Federal investigation finds state psychiatric hospital responsible for patient's starvation death

December 13, 2012

When Brandy Bell was committed to Rusk State Hospital on May 14, there was little doubt she was a complicated patient with a long history of psychiatric problems. But one of her current struggles was painfully obvious.

“She was starving herself,” said Bell’s mother, Rita. “She wanted to die.”

During the Conroe woman’s 16 days at the state hospital, Bell virtually stopped eating. She lost 9 pounds in nine days, according to her medical records, grew dehydrated and lost strength. She began using a wheelchair.

On May 30, she died. She was 33.

Officially, Bell’s autopsy said she died from blood clots in her lungs. But a subsequent examination of her case by a federal Medicare investigator also concluded the hospital made crucial mistakes by neglecting Bell’s self-starvation and providing substandard nursing care.

Bell’s case is one of three cases involving state hospital patients with eating disorders being investigated by Disability Rights Texas, a federally funded protection and advocacy group. The other two patients — one is in Austin State Hospital, the other in Big Spring — are still alive.

For clinicians, eating disorders can further complicate treatment of patients who already have serious psychiatric problems. Experts say the circumstances surrounding Bell’s death while in state care pose a host of medical and legal questions on how best to monitor and treat patients who endanger themselves by refusing to eat — and when to force-feed them, if necessary.

“The question is whether or not the patient was engaging in behavior that was posing a significant risk to his life,” said Floyd Jennings, a clinical psychologist and attorney who advises the Harris County Public Defender’s Office. He stressed that while he had no direct knowledge of Bell’s case, “clinicians have a duty to begin intervening before it becomes a matter of life and death.”

The are currently 85 patients with diagnosed eating disorders at the state psychiatric hospitals, said Carrie Williams, spokeswoman for the Department of State Health Services, which oversees the facilities. That doesn’t include people without such diagnoses who temporarily refuse food for other reasons, such as paranoia.

The state psychiatric hospitals have no set protocol for treating patients with eating problems, Williams said. People whose primary illness is an eating disorder generally aren’t admitted to state psychiatric hospitals. But when they are, she said, treatment is determined on a case-by-case basis and might include extra attention to a patient’s physical condition, food intake and hydration.

According to medical records obtained by the Statesman, that never happened with Bell — even though Rusk State Hospital staffers knew from the start that she had struggled with eating problems.

Bell “was a known patient at Rusk with an identified eating disorder,” said Robin Thorner, a Disability Rights attorney. “Her death raises many questions about how the state hospitals identify and treat patients with eating disorders. It remains to be seen whether staff have sufficient expertise to provide quality care to patients with a co-occurring eating disorder.”

Williams said quality treatment is a priority at all the hospitals.

“The goal is to meet the needs of every single one of our patients and provide good, quality care,” she said. “We’re constantly evaluating how we’re doing. There is always room for improvement, and we learn from our experiences.”

Rusk State Hospital has figured in previous reporting by the Statesman this year. In February, a psychiatrist who had been sanctioned for having sexual relationships with his patients resigned after the hospital began disciplinary action against him because he appeared to be under the influence of drugs or alcohol at work. He was one of two psychiatrists at Rusk with a history of sexual misconduct, the Statesman reported.

And in April the state opened an investigation into the case of a patient at Rusk who overdosed on illicit drugs at the facility. Records showed the patient claimed he obtained the drugs from a hospital employee.

‘She was sick’

According to her mother, Bell had struggled in the weeks before her admission to Rusk State Hospital. Embroiled in a Child Protective Services case involving her three young children, she refused to take her psychiatric medicine. At one point, she tried to jump out of a moving vehicle.

Already diagnosed with schizophrenia, bipolar and borderline personality disorders, Bell had been admitted to Rusk State Hospital two other times, Rita Bell said. By May, Brandy Bell was living at her parents’ home, refusing to eat and lying on the couch all day.

“She couldn’t help it,” Rita Bell said. “She was sick.” After several days in a local mental health center, Brandy Bell was committed by a court to Rusk State Hospital, a 335-bed inpatient facility about 130 miles southeast of Dallas.

