Universal Health Services' Riveredge Hospital put suicidal patient in jeopardy

September 23, 2013

Diana*, of Janesville, Wisc., said goodbye to her 47-year-old comatose daughter in a hospital room at Loyola University Medical Center in Maywood on June 12.

"She was beautiful when we saw her. The nurses had French-braided her hair and her face was beautiful," said. "But I'm a nurse and I took one look and knew she was gone."

The comatose woman, Kristine, mother of two from Buffalo Grove, had been admitted to Riveredge Hospital, 8311 Roosevelt Road, in Forest Park on June 7, with a diagnosis of major depression with suicidal ideation after a six-week stay at Elgin Mental Health Hospital, according to the Cook County Medical Examiner's report.

Early the next morning, Riveredge staff found Kristine with a bed sheet tied around her neck threaded through the slats of a vent in the ceiling. Kristine was alive, her feet touching the floor, but she was unresponsive and was taken by Forest Park ambulance to Loyola.

At the hospital, the woman was kept alive for four days while preparations for organ donation were made by her family, her mother said. Family members gathered to say goodbye at the hospital.

"She was very healthy and didn't drink or do drugs, and she was an athlete," her mother said. "So she was able to donate a lot of organs. That's what kept [the family] going," she added.

According to the medical examiner's report, Kristine had been talking about attempting suicide because she feared criminal prosecution for a case pending against her. Diagnosed with major depression and post-traumatic stress disorder, she had been arrested in Buffalo Grove a number of times for minor and quirky crimes, according to Waukegan lawyer Mark Vogg, an attorney hired by the family.

Published records show she had been charged with an April 2012 burglary of a car in which she allegedly removed a wallet and checkbook from a neighbor's parked car overnight, but then returned the wallet between the owner's screen door and front door with a check for the cash removed.

Her husband told the medical examiner she had also "attempted to blow up the house by cutting the hose that runs into the furnace, thinking it was a gas line," the report said.

Kristine's transfer to Riveredge in Forest Park was a decision made by health professionals without knowledge of her husband or family, Vogg said.

"She checked in at 3 p.m. on a Friday afternoon and 12 hours later she was dead," Vogg said.

Didn't want to go back to jail

The journey to Riveredge began after one of her brushes with the law, Vogg said. He did not give details of the incident that put Kristine into police custody. Kristine was placed in Lake County Jail in April 2013. After it became clear the jail setting was severely aggravating her mental health problems, a judge placed her into a program for mentally ill offenders and she was transferred to Elgin Mental Health facility on April 18.

She stayed there for six weeks, according to records, and then was evaluated and found to be stabilized and able to be released back into the custody of the Lake County Sheriff.

But, when told that she was going back into police custody June 7, Kristine took a chair and broke a window of the Elgin facility, a report from that agency said. She admitted to the staff that she was acting out so she would not have to return to Sheriff's custody and jail.

At that point, arrangements were made "within about 60 minutes" to transfer the patient to Riveredge in Forest Park, Vogg said. Her family was never contacted, her mother and Vogg confirmed.

According to the medical examiner's report, Kristine attempted to harm herself in the Lake County police vehicle on the way to the hospital by using the seatbelt to choke herself.

When she arrived at Riveredge, physician's orders said Kristine should be put on suicide, assault and elopement precautions. A doctor instructed hospital staff to check on her every 15 minutes.

At 3 a.m., staff records noted the patient was "in-bed-asleep" but at 3:05, staff was "attempting to free the patient from a sheet she had strung through the vent," records said.

Her husband, a Danish national, was first informed of his wife's condition by Loyola hospital.

When asked about the death by Forest Park Review, a spokeswoman at Riveredge emailed a statement saying, "The management and staff of Riveredge Hospital are deeply saddened by the loss of one of its patients and extends its heartfelt sympathy to the patient's family." The hospital cited "strict patient confidentiality and privacy laws" as the reason it was "precluded from discussing specific details of any individual case."

Investigation by state regulators

State investigators and Forest Park police followed up by initiating an investigation June18 and 19. The state regulator report found Riveredge to have put Kristine in danger of 'Immediate Jeopardy' by placing her in a room with a ceiling vent that put her at risk of ligature, documents obtained through the Freedom of Information Act said.

According to the Illinois Department of Health and Human Services report, Riveredge knew about the ligature risk posed by the ceiling vent covers which were described as "long slat type." According to the report, Riveredge was "aware of the potential risks of the vent covers, and were in the process of changing the covers to ones with small holes and not slats." Hospital personnel told investigators they had started switching out the vent grilles between 2007- 2008 to circular mesh screens affixed with tamper resistant screws. But 34 grilles had not been switched out, including the grille in Room 212 where Kristine was placed. That room had a seven-foot ceiling.

On June 19, investigators from the Department of Health and Human Services immediately ordered Riveredge to move 40 patients out of units 1West, 1 South and 2 North until the new screens were in place. The hospital had 106 total patients, the report said, and 61 patients, or 66 percent, were on suicide precautions.

On June 18, Carey Carlock, CEO of Riveredge, instructed the plant operations director to modify all remaining ceiling vent covers with the mesh grille, the IDHHS report said.

Because the grilles were modified quickly, an Illinois Department of Public Health investigation cleared Riveredge of the condition of Immediate Jeopardy after completing their investigation on July 11, said spokeswoman Melaney Arnold. The Centers for Medicare and Medicaid services do not assess fines to non-compliant hospitals, she said.

Vogg said the family has not yet filed any lawsuit in Kristine's death.

Incidents in the past and new management

The Chicago Tribune has reported extensively on issues at Riveredge in recent years. In 2009, Riveredge came to the attention of the IDPH for a patient death in 2007, when the hospital failed to report the death of a pregnant patient, Tameka Williams, 27, according to the Tribune. Williams died in the Loyola emergency room after a reaction to an anti-psychotic drug. An employee reported the death to state regulators a year later.

In 2008, officials at the Illinois Department of Children and Family Services stopped sending wards of the state to Riveredge because of "serious concerns" after a report of two alleged rapes a day apart of a 19-year-old boy and the fact that the incidents were not reported to police, nor was the alleged victim given medical treatment. Ten mentally disabled children were reported to have been sexually assaulted at Riveredge between 2004-2007, regulators said.

Since then, the hospital has come under new management. Tennessee-based Psychiatric Solutions, Inc. sold the facility to Pennsylvania-based Universal Health Services, in August, 2010.

"Riveredge remains fully dedicated and committed to its mission of providing the highest quality of care to patients with special, and sometimes complex, mental health needs," the hospital's statement said.

Kristine's June 12 death was reported to state regulators within the required 10 day window, IDPH spokeswoman Arnold confirmed. No fine or censure was given to Riveredge by regulatory agencies because the hospital took steps to correct the items found in the investigation, she said.

Kristine's husband sold the couple's home in Buffalo Grove and returned with his children ages 15 and 17 to Denmark, Diana said. "He has a lot of relatives there, and a big support system," she said.

*The last names of the family members in this story are being withheld, at the family's request.

Source: Jean Lotus, "Mom's suicide at Riveredge came 12 hours after transfer," Forest Park Review, September 23, 2013.