CoxHealth terminated six employees and overhauled its policies for psychiatric patients after a suicide at Cox North in December.

An inspection, triggered when CoxHealth self-reported the suicide to the state, found that employees falsified paperwork about how often they checked on the safety of psychiatric patients.

Anthony Gillham, 34, who was described as homeless in state reports, hanged himself in a 50-minute period on Dec. 5 when staff at the Adult Psychiatry I unit failed to monitor him as required, according to a report from the state Department of Health and Senior Services. The report said employees filled out paperwork indicating that they had checked on him every 15 minutes, but video showed the man hadn’t been checked on from 4:20 p.m. to about 5:10 p.m., when the man’s roommate discovered him and began screaming.

The inspection, done after the state Department of Health and Senior Services was notified Dec. 7, found that the problems at Cox North “created an unsafe psychiatric patient care environment.” The inspection, which began Dec. 9, found that the hospital was out of compliance with federal requirements to receive payments from Medicare and Medicaid. That means the hospital was at risk of losing these payments.

Jacqueline Lapine, the spokeswoman for the state Department of Health and Senior Services, said the hospital took immediate action to correct the problem. When the agency left on Dec. 15, the safety of psychiatric patients was no longer considered to be in immediate jeopardy, Lapine said.

Lapine said Cox had 90 days to fix the problems that could have affected payments from Medicare and Medicaid. The agency returned to survey the hospital and found conditions acceptable.

Laurie Duff, the vice president of corporate communications for CoxHealth, said the company “is committed to providing patients with the best and safest possible care.”

Gillham’s death is the only suicide that has happened at the psychiatric facility. The hospital has four inpatient units for psychiatric patients – two adult, one senior adult, and one child/adolescent. The first unit opened in the 1980s.

Nationwide, there were 67 suicides at hospitals last year, according to The Joint Commission which accredits hospitals. Two suicides were reported at hospitals in Missouri last year.

“We are greatly saddened by this tragic event and offer our deepest sympathies to the patient’s family,” Duff said in a statement. “Due to privacy laws and pending litigation, we are unable to discuss the details of the situation. However, we can say that we have taken this situation very seriously. Immediately following the incident, we conducted a thorough investigation and put in place extensive additional measures to ensure the safety of the patients on the unit. We also self-reported the incident to the Department of Health and Human Services and cooperated fully with its investigation. We submitted our plan of correction to DHHS, which was approved, and all items outlined in our plan have been implemented.”

The News-Leader was unable to find any civil lawsuits connected to the death in online records or at the Greene County Clerk’s Office. However, sometimes litigation can be signaled with a notice to a party without a public docket being started.

Changes outlined in the correction plan include requiring psychiatric patients to remain in view of hospital staff during waking hours, hiring more employees to help monitor the patients, and checking patients at 12- to 18-minute intervals. That is designed to limit patients’ ability to predict when they will be checked.

The hospital also removed potentially unsafe objects from patient rooms such as heavy shower curtains and updated a policy for resuscitating patients.

The hospital told state regulators that six staff members were put on administrative leave and terminated in January “for improper documentation and/or inadequate supervision.” Staff members were not identified by name, but they included a charge nurse and a unit manager. An assistant unit manager “was counseled and placed on an action plan to address deficiencies in supervising,” according to the plan of correction CoxHealth gave the state.

Fifty-two patients were at the Cox North psychiatric units about the time Gillham died. The facility is licensed for 72 psychiatric beds. The psychiatric ward provides treatment for people with mental disorders, including patients who are suicidal.

The News-Leader obtained the details of the suicide at CoxNorth after a records request to the state seeking its most recent inspection reports for the CoxHealth system. Other details from the state’s findings, called a “summary statement of deficiencies,” include:

» Gillham, who was unemployed and estranged from his family, had been living in a homeless shelter and had previously attempted suicide. He was released from another psychiatric facility about a day and a half before coming to the emergency room complaining about auditory hallucinations and thoughts of harming himself. He was admitted to the psychiatric unit for recurrent major depression.

» On Dec. 5, Gillham talked about plans for Christmas and was looking forward to positive things, according to a review of medical records mentioned in the agency’s report. Paperwork said that staff at Cox North had checked on him at 4 p.m., 4:15 p.m., 4:30 p.m. and 4:45 p.m. and indicated that he was behaving appropriately. But video showed that staff didn’t check on Gillham after 4:20 p.m. At 4:23 p.m., he was seen on video sticking his head out of the room and looking into the hallway. At 4:24 p.m., the door to the room closed. At 5:10 p.m., Gillham’s roommate found him with a sheet tied around his neck and looped over the door.

