Psych unit terminates six employees after suicide investigation

May 17, 2011

This story is reminiscent of that of Esmin Green, who died in Summer 2008 in the waiting room of the psychiatric unit of a Brooklyn, New York hospital--utterly ignored by staff--all of which was captured on psych ward surveillance video.  This past March, the King's County (New York) District Attorney filed criminal charges on two psych unit staffers for falsifying Green's records to make it look like she was alive and well, when corresponding video footage shows she was lying on the floor of the waiting room, convulsing.

CoxHealth (a hospital in Springfield, Missouri) 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.

Source: Sarah Okeson, "Hospital terminates 6 employees after death investigation," New -Leader, May 13, 2011.