Inspectors find inadequate care at SouthPointe
February 18, 2001
By Judith VandeWater
St. Louis Post-Dispatch

SouthPointe Hospital in St. Louis is under investigation by state and federal authorities because of numerous incidents that threatened the safety, health and privacy of its psychiatric patients.

A scathing report prepared by state and federal regulators and obtained by the Post-Dispatch last week found that although no patients were seriously harmed in the incidents last year and this year, some were placed in "immediate jeopardy."

The regulators have put the hospital on notice that it is at immediate risk of being shut down unless managers rectify the situation. State and federal officials suggested that poor training of temporary employees and inadequate staffing contributed to a lack of supervision and care of psychiatric patients at SouthPointe.

Tenet Healthcare, which owns SouthPointe and three other hospitals in the area, said in a statement that the hospital was seeking to correct the problems and to comply with federal and state requirements. The hospital, at 2639 Miami Street, was once known as Lutheran Medical Center.

Among the report's findings:

* During 10 days in April, a male patient with a history of setting fires got cigarette lighters and used them to set fire to the beds of three patients while the patients were in their beds. No patients were injured, state inspectors said.

* Two claims of male-on-male sexual assault between patients were inadequately handled by the hospital.

* Several instances of consensual sex or sexually suggestive contact took place between psychiatric patients.

* Adolescent and adult patients on suicide watch had access to materials in unlocked laundry rooms or unwatched housekeeping carts that could have been used to inflict serious or fatal self-injury.

* Patients placed in restraints or seclusion were not always seen by a physician within one hour - a requirement under hospital policy.

* On multiple occasions, hospital employees did not make the required 15-minute checks on patients or did not make such checks thoroughly.

In one instance, a medical record review showed a patient-care assistant on Dec. 16 found a woman, 69, dead in her room at 7:45 a.m., her body stiff. Hospital records indicated that the woman had been last checked at 7:15 a.m.

The emergency room doctor who examined the body at 8:15 a.m. noted the stiffness as rigor mortis. That could suggest that the patient may have been dead for a longer time without anyone noticing. Pathology texts say that, depending on climatic and biological factors, rigor mortis sets in three to eight hours after death.

Lack of supervision

The report also notes multiple cases of inadequate supervision of patients, including a lack of monitoring patients in smoking lounges, where the hospital's own policy requires it.

In cases in April and June of last year patients got punched by other patients in unsupervised lounges. In January, an inspector looking through the window of an empty smoking room saw something on the floor. The vice president of psychiatric services was called to the door and identified the matter as two piles of stool. A patient had just been in the room.

During one inspection this month, an elderly man wearing nothing but slippers walked into a dayroom where nine other patients were gathered. The man suffered from a psychotic disorder. A social worker took the man back to his room but did not help him get dressed. Twelve minutes later, he returned - still naked.

Fixing the problems

SouthPointe has until Tuesday to develop a satisfactory corrective action plan, including a process for educating permanent and temporary staff in hospital policy.

Carey Smith, chief of the state health department's facility regulatory staff, said a team of state investigators will reinspect the hospital Tuesday to measure what progress has been made and to satisfy themselves that the hospital administration is working diligently to correct the problems.

In the meantime, a state Health Department inspector has been conducting a daily inspection of the hospital.

The Health Department could suspend or revoke the hospital's license at any time. Under current law, Smith said, the state cannot just shut down the psychiatric floors and keep the rest of the hospital open. It would have to pull the entire hospital's license to operate.

But Smith said such drastic action was unlikely and would be unprecedented.

"Nobody in the state or federal government wants to see that hospital closed," Smith said. "There are some areas of the hospital that are functioning very well."

Meanwhile, the Kansas City regional office of the Health Care Financing Administration, the federal agency that oversees Medicare, has set a deadline of March 3 for compliance. Unless the hospital corrects its deficiencies by then, it will lose its Medicare certification and the ability to be reimbursed for treating Medicare patients.

SouthPointe and Tenet limited comments on the regulatory action to a short statement issued last week in response to an inquiry from the Post-Dispatch.

"Patient care and safety are the top priorities at SouthPointe Hospital, and we are making this matter our top priority as well," the statement said.