» Employees told an investigator that they would at times — the report didn’t note how often — write that they had done safety checks on psychiatric patients even though those checks hadn’t been performed.

» After Gillham was discovered, an employee called for help in trying to resuscitate him, but didn’t use the switchboard, meaning emergency room staff weren’t notified. The call was limited to the intercom for psychiatric units only. Advanced life support efforts didn’t start until Gillham was taken to the emergency room at Cox North.

» The investigation also found that the psychiatric facility was short-staffed on the day Gillham died with only one psychiatric technician responsible for 13 patients in the section that Gillham was in. On Dec. 5 one of the psychiatric technicians assigned to cover the 3 to 11 p.m. shift called in sick, leaving only two technicians assigned to the adult halls.

The staffing guidelines called for the charge nurse to ensure sufficient staffing, but the hospital told the state that the employee failed to secure additional staffing or ask for help in getting additional staffing.

URL: http://www.news-leader.com/article/20110513/NEWS01/105130329/1007/?odyssey=nav|head

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Last October it was a Napa State hospital staff member who was murdered by a patient. Last week, it was a patient who died. His name was William Roebling. He had attacked a fellow patient but as staff members tried to subdue him, Roebling stopped breathing. The coroner’s preliminary report says that he died of natural causes, including coronary disease — not because of the staff intervention.

“I can only imagine how the staff that works there feels,” says state Sen. Noreen Evans, who represents the Napa area. “They’re not only frustrated, they are scared.”

After Roebling’s death, she and another lawmaker wrote to Gov. Jerry Brown demanding that something be done about the dangerous conditions at Napa State Hospital.

“I was willing to give the new administration some opportunity to try to address the problems,” Evans says. “But that hasn’t happened. And now we’ve seen the second death, in the meantime, we’ve had a number of attacks on staff and patient-on-patient attacks. It’s just not acceptable.”

But it will take some time to fix says Dianna Dooley, California’s secretary of Health and Human Services.

“The conditions didn’t occur overnight and they’re not going to be resolved overnight,” Dooley says.

It’s taken years, she says for Napa’s patient population to change to the point where now more than 80 percent of them are committed through the criminal justice system. They’re not guilty by reason of insanity or incompetent to stand trial, for example. And the hospital just wasn’t designed to handle such patients. So late last week Dooley lifted a hiring freeze to add more clinical and security staff.

“It is a small down payment but I hope it illustrates that I am committed to working with all of the stakeholders to see that we create a save environment for the staff as well as the patients,” Dooley says.

She also met face to face with those stakeholders — including representatives from the Napa staff like Brad Leggs, a psychiatric technician and union representative. He says there was a fair amount of consensus on making changes that the staff has wanted for a long time.

“Having a decent alarm system in place, having good staffing ratios and probably the creation of a unit that would house some of the individuals who are a little bit more difficult to handle,” Leggs says.

One of those “difficult to handle individuals” is accused of murdering a Napa staffer last fall. Last week, California’s Occupational Safety and Health agency cited the hospital’s failure to deal with that patient and other safety defects as violations of state labor law. The agency fined Napa $100,000 and gave the hospital just a few weeks to fix the problems.

But Cliff Allenby, acting director of the department of mental health says those citations will be appealed “because we believe they’re not appropriate and they’re not right.

Though Allenby wouldn’t say what was wrong with them. But he cautioned that the appeal shouldn’t be mistaken for a lack of commitment to improve safety at the hospital.

“We need to have protection for our employees and for the other folks that are in our system,” Allenby adds.

But that’s mostly still in the planning stages — just like it was before there was a second death at Napa State Hospital.

URL: http://www.npr.org/2011/04/18/135443369/hiring-may-ease-violence-at-calif-mental-hospital

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NAPA, Calif — A six-month Cal-OSHA investigation triggered by the murder of a psychiatric technician has found several safety inadequacies at the troubled Napa State Hospital and levied more than $100,000 in fines, according to documents released to KTVU Wednesday.

The state agency found the violations while investigating the circumstances behind the murder of Donna Gross at the hospital last October.