Texas’s 10 state-run psychiatric hospitals provide medication and treatment programs for people with profound mental illnesses. About 2,500 patients reside in those hospitals at any day, and 14,400 people are admitted each year. The facilities provide routine medical care, such as basic physicals and monitoring of stable patients with disorders such as high blood pressure or diabetes, Williams said.

She added that, for those with serious eating issues, doctors might order diagnostic tests, consultations with dietitians and regular assessments of nutritional status by registered nurses. Patients may be placed on special precautions, with increased monitoring of weight, food and fluid intake.

A May 15 chart entry observed that Bell hadn’t been eating much in the three weeks preceding her admission and that she had once been diagnosed with bulimia. A nutritional assessment two days later noted that she had an “eating disorder” but offered no specific diagnosis, such as bulimia or anorexia.

Complicating Bell’s food history was that at 5’4” and 151 pounds, she was borderline obese, Rusk records said. A nutritional assessment in her chart noted that she had been counseled on “the importance of a healthy diet, limiting sugar and making healthy food choices.” She was also encouraged to exercise regularly.

In the early days of her admission, Bell was monitored closely to ensure she didn’t hurt herself, the documents show. After she showed no signs of obvious self-abuse, she was placed on routine supervision. When Bell continued to reject medication, staffers got a court order requiring her to take the drugs.

Food was another matter. More than a dozen entries in Bell’s records document her self-starvation, noting that she “has not eaten in days,” was “refusing most meals,” and “refused to eat lunch.”

It is not uncommon for psychiatric patients to refuse food in the hospital — and not easy to decide when to intervene, said Dr. Susan Stone, a Bastrop County psychiatrist and lawyer. Some medications are appetite suppressants. Rejecting food can also be related to paranoia or other conditions.

Whether seeking legal permission to force nutrition or medication on a patient, the grounds are similar, Jennings said: “It is subjective, but would be tested by reasonableness and evidence. For example, even if a person hadn’t been eating for a while, had he been drinking? Do blood tests show an electrolyte imbalance that puts his health at risk?”

If so, the treating physician can ask a judge to order feeding, which at Rusk would require transfer to another medical facility for tube feeding.

But her medical records indicate that was never done, even as Bell kept refusing to eat, and her condition continued to deteriorate. One chart entry states that she appeared depressed, wouldn’t participate in activities and often refused to speak.

“She is spending most of her time on the ward just sitting and staring with little to no interaction with her peers,” her social worker wrote.

‘Unresponsive’

One week before Bell’s death, a psychiatrist wrote in her medical chart that she had lost 9 pounds in nine days. The doctor suggested giving her liquids with electrolytes, such as Pedialyte or Gatorade.

“Otherwise, the role of non-psychiatric health care intervention is very limited at this time,” he wrote. “Ms. Bell’s refusal to eat, like her refusal to speak, appears to be psychogenic in origin, exactly why she was admitted to (Rusk State Hospital) in the first place.”

Bell had become paranoid, suspicious and depressed, records state. One day, she pulled off all her clothes and sat on a dayroom couch. On May 26, after nine days without a shower, staffers convinced her to bathe.

“Staff reported that she was in tears the whole time she showered and would not tell her what was wrong or talk to her,” medical document note.

By May 29, Bell was very pale and had thrown up twice that morning, her medical records show. That day, a nurse wrote in Bell’s medical records “Med clinic referral put in for c/o sore throat and not eating for days.”

“The night before she died, they tried to give her two cans of Ensure,” recalled Lea Miller, a fellow patient in Bell’s unit who has since been discharged. “She took one can and gave it away. The other can, she drank about half of it and poured the rest down the drain.”

Shortly after 6 a.m. on May 30, a nurse found Bell asleep on a dayroom couch and told her that she needed to have some blood drawn. Bell walked to the lab room, but was unsteady on her feet, records state.

“She sat in the chair and I turned to get the supplies,” the nurse wrote. “When I turned back to Brandy, she was slumped over forward and I thought she was doing something with her shoe. I asked her to sit up for me and she did not move. I touched her to help her sit up and realized she was unresponsive.”

Bell was revived and taken to East Texas Medical Center, where she was diagnosed with dehydration, low potassium and low blood pressure. “While at the emergency room, the decedent requested to use the restroom and during transfer to the restroom she became acutely unresponsive,” states the autopsy report by Forensic Medical Management Services of Texas.

