“There comes a point where state officials must make a determination as to whether it is prudent to allow continued operation of a facility that has recurring serious problems in patient care.” — Paul Levy, hospital safety analyst and former CEO of Beth Israel Deaconess Hospital in Boston
“Timberlawn Behavioral Center in Dallas, Texas, must be shut down,” CCHR says
By CCHR International
Mental Health Industry Watchdog
December 12, 2017
Universal Health Services (UHS)-owned Timberlawn behavioral health hospital came under fire again on December 10, 2017, with another Dallas Morning News investigation that questioned safety of patients at the facility, especially against sexual abuse. Headlined, “’Immediate jeopardy’: How safe are kids at state-monitored Timberlawn psych hospital?,” the article by Sarah Mervosh, Sue Ambrose and contributed to by Miles Moffeit, detailed the long history of abuse exposed at Timberlawn.
In 2015, the report says, “after problems piled up, the government stopped reimbursing Timberlawn for patients on Medicare and Medicaid, the federal insurance programs for the poor, elderly and disabled. Those patients, court records show, made up most of Timberlawn’s business. The state threatened to fine the hospital $1 million and revoke its license. But Timberlawn, a for-profit hospital that’s part of a national chain, Universal Health Services Inc., negotiated a way to stay open: It would pay $190,000 and agree to a three-year probation. The hospital also made improvements so it could requalify for federal funding.”
According to The Dallas Morning News, “Probation means extra scrutiny: Inspectors pop in unannounced, in addition to responding to complaints. But the state says it hasn’t always responded right away if patients aren’t in immediate jeopardy. Earlier this year, inspectors waited nearly two months to visit Timberlawn after police were called to the hospital on separate occasions. Three women complained to police that the same male patient had inappropriately touched, harassed or exposed himself to them over several days in March, police records show.”
Usually, as a result of CMS or Texas Health and Human Services Commission inspections, the hospital is given the opportunity to propose and carry out a correction plan. However, since 2015, Citizens Commission on Human Rights International (CCHR) has filed numerous complaints against Timberlawn and other UHS-owned psychiatric facilities in Texas to state authorities, stating, “It shouldn’t take more than one ‘Plan of Correction’ to ensure safeguards to prevent sexual assault of patients—by fellow residents or staff. Or to ensure that patients are never again neglected to the point that they commit suicide or are restrained to the point of being harmed and even killed.”
Similarly, Paul Levy, a hospital safety analyst and former CEO of Beth Israel Deaconess Hospital in Boston, told Dallas Morning News, “There comes a point where state officials must make a determination as to whether it is prudent to allow continued operation of a facility that has recurring serious problems in patient care.”
In CCHR’s letter sent in November that was sent to Texas health and law enforcement officials and to the U.S. Centers for Medicare and Medicaid Services (CMS), CCHR called for a “review of Timberlawn’s Medicaid and Medicare funding and its billings with the view to it having its CMS contract terminated. To quote The Dallas Morning News from 24 October 2017, ‘Dallas’ Timberlawn psychiatric hospital has run out of second chances.”
The letter pointed to the sexual and other abuses occurring at UHS behavioral facilities around the country that cannot be dismissed. It countered comments that James Miller, Timberlawn’s chief executive made in a letter to the Dallas Morning News, claiming: “we believe our rate of serious incidents [of sexual abuse] associated with the patient population treated at Timberlawn is within industry norm.” [Emphasis added] There are no “acceptable levels” of sexual abuse in any mental health facility, CCHR asserted.
In a response to CCHR dated 27 November 2017, CMS stated, “During a recent survey, this hospital was found out of compliance with Medicare requirements and enforcement action was initiated.” However, two years ago, Texas threatened to shut down Timberlawn over severe safety problems that investigators said put patients in jeopardy. Instead, the state decided to let the Dallas hospital stay open but to “monitor” it more closely. Yet on the state’s watch, Timberlawn has had many of the same problems—and at least one new one, according to interviews and inspection records obtained by The Dallas Morning News.
“We’re monitoring the Timberlawn situation very closely,” Carrie Williams, spokeswoman for the Texas Health and Human Services Commission told the Dallas Morning News, the latter adding: “If Timberlawn does not make enough improvements, it could again lose federal funding—and possibly be shut down.”
CCHR says such statements are false assurances that are wearing thin. It suspects a conflict of interest in allowing Timberlawn to remain open at the expense of patient safety and lives.
Other allegations The News reported:
- Timberlawn placed boys and girls in bedrooms near one another. Experts say this poses a problem when combined with poor staffing; inspectors cited this in their report about the alleged rape in October.
- Inspectors found a 10-year-old patient went to another hospital with a head injury after two teenage girls assaulted her. The attack happened at a time when Timberlawn had only one mental health aide to oversee 14 patients on a unit.
- Falsifying records: The night of an alleged assault on a 13-year-old girl by a 17-year-old male patient, Timberlawn had put 16 adolescents under the watch of just one mental health aide. The aide on duty that night falsified paperwork to make it look like the 13-year-old and 17-year-old were in common areas at the time of the alleged assault, staffers told inspectors. Video evidence showed that the teens were not there; Timberlawn fired the aide, according to inspection paperwork.
- Inspectors saw no evidence that nurses gave any care to the 13-year-old after she reported the assault. The report notes that the girl was sent later that evening to an emergency room, where she reported abdominal and pelvic pain and got a rape exam.
- One 27-year-old woman said a male patient pressed his erect penis up against her in the lunch line and later made a choking gesture while staring at her. She reported the man to Timberlawn staff. But she said employees would not remove him from the unit, where both she and the man slept—with bedroom doors unlocked. The woman later called 911, police records show.
- A second woman told police the man sat down next to her and began masturbating. She said she, too, reported the incident to Timberlawn staff. “I feel unsafe with him here,” that woman told police.
- Yet another woman reported the man to police. She said he had grabbed her butt and pulled out his erect penis, but the police report says Timberlawn staff could not find video evidence to confirm her allegations. Police cited the man for misdemeanor assaults. Court records show he was later found incompetent to stand trial for separate charges and is in custody at a state hospital.
Anyone who has been abused in a UHS behavioral facility or other for-profit psychiatric facility or has witnessed this, such as nurses or other staff, please report this to CCHR International. Call 1-800-869-2247 or click here to file a report online.
 Sarah Mervosh, Sue Ambrose, “’Immediate jeopardy’: How safe are kids at state-monitored Timberlawn psych hospital?,” The Dallas Morning News, 10 Dec. 2017, https://www.dallasnews.com/news/investigations/2017/10/26/timberlawn-history-sexual-assault-reports-13-year-olds-case-surfaced.
 “Dallas’ Timberlawn psychiatric hospital has run out of second chances,” Dallas Morning News, 24 Oct. 2017, https://www.dallasnews.com/opinion/editorials/2017/10/24/dallas-timberlawn-psychiatric-hospital-run-second-chances 4/.
 Op. Cit., Sarah Mervosh, Sue Ambrose, Dallas Morning News.
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