State makes unannounced visit to Indiana psych facility on reports of understaffing

May 30, 2013

PLYMOUTH -- Indiana Department of Child Services officials report that they found inadequate staffing levels for children at the psychiatric facility Michiana Behavioral Health on March 20, following up on issues raised by former employees about understaffing.

The former employees alleged that the understaffing at the Plymouth facility caused risks for patients and staff.

But the facility's CEO disagrees with the assessment from state licensing officials and argues that nurses should be counted in staffing ratios.

DCS still has questions it's trying to resolve about issues such as the use of medications and behavior plans for the children.

The Tribune recently obtained a letter from DCS that spells out what the agency found on the unannounced visit March 20, along with CEO Bryan Lett's written response on April 29.

As The Tribune reported on April 7, a group of former nurses and mental health technicians have been holding weekly protests near the facility since mid-March. They continue to do so.

In written and verbal statements to The Tribune, they've claimed that one worker often would supervise 15, 20 or more children at a time. But state licensing reviews hadn't shown that over the past five years.

Lett had told The Tribune the group's claims were false.

Lett said that an average of 50 children and adolescents and seven adult patients were lodged there in February. The youths come from 15 Indiana counties, including St. Joseph, and from Michigan.

DCS reports that it interviewed several staff and residents and made observations on its visit.

What letters from DCS and Lett don't address is whether or not children have acted out sexually at the facility, an issue that former staff had raised, including Dominique Smith, who quit her job as a mental health technician last year and is spearheading the group that's raising concerns. She alleged that sexual activity is occurring because of lack of staff and their inability to supervise children closely enough.

Meanwhile, the Indiana Division of Mental Health and Addiction expects to file a letter soon on what auditors found on their visit the week of March 25, a spokeswoman said.

The Joint Commission, the nonprofit organization that accredits the facility, also did an on-site survey April 9 and 10 to look into complaints it had received about the facility. So far, spokesman Bret Coons said, the commission hasn't required Michiana Behavioral to make any improvements as a result.

Also, one of the former nurses in The Tribune story April 7 has filed a lawsuit against Michiana Behavioral and against Lett, alleging that she was wrongfully terminated and that Lett slandered her by telling other employees that she was fired for falsifying medical records and lying to a doctor.

That nurse, who asked to only be named by her initials, DC, since she said was seeking another job, said she was fired after an incident where she sought to put a young boy under the facility's own policy of "sexual acting out precautions."

Staffing levels

State code requires that, in a child psychiatric facility like this, there must be one direct-care staff member for every four children while the children are awake.

On March 20, DCS found four mental health technicians who were supervising two living units and one nurse on duty, plus other staff that couldn't be included in the ratios. There were 29 children lodged in the units, though Lett notes that there was one less by the day's end.

DCS wrote that the facility was including nurses in the staff-child ratios, pointing out that nurses aren't typically part of that ratio because they have duties other than direct care of the children. Even if they were included, the letter said, there still wasn't enough staff. DCS pointed out "confusion" over which staff can be included in that ratio.

Lett cited a state statute and argued that it isn't clear which staff are "responsible for daily direct care and supervision of children" -- nor, he wrote, does it preclude nurses from that. He argued that his nurses do direct care and should be counted in child-staff ratios.

A follow-up letter from Michiana Behavioral's attorney said three nurses were on duty, providing what it saw as 10 direct-care staff for 29 kids.

Lett wrote that the ratio that DCS observed was only true from 8:30 to 9:30 p.m. And since 8:30 p.m. is bed time, he wrote, that met the state's ratios. (Indiana code calls for a staff-child ratio of 1:12 when the children are asleep.) Time cards and security cameras back that up, he wrote.

To avoid any more gaps in child-staff ratios, Lett wrote that the facility has revised its schedules for mental health technicians so that they work solid, 3-to-11 p.m. shifts. Also, he wrote that the facility reviewed its process for scheduling staff when other staff are sick, on vacation or otherwise absent -- and would retrain its staff on this process.

Extra attention

The DCS letter also raises questions about staffing in cases of "special precautions," which, per Michiana Behavioral's policies, is "when a child has a severe behavioral incident requiring one-on-one supervision as a result of being a danger to themselves or others."

Former staff had raised specific issues about its policies for "sexual acting out precautions" when children have been known to act out sexually. Among other things, former staff said, the policy requires staff to have a "line of sight" on the child at bedtime, but they stressed to The Tribune that it's difficult to keep up with that when they are understaffed.

Both situations involve calling on extra staff to supervise the child, and the DCS letter states, "It is reported by staff that attempting to secure relief staff is sometimes challenging."

In response, Lett again points DCS to Michiana Behavioral's efforts to fill gaps when staff are absent.

Ages and genders

The DCS letter pointed out how children of "varying ages and genders" were found on the units.

It also reported that each living unit may house no more than 15 children but that, on March 20, one unit had 19 children while the other one had 10.

Lett responded that that was because the facility aims to keep children together and adolescents together for programming during the day, although it uses the combined bed capacity for sleeping arrangements.

"Generally, adolescents are roomed together," Lett wrote.

DCS reviewers found a child in what appeared to be a "time out room," though DCS perceived that to be "seclusion" since a staff member used his body to keep the child from leaving. DCS suggested that the staff be retrained on the difference between the two -- so that it's reported correctly.

Lett agreed to retrain the staff on this.

Psychotropic drugs

There are some concerns that DCS is still trying to resolve. Specifically:

Were psychotropic drugs used to subdue children whose behavior needed to be restrained? These are known as "chemical restraints." DCS doesn't generally allow drugs to be used to restrain a child's behavior, the DCS letter states. Such drugs may only be given via a "stat" order by the prescribing physician for a one-time emergency basis when a child is agitated or after developing a "behavior management plan" for the specific child that first seeks to use less restrictive methods, the DCS letter states.

Were psychotropic drugs ordered for children without a behavior management plan? And if so, were the drugs ordered as part of a chemical restraint?

When asked about both issues, DCS spokeswoman Stephanie McFarland said, "It's unclear, so we're trying to assess that." In other words, she said, DCS continues to ask questions of Michiana Behavioral.

The DCS letter states that four children lacked a behavior management plan.

But Lett countered that such plans are incorporated into the child's "master treatment plans" so that all staff are aware of what triggers a child to be aggressive and the options for controlling the child's behavior. He provided DCS with the plans for the four children.

He also wrote that mandatory trainings for all staff would cover the use of "chemical restraints" and behavior plans.In her follow-up letter, Michiana Behavioral's attorney wrote that the facility didn't give drugs in violation of DCS rules. Nor, she wrote, does it believe its policies on chemical restraint conflict with the state's policies.

Source: Joe Dits, "Staff ratios under review; Michiana Behavioral Health facility CEO disagrees with DCS report," South Bend Tribune, May 18, 2013.