers for Medicare and Medicaid Services.
“I was disturbed and upset by what I saw and what I read,” said Gena Terlizzi, executive director of the Missouri chapter of the National Alliance on Mental Illness. “People need to be able to feel secure in getting treatment. And when things like this happen, it erodes that confidence in the system.”
Federal regulators at CMS put Mercy Hospital Springfield, which is part of a Catholic health system based in Chesterfield, on "immediate jeopardy" status in late August, risking the loss of its federal funding through Medicare. The 400-bed hospital has since agreed to a corrective plan overseen by federal regulators.
Investigators reviewed the four cases in August, consulted surveillance camera footage and compared it with staff reports at the time. Investigators found anomalies between what staff claimed had occurred and what the tapes proved. Mercy officials fired or accepted the resignations of 12 people identified in the incidents, and implemented mandatory training, monitoring and leadership changes as part of a corrective plan.
“While we deeply regret that these incidents occurred, we have treated this as a learning opportunity as we reaffirm our commitment to our mission, values and charism,” Mercy officials said in a statement.
In one instance in February, hospital workers placed a 22-year-old patient in the hospital’s psychiatric center in seclusion and restrained her on a bed with her arms above her head for hours, investigators wrote. During an altercation, a security guard may have broken her thumb in an improper hold, and nurses later refused to give the patient pain medication. The patient, who was suicidal, had tried to hurt herself earlier in the day but was not a threat to herself at the time, the report said.
In May, a 28-year-old woman staying in the psychiatric center yelled at staff after a male patient touched her roommate, the report said. Hospital personnel did not de-escalate the situation, investigators wrote, and after the conflict continued staffers restrained the patient on the floor. The patient pulled the hair of one employee, and another staffer used a closed fist to hit the patient on the back of her hand to force her to let go.
That same month, nurses held an 18-year-old patient in the psychiatric center on a bed and forcibly gave her oral medication, though she had a legal right to refuse it, the report said. The nurses did not report the incident to supervisors, and staffers said they feared retaliation, it noted.
In June, the report describes a patient who reported numbness in his left arm and fell to the ground, shaking, in the emergency room. A staff member stood near him and sarcastically said, “You’re all right,” investigators reported. After staffers brought a gurney and the patient became agitated, he walked out the door, and staffers followed him outside. During an altercation, two staff members tackled the patient to the ground. He sustained a head injury after hitting the concrete, and was handcuffed while lying on his stomach.
“No de-escalation techniques were used by nursing staff or security,” investigators wrote.
The cases follow an investigation in January of this year, in which federal investigators followed up on allegations of patient abuse, and staffers who were not removed from patient care immediately after the accusations.
During the latest round of interviews with investigators, hospital leaders “felt the mismanagement of the patients were engrained in their culture, and that it was not the manner in which the hospital expected their patients to be treated,” the report said.
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