The Kansas City Star

A Kansas City psychiatric hospital with a history of patient-care problems failed to adequately monitor a suicidal patient, federal records show, and then bungled attempts to resuscitate her after she strangled herself with a strap.

Now the hospital faces federal sanctions.

The March 12 suicide is at least the second at Two Rivers Psychiatric Hospital since 2008.

Federal officials plan to drop Two Rivers from the Medicare program on Monday unless the hospital has adequate suicide precautions in place.

The 105-bed hospital at 5121 Raytown Road also faces a June 2 deadline to demonstrate to Medicare that it has taken care of several other serious problems, including keeping patients who’ve committed sex offenses away from other patients.

Termination means the government Medicare and Medicaid programs would no longer pay Two Rivers to care for patients. The measure is considered a last resort when medical facilities fail to meet critical standards.

“Two Rivers disputes any contention that there is an immediate jeopardy to patient safety,” Kevin Young, the hospital’s CEO, said Friday in a written statement.

“The hospital continues to participate in the Medicare program and is working diligently with (Medicare) and the Missouri Department of Health and Senior Services to demonstrate that the hospital is in compliance with the Medicare rules,” Young said. “We have instituted significant improvements and enhancements in patient care and safety.”

Medicare officials said Friday that they were awaiting the results of a recent inspection to see whether Two Rivers had improved its suicide precautions.

If Medicare and Medicaid are terminated, the programs will continue to pay Two Rivers for 30 days for patients already in the hospital, but not for new admissions. Provisions have been made to transfer Two Rivers patients to other hospitals, officials said.

Two Rivers is one of just a handful of in-patient psychiatric facilities in the area, and beds for people in crisis are in short supply, said Susan Crain Lewis, president of the advocacy group Mental Health America of the Heartland.

“Our community cannot afford to lose 105 beds,” Lewis said. “But individuals in our community who are struggling with a mental health issue can’t afford substandard treatment.”

Repeated problems

Two River opened about 25 years ago. For the past three years, the for-profit hospital has had repeated run-ins with Medicare.

“We have had intermittent issues with other psychiatric hospitals, but we don’t see them happen over and over,” said Jeri Jackson, an expert on psychiatric hospitals with the Kansas City office of the Centers for Medicare and Medicaid Services.

Two Rivers has faced Medicare decertification several times before, but has been able to correct problems to the satisfaction of federal officials.

Medicare began identifying chronic problems in May 2008, when a complaint about Two Rivers led to a visit by inspectors. They turned up an abuse case in which a staff member poured water over a patient’s head and another in which a nurse put a towel over an elderly patient’s mouth to stop the patient from screaming, according to inspection reports.

Another visit about six weeks later uncovered cases in which bed alarms had failed. One patient found on the floor at 3:12 a.m. had suffered a broken hip and shoulder, according to the Medicare reports.

Treatment plans showed that staff had failed to include suicide precautions for a patient who had thoughts of suicide, or physical therapy for a patient who had recent hip surgery.

In September 2008, an Army soldier committed suicide at the hospital by using bed linens to hang himself in a closet.

The soldier had been experiencing post-traumatic stress disorder and had attempted suicide before. That death triggered another investigation.

After the suicide, Medicare threatened to withhold money from Two Rivers. But the program agreed to continue paying if the hospital improved and an outside expert monitored its progress.

Early in 2009, inspectors examined medical records at Two Rivers and found little evidence that patients were receiving psychotherapy or medical treatment other than medications. In September 2010, the hospital refused the emergency admission of a teenager who had threatened to kill someone. Federal law requires hospitals to see emergency patients.

The teen’s caseworker already had signed admission paperwork at Two Rivers before the police van arrived with the patient. Three officers were needed to restrain the teen, who was placed in shackles.

Instead of admitting the youth, a staff member told the officers to take the teen to detention. The teen was admitted to another psychiatric hospital.

Recent suicide

The case that triggered the current threat of Medicare termination occurred a month ago.

The 59-year-old woman who took her own life had a history of depression, hallucinations, paranoid delusions and thoughts of suicide. She was transferred to Two Rivers from a nursing home on March 9 after she had asked her ex-husband to leave her in the woods to die. Two Rivers immediately placed her under suicide precautions.

Two days later, the patient became very agitated at the hospital, hitting the bathroom walls.

Two Rivers staff were supposed to check on her every 15 minutes. But surveillance videos showed that the patient went for 20 to 31 minutes without anyone looking in on her after midnight.

Hospital staff told inspectors that when they checked on the patient, her blanket was pulled up to her neck. She appeared to be sleeping.

The first sign something was wrong came shortly after 5 a.m. when the patient didn’t respond when asked to raise her arm for a blood pressure check. The surveillance video showed the staff member walking “casually” to the nurse’s station.

Two nurses went to the patient’s room. One started CPR while the other struggled to bring resuscitation equipment.

More nurses arrived at the patient’s room. They found the first nurse doing chest compressions on the patient. The second nurse stood by, nudging the patient’s feet and saying “wake up, wake up.”

Only as staff tried to give the patient oxygen did a nurse discover the two things around the patient’s neck that she had used to strangle herself. One was the black nylon strap of a wrist support. The other suicide device was a bright green stretchable ring toy used to provide sensory stimulation.

By this time, the patient’s face was mottled purple and gray from lack of oxygen. An automated external defibrillator was brought out to shock the patient’s heart to a steady beat. But it was too late.