Bell was declared dead at 10:52 a.m. A Rusk staffer called Rita Bell to give her the news.

“I just started slamming my hand on the table and screaming,” Rita Bell said.

The official cause of death was bilateral pulmonary emboli — blood clots — which can be caused by prolonged immobilization or bed rest. But the autopsy also found that Brandy Bell had starvation ketosis, a condition in which the body burns fat instead of carbohydrates and can lead to coma, seizures or death.

In August, an investigator with the Centers for Medicare and Medicaid Services — which funds treatment for some state hospital patients — made an unannounced visit to Rusk in response to a complaint about the circumstances surrounding Bell’s death. While the investigator didn’t single out any one staffer, she determined that that Rusk had given Bell substandard nursing care by failing to document everything she ate and drank, failing to regularly monitor her weight and failing to assess her care needs and medical status.

Rusk’s quality director, whose job is to improve patient care, responded by saying that the hospital’s “focus was on the psychiatric issues and not the possibility of medical issues,” according the report. She told the investigator that “the patient’s weight was slightly over the weight range for her age and height and that there were no visible signs that the patient was not eating or drinking.”

The federal inspector didn’t fine or penalize the hospital for its failings. In response to the report, Rusk State Hospital said it would make sure registered nurses “evaluate patient care needs, patient health status and patient response to interventions.” It also agreed to develop patient documentation requirements for its nurses, train nurses on how to deal with changes in patients’ eating habits and regularly sample its medical records to ensure proper documentation.

That’s small consolation to Rita Bell, whose grandchildren are now living with relatives. “She should have been in the hospital, and she should have been treated with IVs,” she said.

The family wanted to bury Brandy Bell in a nice coffin, but they couldn’t afford it, Rita Bell said. So they had her cremated, wrapped the plastic box in black velvet, decorated it with a silver bow and buried it.

Now her family is trying to make sense of why she died. “We don’t know what happened,” Rita Bell said. “She went there for help.”

 Saturday, Dec. 1, 2012

STATESMAN INVESTIGATES: State Hospital Care
Federal investigation says state hospital failed in care of patient who died


By Andrea Ball and Eric Dexheimer

American-Statesman Staff

When Brandy Bell was committed to Rusk State Hospital on May 14, there was little doubt she was a complicated patient with a long history of psychiatric problems. But one of her current struggles was painfully obvious.

“She was starving herself,” said Bell’s mother, Rita. “She wanted to die.”

During the Conroe woman’s 16 days at the state hospital, Bell virtually stopped eating. She lost 9 pounds in nine days, according to her medical records, grew dehydrated and lost strength. She began using a wheelchair.

On May 30, she died. She was 33.

Officially, Bell’s autopsy said she died from blood clots in her lungs. But a subsequent examination of her case by a federal Medicare investigator also concluded the hospital made crucial mistakes by neglecting Bell’s self-starvation and providing substandard nursing care.

Bell’s case is one of three cases involving state hospital patients with eating disorders being investigated by Disability Rights Texas, a federally funded protection and advocacy group. The other two patients — one is in Austin State Hospital, the other in Big Spring — are still alive.

For clinicians, eating disorders can further complicate treatment of patients who already have serious psychiatric problems. Experts say the circumstances surrounding Bell’s death while in state care pose a host of medical and legal questions on how best to monitor and treat patients who endanger themselves by refusing to eat — and when to force-feed them, if necessary.

“The question is whether or not the patient was engaging in behavior that was posing a significant risk to his life,” said Floyd Jennings, a clinical psychologist and attorney who advises the Harris County Public Defender’s Office. He stressed that while he had no direct knowledge of Bell’s case, “clinicians have a duty to begin intervening before it becomes a matter of life and death.”

The are currently 85 patients with diagnosed eating disorders at the state psychiatric hospitals, said Carrie Williams, spokeswoman for the Department of State Health Services, which oversees the facilities. That doesn’t include people without such diagnoses who temporarily refuse food for other reasons, such as paranoia.

The state psychiatric hospitals have no set protocol for treating patients with eating problems, Williams said. People whose primary illness is an eating disorder generally aren’t admitted to state psychiatric hospitals. But when they are, she said, treatment is determined on a case-by-case basis and might include extra attention to a patient’s physical condition, food intake and hydration.

