Outdated patient records blamed for Eleanor Slater Hospital confusion

PROVIDENCE — This is the explanation given state lawmakers for the sudden and seemingly inexplicable surge in the percentage of "psychiatric patients" that has placed the state hospital at risk of losing millions of Medicaid dollars:

Patient records had not been updated for years and, in many cases, since before the turn of the century.

But members of the House Finance Committee on Wednesday night continued to be skeptical about why the number of psychiatric patients on the Zambarano campus in Burrillville shot from 2% to 58% since last May, and from 49% to 79% hospital-wide.

They were told that, for example, a patient admitted with a serious brain injury from a car accident may have arrived as a "medical" patient a decade ago and, over time, developed dementia or some other behavioral problem requiring drugs that place them in the "psychiatric" category.

The state's Medicaid director, Benjamin Shaffer, pushed back.

Clinical staff at Butler Hospital have been asked to conduct an independent review, but "it is my understanding that dementia is not included and should not be included'' as a mental disease, as it has been in the latest count of patients by doctors and administrators at the state hospital, Shaffer said.

"Quite frankly from a regulatory perspective the only opinion that matters is the opinion of the Medicaid agency,'' Shaffer said.

This back-and-forth took place amid allegations that doctors at the state's Eleanor Slater Hospital withheld medications from patients to make them more acceptable candidates for nursing home placements and, in at least one documented case, circulated private medical information about a patient who had unknowingly been targeted for discharge.

Nurse says medicine was manipulated so hospital could meet targets

In written testimony, certified nursing assistant Cynthia Bolduc said she has witnessed doctors "taking patients off of necessary medicines that stabilize their behaviors in order to be able to ship them out to private nursing facilities in the community ... [that] will not accept patients who are on certain kinds of medication."

"Unfortunately, we have recently lost a patient who died after being removed from the medication who then ceased all eating,'' Bolduc wrote. (State officials have not yet responded to questions about her allegations.)

*The Rhode Island Department of Health last week provided The Journal with findings of investigations, including an April 13 finding that the state hospital had released private patient information to a "long-term care" facility without the patient's permission.

Though federal health-care privacy law "allows for patient information to be shared in some circumstances to assist in discharge or transfer to another health facility, [the hospital] has now agreed to ... [obtain] patient or family consent before sharing such information'' in the future, said Randal Edgar, a spokesman for the state agency that runs the hospital.

The stakes: the state has not billed Medicaid for upwards of $60 million in potential payments since August 2019 while state hospital administrators, on their own, raised questions about the makeup of the patient population.

The state won a federal agency's approval to resume billing in March, but has not yet done so amid fresh questions about whether the state hospital is impacted by federal rules ban Medicaid payments to facilities where more than 50% of the patients have mental disease.

"Let's take a step back,'' said Rep. Alex Marszalkowski, deep into the five-hour hearing. "What changed?"

"Their diagnosis affects everything,'' said Jennifer White, chief financial officer of Eleanor Slater Hospital.

"The issue [that] had come up was whether our charts were as robust as they should be. We were looking at discharging [patients] ... so we asked our [doctors and administrators] to look into: is our documentation what it needs to be? Are our patients in the right categories based on their diagnosis codes?"

."What was being kept in the system was their original diagnoses upon admission."

"The folks over at Zambarano shouldn't have had such an uptick, if there [are] no psychiatrists, right, at Zambarano?" said Marszalkowski.

Elaborating, Dr. Brian Daly, the chief medical examiner, said patients who were admitted to the hospital with brain traumas and other significant medical issues continued to be listed as "medical" patients, even though some developed dementia, "which is in the diagnostic and statistical manual of mental disorder, so it is a mental disease."

In his turn, Dr. Andrew Stone, the assistant medical director, said: "Not everyone with dementia has what I would call a behavioral health problem that needs institutionalization ... [or] a locked unit."

But if they have a problem that involves the need for psycho-tropic medications, specifically anti-psychotic medications, he said, that pushes people over to the mental disease category. "That's true of many of the folks at Zambarano."

"States all across the country have Institutes for Mental Disease for people just like Mrs. Smith, who has dementia, but her particular variety of dementia results in assaultive or self-injurious ... behaviors,'' said Stone, citing a hypothetical patient.

The state has asked the federal Centers for Medicare and Medicaid Services for guidance on whether patients with dementia, Alzheimer's, autism or traumatic brain injury have "mental disease" because they receive psychotropic medications to help manage their behavioral issues. In the letter, Shaffer says he does not believe so.

This article originally appeared on The Providence Journal: Outdated patient records blamed for Eleanor Slater Hospital confusion

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