The latest disclosures aren't the first dangerous incidents to come to light at SouthPointe. Another incident - one that proved fatal - occurred in an operating room at the hospital last April. As previously reported, an 84-year-old woman in for minor eyelid surgery was accidentally set on fire after a spark from a piece of surgical equipment ignited a flash fire in the oxygen-rich environment. She died two weeks later.

A predecessor of Tenet, National Medical Enterprises, has a dark history in its psychiatric division.

In 1994, after the company pleaded guilty to federal fraud charges, it was ordered to sell its psychiatric hospitals in Texas. In 1996, the company paid a $100 million settlement of nearly 700 suits filed by former patients in Texas who claimed that National Medical Enterprises held them against their will until it drained their insurance.

Tenet, one of the country's largest for-profit hospital companies, was formed in a 1995 merger of American Medical Holdings and National Medical Enterprises.

National Medical Enterprises had entered the St. Louis market in 1984 when it acquired Lutheran Medical Center. In the 1990s, Tenet also acquired the Deaconess-Incarnate Word Health System and St. Louis University Hospital.

SouthPointe has 408 licensed beds. Its psychiatric service has 104 beds in seven units on six floors. Smith said that the hospital regularly fills almost all its psychiatric beds, proving there is a community need for the service.

A widening inspection

A small team of state inspectors visited the hospital Jan. 22 through Jan. 24 to investigate a complaint about psychiatric services and found conditions warranting a full investigation.

The Health Department normally acts in a dual role as an agent of the state and Medicare regulators, but in this case two Medicare inspectors joined a larger state investigation team that returned to the hospital Feb. 3 through Feb. 9.

That team conducted a review of the entire facility, but the report obtained last week was limited to the potentially dangerous problems in psychiatric services.

Smith said the problems found in general medical services were more routine concerns including deficiencies in keeping medical records. That report has yet to be completed.

Inspectors interviewed staff and patients, reviewed patient records and made observations all hours of the day and night.

They concluded that the facility failed to provide care in a safe setting, and it failed to protect patient rights to personal privacy - a deficiency demonstrated by the lack of effective security measures in place to prevent sex acts from taking place, according to the report.

"You need to protect the patients," Smith said. "It's not so much a rule against sex as it is a rule to protect patients' privacy" and health. "There is concern that even consensual sex could result in the transmission of venereal disease or hepatitis."

With psychiatric patients there is an added concern that medications or a psychiatric condition may cloud judgment and the ability to consent to sex.

Consider the case of one woman, 49, whose bipolar disease caused a psychotic detachment from reality. Two days after her admission to SouthPointe in early March last year, an entry in the hospital's critical-incident log noted the patient had "consensual" sex.

That evening, the patient's condition was noted as being so distressed that she was placed in seclusion for slapping staff members. She was given repeated doses of anti-psychotic, anti-anxiety and anti-mania medications. That night she stripped nude, rambled incoherently and smeared her room with feces.

Shortage of staff

SouthPointe's staff was spread too thin and did not meet federal standards, according to the report. Although there is no federal or state regulation that mandates minimum nurse-to-patient ratios in acute-care hospitals such as SouthPointe, federal law requires the immediate availability, when needed, of a registered nurse for bedside care.

A description of a safety drill conducted at 5:26 a.m. on Feb. 5 shows that six of the psychiatric units - wards containing between 11 and 18 patients - were each staffed by only one registered nurse and one patient-care assistant. The seventh unit had a nurse and two aides.

The drill, which requires all available hospital personnel to respond to a potentially threatening situation, left some of the units with only one person to care for all the patients.

Even so, Smith said SouthPointe's problems had more to do with poor orientation on hospital policy than with low staff-to-patient ratios.

Smith said the national nursing shortage has forced many hospital administrators to increasingly rely on technicians to deliver patient care rather than registered nurses. "There are just not enough RNs," he said.

SouthPointe's problems

A government audit cited numerous deficiencies in the hospital's psychiatric wards. Among them:

* Failure to provide care in a safe setting.

* Failure to conduct 15-minute safety checks on all patients.

* Failure to have sufficient trained staff to respond to a potentially threatening situation.

* Failure to ensure the privacy rights of patients.

* Failure to assure that residents were free from abuse or harassment.

* Failure to ensure that patients are free from unnecessary physical restraints.

* Failure to provide training for temporary agency staff on the proper and safe use of restraints.

* Failure to provide supervision in smoking lounges.