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Federal probe found lapses at psychiatric hospitals

The federal government threatened to stop Medicare payments to three Massachusetts psychiatric hospitals last month, citing safety lapses that caused two mentally ill patients to go without critical medicines for days. One of the patients had a seizure and fell, suffering a traumatic head injury, as a result.

The facilities — Pembroke Hospital, Lowell Treatment Center, and Westwood Lodge — are owned by for-profit Arbour Health System, the largest, and most troubled, mental health care provider in Massachusetts.

The Centers for Medicare and Medicaid Services said conditions found at the hospitals Aug. 28, 29, and 30 “posed an immediate jeopardy to the health and safety of patients,’’ according to a letter dated Sept. 8 to Arbour’s chief executive, Dania O’Connor. “These deficiencies have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care.’’


At the time of the federal inspections, Massachusetts regulators had already closed Westwood Lodge after conducting an earlier investigation, but federal investigators reviewed records there. Westwood Lodge, Pembroke Hospital, and Lowell Treatment Center shared a state license.

Arbour spokeswoman Judy Merel said in an e-mail to the Globe that the company “takes all survey feedback seriously.’’ She said the “majority of issues were in the area of physical environment.’’

Federal inspectors found, for example, that an exposed sprinkler head and toilet handles could be used by patients to strangle themselves — items that Arbour had been cited for previously but failed to fix, according to the inspection report obtained by the Globe under the public records law.

Investigators from the Massachusetts Department of Public Health accompanied Medicare inspectors, and the group also found lapses regarding patients rights, nursing services, and infection control.

After a follow-up inspection on Sept. 21, the federal government lifted its threat to cut off Medicare funding to the hospitals.


The Massachusetts Department of Mental Health permanently closed the 89-bed Westwood Lodge Aug. 25, citing “critical safety issues’’ — just four weeks after clearing it to accept new patients and after promises by O’Connor that the treatment facility had emerged from its troubled past “as a stronger organization.’’

An employee told the Globe the final straw for the state was an allegation that a male patient sexually assaulted a female patient in her room.

When Medicare inspectors reviewed records and videotape of the Westwood incident the week of Aug. 28, they found staff had allowed the alleged perpetrator to wander the halls for 45 minutes after the assault accusation, enabling him to come face to face with the alleged victim. This could lead to “potential intimidation of the alleged victim and psychological trauma,’’ inspectors said in citing the hospital.

The federal government also criticized Lowell Treatment Center for a fight that broke out in the adolescent unit Aug. 26. Patients grabbed ceiling tiles and hit one another, staff, and police officers with them. Two patients said staff were aware that they had removed the tiles in the past.

Inspectors cited nurses and doctors for failing to ensure patients got necessary medications. The patient who suffered the seizure in May had not received a routine anti-seizure medication, Depakote, for days at a time. One month after admission, the patient began to convulse and was taken to the emergency room.

Another patient, who had diabetes, did not receive insulin for 48 hours after admission, putting the patient at risk for life-threatening unstable blood sugar levels. The federal report did not name the hospital at which the medication errors occurred.


After the initial federal inspection, state public health officials notified the state Department of Mental Health, which went into Lowell and Pembroke Aug. 31, to do its own inspections. At the time, it suspended admissions to Lowell Treatment Center, which it allowed to resume Monday.

“DMH Licensing will continue to monitor the situation closely,’’ the agency said Monday in an e-mail from spokeswoman Daniela Trammell.

The recent safety problems at Pembroke, Lowell, and Westwood occurred despite assurances from the mental health department that it has been closely supervising Arbour facilities.

The mental health department has defended its decision to give the Arbour hospitals numerous chances to improve, saying that regulators have been a near-constant presence in the facilities. Between January 2015 and this Aug. 24, the state mental health agency said it inspected the Arbour facilities on 91 occasions. That compares to 116 inspections for the state’s 60 other psychiatric hospitals.

Liz Kowalczyk can be reached at