According to medical records obtained by the Statesman, that never happened with Bell — even though Rusk State Hospital staffers knew from the start that she had struggled with eating problems.

Bell “was a known patient at Rusk with an identified eating disorder,” said Robin Thorner, a Disability Rights attorney. “Her death raises many questions about how the state hospitals identify and treat patients with eating disorders. It remains to be seen whether staff have sufficient expertise to provide quality care to patients with a co-occurring eating disorder.”

Williams said quality treatment is a priority at all the hospitals.

“The goal is to meet the needs of every single one of our patients and provide good, quality care,” she said. “We’re constantly evaluating how we’re doing. There is always room for improvement, and we learn from our experiences.”

Rusk State Hospital has figured in previous reporting by the Statesman this year. In February, a psychiatrist who had been sanctioned for having sexual relationships with his patients resigned after the hospital began disciplinary action against him because he appeared to be under the influence of drugs or alcohol at work. He was one of two psychiatrists at Rusk with a history of sexual misconduct, the Statesman reported.

And in April the state opened an investigation into the case of a patient at Rusk who overdosed on illicit drugs at the facility. Records showed the patient claimed he obtained the drugs from a hospital employee.

‘She was sick’

According to her mother, Bell had struggled in the weeks before her admission to Rusk State Hospital. Embroiled in a Child Protective Services case involving her three young children, she refused to take her psychiatric medicine. At one point, she tried to jump out of a moving vehicle.

Already diagnosed with schizophrenia, bipolar and borderline personality disorders, Bell had been admitted to Rusk State Hospital two other times, Rita Bell said. By May, Brandy Bell was living at her parents’ home, refusing to eat and lying on the couch all day.

“She couldn’t help it,” Rita Bell said. “She was sick.” After several days in a local mental health center, Brandy Bell was committed by a court to Rusk State Hospital, a 335-bed inpatient facility about 130 miles southeast of Dallas.

Texas’s 10 state-run psychiatric hospitals provide medication and treatment programs for people with profound mental illnesses. About 2,500 patients reside in those hospitals at any day, and 14,400 people are admitted each year. The facilities provide routine medical care, such as basic physicals and monitoring of stable patients with disorders such as high blood pressure or diabetes, Williams said.

She added that, for those with serious eating issues, doctors might order diagnostic tests, consultations with dietitians and regular assessments of nutritional status by registered nurses. Patients may be placed on special precautions, with increased monitoring of weight, food and fluid intake.

A May 15 chart entry observed that Bell hadn’t been eating much in the three weeks preceding her admission and that she had once been diagnosed with bulimia. A nutritional assessment two days later noted that she had an “eating disorder” but offered no specific diagnosis, such as bulimia or anorexia.

Complicating Bell’s food history was that at 5’4” and 151 pounds, she was borderline obese, Rusk records said. A nutritional assessment in her chart noted that she had been counseled on “the importance of a healthy diet, limiting sugar and making healthy food choices.” She was also encouraged to exercise regularly.

In the early days of her admission, Bell was monitored closely to ensure she didn’t hurt herself, the documents show. After she showed no signs of obvious self-abuse, she was placed on routine supervision. When Bell continued to reject medication, staffers got a court order requiring her to take the drugs.

Food was another matter. More than a dozen entries in Bell’s records document her self-starvation, noting that she “has not eaten in days,” was “refusing most meals,” and “refused to eat lunch.”

It is not uncommon for psychiatric patients to refuse food in the hospital — and not easy to decide when to intervene, said Dr. Susan Stone, a Bastrop County psychiatrist and lawyer. Some medications are appetite suppressants. Rejecting food can also be related to paranoia or other conditions.

Whether seeking legal permission to force nutrition or medication on a patient, the grounds are similar, Jennings said: “It is subjective, but would be tested by reasonableness and evidence. For example, even if a person hadn’t been eating for a while, had he been drinking? Do blood tests show an electrolyte imbalance that puts his health at risk?”

If so, the treating physician can ask a judge to order feeding, which at Rusk would require transfer to another medical facility for tube feeding.

But her medical records indicate that was never done, even as Bell kept refusing to eat, and her condition continued to deteriorate. One chart entry states that she appeared depressed, wouldn’t participate in activities and often refused to speak.

