Parkland psych ER is again scene of patient abuse

July 8, 2014

The psychiatric patient spat at Parkland Memorial Hospital staff as they strapped her into a chair. Then a nurse shoved a toilet paper roll into her mouth, while a co-worker put a sheet over her head.

“Blood stains can be seen on the toilet tissue” after its removal, says a police report that describes security camera footage. A follow-up report says a third employee warned the caregivers that their actions were “illegal.”

Texas health authorities are investigating the March incident — the first abuse in Parkland’s psychiatric emergency room to become public since the hospital hired a new chief executive. One nurse involved in the gagging was also involved in the 2011 restraint of a psych ER patient whose death triggered a federal investigation and virtual takeover of Parkland.

State health regulations prohibit restraint that obstructs a psychiatric patient’s airway or ability to communicate. A prior state enforcement action against Parkland requires hospital managers to report patient abuse within two days of becoming aware of it.

Parkland reported the gagging incident more than three weeks after it occurred. The hospital said managers didn’t know about it initially but acted promptly once they did.

“Employees on site did not elevate this incident appropriately,” Parkland spokeswoman April Foran said. The hospital fired two of five employees who were present during the restraint, she said. Two others resigned, and a fifth “received corrective action.”

Parkland, which collects hundreds of millions of dollars a year from Dallas County taxpayers, would not name the employees. But The Dallas Morning News confirmed the identities of two: Charles Enyinna-Okeigbo, the nurse who forced the toilet paper roll into the patient’s mouth, and Sherwin De Guzman, a supervising nurse.

Authorities have previously investigated both nurses: Enyinna-Okeigbo for domestic violence, and De Guzman in connection with the 2011 death of psych ER patient George Cornell. State and federal regulators found that Cornell was illegally restrained shortly before dying. They cited De Guzman for failing to supervise the technicians who subdued Cornell.

Parkland’s in-house police department investigated the March incident and asked the Dallas County district attorney’s office whether assault charges should be filed. A prosecutor said that the use of force was “unfortunate” but not criminal.

Both nurses declined to comment to The News. Enyinna-Okeigbo told police that he was merely trying to stop the spitting and was not angry with the patient, according to Parkland records.

UT Southwestern Medical Center, whose physicians supervise care at the public hospital, identified the psychiatrist in charge as Dr. Uros Zrnic. He “was not informed or aware of the incident until the videotape was reviewed” in April, UTSW said.

Terrified patient

Experts criticized Parkland after reading police reports on the latest incident at The News’ request.

“When a patient spits, it’s the last resort of a terrified human being, and being restrained like this is terrifying,” said Dr. Peter Breggin, a New York psychiatrist and former consultant for the National Institute of Mental Health.

“Trained mental health workers in this day and age know that spitting is a cause for staff to back off,” he said, adding that forcing objects into patients’ mouths can escalate violence. “There’s no excuse for this abuse.”

Dennis Borel, executive director of the Coalition of Texans with Disabilities, said some Parkland psych workers “still don’t get it.”

“This is pretty outrageous when it was just a few years ago that these kinds of actions were supposed to trigger training and other safe approaches at Parkland,” Borel said. “Everything in the patient’s behavior indicates she was desperately trying to protect herself, and they were making it worse. They failed the patient miserably.”

The state health department hit Parkland in 2012 with a $1 million fine because of Cornell’s death and several other “egregious deficiencies.” It was by far the largest hospital fine in Texas history.

Under a settlement, the hospital paid $750,000. It can avoid paying the rest if, by later this summer, it demonstrates compliance with safety requirements.

Because of the gagging incident, regulators are investigating whether there have been more “significant, egregious deficiencies and a failure to correct them or an attempt to hide them,” said health department spokeswoman Carrie Williams. “It’s an open investigation, and there have been no findings in this case so far.”

Parkland also remains under a 2013 corporate integrity agreement with the U.S. Department of Health & Human Services. It requires periodic reports on patient safety, among other steps.

Compliance with that agreement is a top stated priority of Dr. Fred Cerise, Parkland’s new chief executive. He started work about a week after the March gagging incident.

Cerise and other hospital officials declined to be interviewed for this report. In written responses to questions, Parkland said “the event was discovered” on April 8 during a routine review of security video from March 16. Parkland notified the Texas health department within a day, they said, in compliance with state regulations.

Parkland also said that in addition to taking personnel actions, it now requires video reviews of restraints within 24 hours. But it would not say whether it previously had a schedule for reviewing the security videos, or why it took more than three weeks to detect the gagging incident.

Quick investigation

The criminal investigation lasted less than 48 hours before the case was closed as “unfounded,” police reports show. A News investigation last year found that Parkland police have a history of quickly closing cases in which hospital employees are accused of abuse.

The hospital released nine pages of reports on the investigation, blacking out the names of employees and the patient. It released no information about why the patient was in the psych ER or whether she was injured in the restraint incident. There is no indication in the records that police tried to interview the woman.

