In recent months, the University of Minnesota’s Fairview–Riverside Medical Center allowed at least seven major security breaches, including a patient who escaped the hospital on June 4, according to health agencies and those close to patients.
All seven cases affected mental health patients, including one that led to an investigation by the Centers for Medicare & Medicaid Services, a federal agency within the U.S. Department of Health & Human Services. Fairview later addressed the agency’s concerns.
But a new CMS investigation opened June 1. If further violations are found and aren’t fixed, Fairview can lose federal healthcare funding, said CMS spokesperson Elizabeth Schinderle in an email.
“It’s clear that securing potentially dangerous patients and monitoring patients who are vulnerable is a recurring problem for the hospital,” said Jeff Storms, a lawyer currently suing Fairview for one of the security breaches.
A History of Escapes
Storms is representing a developmentally disabled minor who fell victim to Fairview’s poor security last fall, the first in the string of seven incidents.
On Nov. 9, 2016, the 15-year-old patient was sexually assaulted in the center’s emergency department by 29-year-old Jamal Strong, another patient, after he was able to enter her room not once, but twice, within the hour, Storms said.
In December, a 13-year-old boy in the child behavioral health unit was escorted out of the secure unit despite a suicide attempt two days prior.
He then evaded staff and escaped through an unsecured hospital door before the Minneapolis Police Department found him 35 minutes later on the Franklin Avenue Bridge and returned him to the hospital, according to CMS investigation documents.
“Fairview has been taking a defensive posture,” said Ryan Jancik, the boy’s stepfather. “They’re not admitting their mistakes.”
The next security breach didn’t occur until spring, when a mental health patient allegedly escaped by forcing through a magnetic door on April 26.
Three other patients were able to escape in the same way four days later, despite attempts to fix the door, said Dean Carlson, father of one of the escapees.
Fairview again addressed the magnetic door issues and got better results, Carlson said.
“The hospital was in panic mode. That’s the impression we got,” he said.
The latest reported incident happened June 4 when another patient escaped the hospital and was found at a nearby restaurant and returned to the hospital 30 minutes later.
“When we become aware of a patient safety or security issue, we investigate promptly, look for ways to improve our policies and procedures and take other appropriate action,” said Camie Melton Hanily, a Fairview spokesperson, in an emailed statement.
CMS first launched an investigation into the hospital’s practices after the December escape.
Various violations found in the investigation pushed CMS to determine the center’s negligence posed “an immediate jeopardy to the health and safety of patients,” according to a statement of deficiencies document submitted by CMS on Dec. 12.
A hospital is cited with “immediate jeopardy” if a CMS investigation shows the situation has “caused, or is likely to cause, serious injury, harm, impairment, or death to a resident,” according to CMS guidelines.
Fairview responded to the statement of deficiencies within three days with a plan of correction, which was accepted by CMS, and Fairview’s “immediate jeopardy” citation was removed.
The hospital also later passed an unannounced site visit by CMS to ensure it was following through on changes.
Schinderle said if Fairview failed to draft a corrections plan or pass the site visit, it could have lost Medicaid and Medicare funding.
“Should an allegation of noncompliance resurface, another [investigation] may begin,” Schinderle said in an email.
Despite apparent fixes, the latest security breaches, in April and earlier this month, have put Fairview under renewed scrutiny.
The second CMS on-site investigation was conducted on June 1, according to a letter sent from CMS to Jancik.
The investigation was headed by the Minnesota Department of Health and found Fairview “failed to ensure that each patient received care in a safe setting,” and will be required to make corrections, the letter stated.
The Joint Commission on Hospital Accreditation — a non-profit organization that verifies the quality of U.S. hospitals — conducted a separate on-site evaluation on June 2, said commission spokesperson Elizabeth Zhani in an e-mail.
Zhani said in the email the commission makes visits like these if an incident “raises concerns about a continuing threat to patient safety or if it suggests a failure to comply with Joint Commission standards.”
Results of both the new investigations are still under review.
For the time being, Fairview remains part of both the Medicare and Medicaid and the Joint Commission accredited programs.
“Fairview Health Services is committed to working with patients as well as regulatory and accrediting agencies…” said Melton Hanily in an emailed statement. “Quality and patient safety are of utmost importance.”