Cal-OSHA said it found a “lack of adequate employee alarm systems on the units, non-existent alarm systems in the STA outside of the units, inadequate police presence in the event of assaults, no enforcement of written policies …by the employer, and an ineffective Injury and Illness Prevention program.”

The hospital was ordered to correct specific violations, by either April 25 or May 15, depending on the type of violation.

The hospital can appeal the fine, but must correct the violations, state officials said.

Meanwhile two California lawmakers were decrying safety conditions at state-run mental hospitals and calling on the governor to push for immediate improvements.

State Sen. Noreen Evans and Assemblyman Michael Allen in a letter Tuesday called the level of violence at Napa State Hospital and others “unacceptable.”

On Monday night, a hospital patient died when he was subdued after he allegedly attacked his roommate, a Napa County sheriff’s captain said.

William Roebling, 47, allegedly attacked another patient in ward T-12 at the hospital just after 5 p.m. Monday, Capt. Tracey Stuart said.

Roebling died when psychiatric technicians intervened in the attack and subdued him, Stuart said.

Roebling was given CPR, but he was pronounced dead at 5:43 p.m., Stuart said. An autopsy is scheduled for today.

The patient who was attacked was not injured, Stuart said.

Roebling was being held in a secure area of the hospital, indicating he was not at the hospital under a civil commitment, Stuart said.

Hospital staff members have renewed calls for increased security at the hospital since Gross’ death in an outdoor courtyard on Oct.23.

Patient Jess Williard Massey, 37, is suspected of strangling Gross and stealing her jewelry, some gum and less than $2. His preliminary hearing is scheduled for May 2 in Napa County Superior Court.

Since the murder, two other Napa State Hospital patients who were charged separately with assaulting hospital employees have been found incompetent to stand trial and were ordered back to mental health hospitals.

URL: http://www.ktvu.com/news/27534002/detail.html
Related story: Patient dies at Napa State Hospital

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ABC7 learned the incident happened on Monday afternoon, between 5 and 6 p.m. in a high security section, surrounded by fencing and razor wire. It is an area where people found incompetent to stand trial are housed.

According to the sheriff’s department, 47-year-old William Roebling was subdued after he allegedly attacked another patient. The staff performed CPR, but Roebling died at the hospital and now staff members are worried what other patients might do.

“There’s some individuals, some of the patients, who are now threatening other staff because one of the patients died. And patients and staff are both really worried. They’re scared. They’re scared that something else is going to happen,” said Kathleen Thomas-Morris, a SEIU steward.
Tuesday St. Sen. Noreen Evans and Assm. Michael Allen sent a letter to the governor saying “Quite simply, this ongoing situation in our state hospitals is unacceptable — and deadly. More than 80 percent of those being treated at state hospitals arrive… through the criminal justice system. It is time we have laws, regulations, and on-site practices employed that reflect this new reality.”

Earlier this year employees held several protests demanding more peace officers, a campus-wide alert system and more staffing. That followed the killing six months ago of a psychiatric technician who was attacked by a patient, another patient attacked a therapist in December, and now this incident on Monday.

It’s unclear how the patient died. An autopsy is scheduled for Wednesday.

ABC7 attempted to reach the hospital for comment and were told to call back in the morning.

URL: http://abclocal.go.com/kgo/story?section=news/local/north_bay&id=8069772

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A Kansas City psychiatric hospital with a history of patient-care problems failed to adequately monitor a suicidal patient, federal records show, and then bungled attempts to resuscitate her after she strangled herself with a strap.

Now the hospital faces federal sanctions.

The March 12 suicide is at least the second at Two Rivers Psychiatric Hospital since 2008.

Federal officials plan to drop Two Rivers from the Medicare program on Monday unless the hospital has adequate suicide precautions in place.

The 105-bed hospital at 5121 Raytown Road also faces a June 2 deadline to demonstrate to Medicare that it has taken care of several other serious problems, including keeping patients who’ve committed sex offenses away from other patients.

Termination means the government Medicare and Medicaid programs would no longer pay Two Rivers to care for patients. The measure is considered a last resort when medical facilities fail to meet critical standards.

“Two Rivers disputes any contention that there is an immediate jeopardy to patient safety,” Kevin Young, the hospital’s CEO, said Friday in a written statement.

“The hospital continues to participate in the Medicare program and is working diligently with (Medicare) and the Missouri Department of Health and Senior Services to demonstrate that the hospital is in compliance with the Medicare rules,” Young said. “We have instituted significant improvements and enhancements in patient care and safety.”