When asked, the hospital spokeswoman told The News that “Parkland made multiple attempts to locate the patient” but failed.

The reports contain conflicting versions of what led to strapping the patient to the chair.

Enyinna-Okeigbo told police the woman became “extremely agitated” while in a common area of the psych ER. He said he gave her medication to calm down, but it didn’t work. When staff then directed her toward seclusion rooms, she began to “spit, swing, and kick at the staff,” police wrote, summarizing Enyinna-Okeigbo’s account.

A fellow caregiver who was interviewed “does not recall seeing the patient strike or attempt to strike any staff members,” a police report says. This caregiver also said he didn’t recall seeing the toilet paper roll put into the patient’s mouth or any bleeding. He denied covering the patient’s face with the sheet. The police report noted that “video of the incident contradicts this.”

The reports quote another staffer as saying he saw the bleeding and thought the patient had been “struck by a nurse.” He described the scene as “very chaotic” and said employees lacked training for such situations.

The police description of video footage begins as the patient resists efforts to strap her into a restraint chair: “She appeared to be acting aggressively toward to the medical staff, including spitting on multiple occasions in the direction of the staff.”

Five staffers approached the woman, including one who “immediately placed the roll of toilet tissue over the patient’s mouth,” a report says. “The patient began to resist,” leading Enyinna-Okeigbo to “shove the end of the roll into the patient’s mouth, at one point even appearing to force the patient’s jaw open to completely insert the roll.”

Then another employee secured the sheet around the patient’s head, and the bloody toilet paper was removed from her mouth. Next, a surgical mask was put on the patient. It, too, later showed blood stains.

A Parkland officer met with Assistant District Attorney Craig McNeil on April 10 to discuss potential criminal charges against Enyinna-Okeigbo. “McNeil stated that he felt the culpable mental state exhibited was negligence, and the mental state that has to be met for assault is reckless,” a police report says. “Therefore, McNeil stated that he did not feel that [Enyinna-Okeigbo] met the culpable state to be charged with a crime.”

McNeil told The News he did not know why the hospital didn’t consider charges against the staff member who put the sheet around the patient’s head. Foran, the Parkland spokeswoman, said hospital police gave the DA’s office “complete details” of the incident and noted that prosecutors have “full discretion” about how to proceed.

No assault

The News became aware of the incident on May 28 and asked Parkland for all related police reports. That same day, a Parkland detective asked McNeil for a written explanation of his reasoning, which the hospital gave The News.

“The use of force against a patient in an altered mental state is always unfortunate and should be avoided,” McNeil wrote. But it “does not appear to have been done with the intent to harm the patient.”

In an interview with The News, McNeil identified Enyinna-Okeigbo as the nurse who stuffed the toilet paper roll into the patient’s mouth.

The prosecutor said that spitting could be considered assault because of the potential for disease transmission. In using that term, he said, he did not mean to suggest that the patient should be charged with assault but added: “You have the right to defend yourself.”

McNeil said he could not tell from the video why the patient had blood in her mouth. He said he saw no footage of the patient being struck.

McNeil handled a 2011 case in which security video showed Parkland psychiatric technician Johnny Roberts choking a patient into unconsciousness. The hospital fired Roberts, but grand jurors declined to indict him.

“I was not happy about that,” McNeil said. “I still don’t know why they did that.”

Troubled pasts

The News’ reporting of George Cornell’s death ultimately led to a regulatory crackdown and two years of round-the-clock federal monitoring of Parkland.

The hospital installed security cameras — the same ones that captured the recent gagging incident. It also promised to fire problem employees and retrain others, especially on patient restraints.

Parkland would not say whether Enyinna-Okeigbo or De Guzman received this training.

De Guzman left his job at Parkland at some point after Cornell’s death in February 2011. He returned to work later the same year, according to hospital employment data. Parkland would not explain his departure or return.

Cornell’s death also led to a federal civil rights lawsuit that’s still pending against the hospital, UTSW, De Guzman and other caregivers. In court records, Cornell’s family has noted ways that regulators found fault with De Guzman.

Enyinna-Okeigbo, who was hired at Parkland in 2005, was charged with misdemeanor assault of his wife in 2008.

Dallas County prosecutors initially proposed a deal under which he could plead guilty and serve probation, court records show. Instead, for reasons the records don’t explain, they dismissed the charge in exchange for his completion of an anger management class. He never entered a plea and has no conviction record.

Parkland would not say whether it was aware of the allegations against Enyinna-Okeigbo. The hospital said that before 2011 it conducted criminal background checks only on prospective employees. It said it now checks existing employees, too.

In 2013, Parkland hired privately owned Green Oaks Hospital to manage its psychiatric services. Green Oaks, which receives $1.1 million a year under the deal, declined to comment for this report. Parkland would not discuss the company’s performance.

Source: Miles Moffeit and Brooks Egerton, "Parkland psych ER is again scene of patient abuse," Dallas Morning News, June 14, 2014.