Violence puts hospital funding at risk

Federal officials have warned Contra Costa Regional Medical Center that it could lose nearly $300 million annually in Medicare and Medicaid funding unless it corrects violence and other problems in its psychiatric unit.

The money represents more than 80 percent of the hospital's $360 million annual operating budget.

"If they were to follow through on removing our funding, it would essentially close down our health system," the hospital's Executive Director Dr. Jeffrey Smith said. "There would be no way of keeping it functional."

Smith said he remains confident the hospital can address the concerns and retain the Medicare and Medicaid contracts.

"We have been aware of some of the problems, and we're trying to deal with them the best we can," he said.

Executives at the county-owned hospital in Martinez, which serves as a safety net for the area's poorest residents, received a notice last month from the U.S. Centers for Medicare and Medicaid Services.

• Nineteen staff members voiced concerns about unsafe conditions and the use of pepper spray on patients.

• Patients were asked to change into pajama bottoms and give private information in a public corridor.

• A woman's rights were violated when she was held 46 days longer than legally justified.

The psychiatric unit treats people undergoing a mental health crisis. Many are brought in by police and placed on involuntary holds after they are deemed a danger to themselves or others. Some arrive from jail after exhibiting mental health issues there.

Smith said the hospital faces increased challenges to care for the mentally ill at a time when community mental health services have been cut sharply since the 1960s.

Employees say they cope with competing pressures to provide a secure environment while treating people as humanely as possible, with dignity and respect.

Jails are filling up with people who can get mental health services nowhere else, Smith said. Meanwhile, a rise in methamphetamine use means mental health workers often deal with more aggressive behavior.

"The thing that's troublesome is, when you have essentially unlimited needs and very limited resources, the system goes tilt," Smith said. "From a statewide perspective, there is a dramatic lack of attention to these issues."

Federal officials informed hospital executives their Medicare contract would be terminated unless they submit an acceptable correction plan, including dates when changes will be made.

The hospital's correction plan, expected to arrive at the federal agency Wednesday, includes changing leadership in the inpatient psychiatric unit and psychiatric emergency services, beefing up staff training and developing procedures for dealing with more acutely disturbed patients.

One thing the plan does not call for is to have uniformed security employees, known as PSOs, brought back into the psychiatric unit, a change many nurses have sought.

The uniformed security personnel used to be stationed in the unit but now patrol other areas of the hospital and assist in the psychiatric unit when problems develop.

Smith said he continues to believe it would be a mistake to expand the role of these employees.

"The PSOs don't have either the training, expertise or legal status to do any of the things nurses would like them to do," Smith said. "It's better to have a clinician involved."

The investigation was sparked by an anonymous complaint and an Aug. 21 Times story detailing violence in the unit, said Deborah Romero, manager of the hospital and community care operations branch of the Centers for Medicare and Medicaid Services.

"Our first obligation is to protect the health and safety of Medicare beneficiaries," Romero said.

The Times' story, based on documents obtained through the California Public Records Act, revealed that 20 employees were injured by assaults in the psychiatric unit in 2004. That was more than double the eight injuries reported in 2003.

In one incident in February 2005, a patient who had just been told he would not be discharged slugged a nurse as she walked through the door, knocking her unconscious.

In another attack in October 2004, a nurse underwent surgery for a torn quadricep muscle and tendon after a patient kicked him in the knee three times.

Complaints about employee safety in the unit were filed with Cal-OSHA in 2005, 2002, 2001 and 1999.

Emmett Teal Young, the registered nurse who underwent knee surgery after being attacked, said he is considering requesting a job shift because working in the psychiatric unit has become too risky.

"There just is not enough protection," Young said. "It's too violent. From the last injury, I'm still limping. I'm still in pain."

The hospital's correction plan includes in-house and outside training for employees in dealing with combative patients. It also calls for better monitoring and tracking of trends to identify problems.

Investigators faulted the hospital for not quickly reporting assaults. Incidents will be reported within 48 hours, the plan states.

A union representative said she will withhold judgment until she sees how the plan is implemented.

"Our concern is a plan is only worth the paper it is written on," said Barbara Lambarida of the California Nurses Association.

"We want to see the actions," she said. "The nurses are just as concerned for the patients' safety as their own."

It is unusual, but not unheard of, for a hospital to have its Medicare funding threatened. Since October, the Centers for Medicare & Medicaid Services has issued 45 warning letters to hospitals in its western region covering California, Arizona, Nevada and Hawaii. These notices have been issued for a variety of reasons covering many parts of a hospital's operation.

Hospitals that lose Medicare funding usually have their Medicaid funding terminated as well. As a result, $300 million is in jeopardy at Contra Costa Regional Medical Center.

Investigators conducted their review of the psychiatric unit from Nov. 28 to Dec. 1.

Now they plan a more extensive analysis. The federal agency recently notified the hospital it will soon conduct a compliance review of the hospital's entire operations.

Smith expects 10 to 12 investigators will arrive unannounced and spend 10 to 15 days at the hospital.

If the hospital passes that review and its correction plan is deemed adequate, it will retain its Medicare contract.

I'll tell you a story. I worked at a state institution for the retarded (that was the term back then) in the severely retarded dormitory. We had some state inspectors doing a walk-through of the facility one day and a really pretty young social worker stopped to coo at one of the residents. This guy was Satan incarnate and I told the lady (who by the way wouldn't listen to anything we said because she obviously knew everything) "you'd better watch out, the guy is dangerous". She blew me off and the next thing you know he'd reached up her skirt and had her by the crotch. She was screaming like a Banshee while my partner and I tried to get her loose. We put him in a lockup while the lady was blaming us for everything that happened. She went to the window of the room and started baby talking him again and he crapped in his hand (one of his favorite tricks) and threw it on her dress. I laughed for days.

You can't deal with some of these people like you would a normal person. I'm not talking about abusing them but sometimes you have to get rough and I would have loved to have some pepper spray when some of those dudes were going upside my head. Mostly I just felt sorry for them because their lives were hell.

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