Medicare officials said Friday that they were awaiting the results of a recent inspection to see whether Two Rivers had improved its suicide precautions.

If Medicare and Medicaid are terminated, the programs will continue to pay Two Rivers for 30 days for patients already in the hospital, but not for new admissions. Provisions have been made to transfer Two Rivers patients to other hospitals, officials said.

Two Rivers is one of just a handful of in-patient psychiatric facilities in the area, and beds for people in crisis are in short supply, said Susan Crain Lewis, president of the advocacy group Mental Health America of the Heartland.

“Our community cannot afford to lose 105 beds,” Lewis said. “But individuals in our community who are struggling with a mental health issue can’t afford substandard treatment.”

Repeated problems

Two River opened about 25 years ago. For the past three years, the for-profit hospital has had repeated run-ins with Medicare.

“We have had intermittent issues with other psychiatric hospitals, but we don’t see them happen over and over,” said Jeri Jackson, an expert on psychiatric hospitals with the Kansas City office of the Centers for Medicare and Medicaid Services.

Two Rivers has faced Medicare decertification several times before, but has been able to correct problems to the satisfaction of federal officials.

Medicare began identifying chronic problems in May 2008, when a complaint about Two Rivers led to a visit by inspectors. They turned up an abuse case in which a staff member poured water over a patient’s head and another in which a nurse put a towel over an elderly patient’s mouth to stop the patient from screaming, according to inspection reports.

Another visit about six weeks later uncovered cases in which bed alarms had failed. One patient found on the floor at 3:12 a.m. had suffered a broken hip and shoulder, according to the Medicare reports.

Treatment plans showed that staff had failed to include suicide precautions for a patient who had thoughts of suicide, or physical therapy for a patient who had recent hip surgery.

In September 2008, an Army soldier committed suicide at the hospital by using bed linens to hang himself in a closet.

The soldier had been experiencing post-traumatic stress disorder and had attempted suicide before. That death triggered another investigation.

After the suicide, Medicare threatened to withhold money from Two Rivers. But the program agreed to continue paying if the hospital improved and an outside expert monitored its progress.

Early in 2009, inspectors examined medical records at Two Rivers and found little evidence that patients were receiving psychotherapy or medical treatment other than medications. In September 2010, the hospital refused the emergency admission of a teenager who had threatened to kill someone. Federal law requires hospitals to see emergency patients.

The teen’s caseworker already had signed admission paperwork at Two Rivers before the police van arrived with the patient. Three officers were needed to restrain the teen, who was placed in shackles.

Instead of admitting the youth, a staff member told the officers to take the teen to detention. The teen was admitted to another psychiatric hospital.

Recent suicide

The case that triggered the current threat of Medicare termination occurred a month ago.

The 59-year-old woman who took her own life had a history of depression, hallucinations, paranoid delusions and thoughts of suicide. She was transferred to Two Rivers from a nursing home on March 9 after she had asked her ex-husband to leave her in the woods to die. Two Rivers immediately placed her under suicide precautions.

Two days later, the patient became very agitated at the hospital, hitting the bathroom walls.

Two Rivers staff were supposed to check on her every 15 minutes. But surveillance videos showed that the patient went for 20 to 31 minutes without anyone looking in on her after midnight.

Hospital staff told inspectors that when they checked on the patient, her blanket was pulled up to her neck. She appeared to be sleeping.

The first sign something was wrong came shortly after 5 a.m. when the patient didn’t respond when asked to raise her arm for a blood pressure check. The surveillance video showed the staff member walking “casually” to the nurse’s station.

Two nurses went to the patient’s room. One started CPR while the other struggled to bring resuscitation equipment.

More nurses arrived at the patient’s room. They found the first nurse doing chest compressions on the patient. The second nurse stood by, nudging the patient’s feet and saying “wake up, wake up.”

Only as staff tried to give the patient oxygen did a nurse discover the two things around the patient’s neck that she had used to strangle herself. One was the black nylon strap of a wrist support. The other suicide device was a bright green stretchable ring toy used to provide sensory stimulation.

By this time, the patient’s face was mottled purple and gray from lack of oxygen. An automated external defibrillator was brought out to shock the patient’s heart to a steady beat. But it was too late.

URL:http://www.kansascity.com/2011/04/08/2787552/after-suicides-two-rivers-hospital.html

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