CMS releases details of Mercy Medicare investigation

Last edited 3:22 p.m., Oct. 19, 2017

The Centers for Medicare and Medicaid Services released a detailed report following incidents at Mercy Hospital Springfield that led to the firing of a dozen staff members, the installation of interim leadership and the risk of the hospital losing its Medicare agreement.

A monthlong investigation began Aug. 22 into the alleged abuse or neglect of four patients, according to documents released to Springfield Business Journal. During unannounced, on-site investigations, CMS representatives screened security camera footage of patient care in the emergency and psychiatric departments between April and August.

One incident began with a security guard asking a patient in the emergency room to stop cursing, shortly before the patient slid out of his chair – his body shaking on the floor. According to CMS, a nurse failed to immediately assess the patient’s changing condition, simply stating, "You're alright.”

When the security guard brought a gurney over, the investigation report indicates, the patient expressed he didn't want to be assisted by the same security guard who asked him to stop cursing. An argument ensued, and the patient decided to leave with a companion. The security guard followed them outside. A second security guard joined the interaction and physically pushed the patient and his friend, both in the back. According to the investigations, the patient sat on a curb and was eventually tackled by the two security guards and handcuffed. The patient suffered head injuries during the struggle.

According to CMS, Springfield Police Department officers arrived, interviewed the patient and his friend, and released them.

The CMS report said Mercy staff members did not recognize the incident as abuse and did not follow policy to remove the co-workers.

A second of the four documented incidents involved staff members moving closer to an upset patient, instead of giving the patient space and using preferred de-escalation techniques, according to CMS.

The interviews resulted in conflicting accounts of what happened, but the report said during an argument and physical struggle with a female psychiatric patient, a staff member may have improperly hit the patient’s hand with his knuckles to remove her hand from another staff member’s hair.

A third incident involved a psychiatric patient reportedly being force-fed a medication that she refused. According to CMS, a fourth patient was reportedly restrained with her arms above her head for hours after attempting to harm herself.

Following these findings, Mercy issued a plan of correction that was rejected by CMS for adequately resolving the problems and responding to the concerns.

On Sept. 13, CMS informed SBJ it determined there was “immediate jeopardy” to the health and safety of a few patients, and Mercy’s Medicare agreement would terminate Sept. 22, if the deficiencies were not corrected. That deadline was later pushed back a week, and on Oct. 2, Mercy officials said the immediate jeopardy status was removed. CMS officials said the hospital is still at risk of Medicare reimbursement termination.

Another review will be conducted by Nov. 5 to determine if the hospital is compliant with conditions of participating for nursing services and patient rights, a CMS official said.

The health system's plan to improve the situation includes the interim leadership team, termination of some employees, additional training for staff and a system for monitoring performance during tense situations.

Mercy spokeswoman Sonya Kullmann issued a statement on behalf of the hospital.

“This plan, which includes training for our co-workers in de-escalating tense situations, has already shown significant success in reducing the number of situations in which our public safety department is called for assistance," the statement reads. “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."