“She is spending most of her time on the ward just sitting and staring with little to no interaction with her peers,” her social worker wrote.

‘Unresponsive’

One week before Bell’s death, a psychiatrist wrote in her medical chart that she had lost 9 pounds in nine days. The doctor suggested giving her liquids with electrolytes, such as Pedialyte or Gatorade.

“Otherwise, the role of non-psychiatric health care intervention is very limited at this time,” he wrote. “Ms. Bell’s refusal to eat, like her refusal to speak, appears to be psychogenic in origin, exactly why she was admitted to (Rusk State Hospital) in the first place.”

Bell had become paranoid, suspicious and depressed, records state. One day, she pulled off all her clothes and sat on a dayroom couch. On May 26, after nine days without a shower, staffers convinced her to bathe.

“Staff reported that she was in tears the whole time she showered and would not tell her what was wrong or talk to her,” medical document note.

By May 29, Bell was very pale and had thrown up twice that morning, her medical records show. That day, a nurse wrote in Bell’s medical records “Med clinic referral put in for c/o sore throat and not eating for days.”

“The night before she died, they tried to give her two cans of Ensure,” recalled Lea Miller, a fellow patient in Bell’s unit who has since been discharged. “She took one can and gave it away. The other can, she drank about half of it and poured the rest down the drain.”

Shortly after 6 a.m. on May 30, a nurse found Bell asleep on a dayroom couch and told her that she needed to have some blood drawn. Bell walked to the lab room, but was unsteady on her feet, records state.

“She sat in the chair and I turned to get the supplies,” the nurse wrote. “When I turned back to Brandy, she was slumped over forward and I thought she was doing something with her shoe. I asked her to sit up for me and she did not move. I touched her to help her sit up and realized she was unresponsive.”

Bell was revived and taken to East Texas Medical Center, where she was diagnosed with dehydration, low potassium and low blood pressure. “While at the emergency room, the decedent requested to use the restroom and during transfer to the restroom she became acutely unresponsive,” states the autopsy report by Forensic Medical Management Services of Texas.

Bell was declared dead at 10:52 a.m. A Rusk staffer called Rita Bell to give her the news.

“I just started slamming my hand on the table and screaming,” Rita Bell said.

The official cause of death was bilateral pulmonary emboli — blood clots — which can be caused by prolonged immobilization or bed rest. But the autopsy also found that Brandy Bell had starvation ketosis, a condition in which the body burns fat instead of carbohydrates and can lead to coma, seizures or death.

In August, an investigator with the Centers for Medicare and Medicaid Services — which funds treatment for some state hospital patients — made an unannounced visit to Rusk in response to a complaint about the circumstances surrounding Bell’s death. While the investigator didn’t single out any one staffer, she determined that that Rusk had given Bell substandard nursing care by failing to document everything she ate and drank, failing to regularly monitor her weight and failing to assess her care needs and medical status.

Rusk’s quality director, whose job is to improve patient care, responded by saying that the hospital’s “focus was on the psychiatric issues and not the possibility of medical issues,” according the report. She told the investigator that “the patient’s weight was slightly over the weight range for her age and height and that there were no visible signs that the patient was not eating or drinking.”

The federal inspector didn’t fine or penalize the hospital for its failings. In response to the report, Rusk State Hospital said it would make sure registered nurses “evaluate patient care needs, patient health status and patient response to interventions.” It also agreed to develop patient documentation requirements for its nurses, train nurses on how to deal with changes in patients’ eating habits and regularly sample its medical records to ensure proper documentation.

That’s small consolation to Rita Bell, whose grandchildren are now living with relatives. “She should have been in the hospital, and she should have been treated with IVs,” she said.

The family wanted to bury Brandy Bell in a nice coffin, but they couldn’t afford it, Rita Bell said. So they had her cremated, wrapped the plastic box in black velvet, decorated it with a silver bow and buried it.

Now her family is trying to make sense of why she died. “We don’t know what happened,” Rita Bell said. “She went there for help.”

Source: Andrea Ball and Eric Dexheimer, "Federal investigation says state hospital failed in care of patient who died," Austin American-Statesman, Saturday, December 1, 2012