Wednesday, February 14, 2018
By Walter F. Roche Jr.
Two patients at a Philadelphia behavioral hospital committed suicide in a five day period, according to a court suit and an inspection report by Pennsylvania Health Department.
The deaths on April 24 and April 29 of last year occurred at the Belmont Behavioral Hospital, part of Acadia Healthcare, a Tennessee based company.
In the April 24 death, which was detailed in a health department inspection report, the patient hung himself in an area that was supposed to be free of fixtures that could be used for ligatures.
The April 29 death involved Jerry W. Gates, 59, a patient who was transferred to Belmont following treatment at a Chester County hospital for dizziness and reporting that "he was hearing voices telling him to harm himself."
The suit charges that despite the diagnosis Belmont determined he "presented a low risk of suicide" and suicide precautions were not provided.
The suit charges Belmont and its parent company Acadia Healthcare with negligence and wrongful death. In a 19-page answer Belmont and Acadia denied any negligence or liability.
The complaint charges that Gates was able to wander from room to room without any supervision and he was not provided with medication for his known insomnia.
The suit adds that he was found at 4:10 a.m.lying on the floor "bleeding profusely from gaping wounds of the neck caused by a portion of a picture on the wall with which he stabbed his neck.
The suit charges that the facility lacked sufficient and appropriately trained staff.
Acadia, the complaint states, was a direct participant and exercised corporate control over Belmont.
Calling the care provided "a gross deviation from accepted standards of care," the complaint charges the defendants with "flagrant and gross negligence."
In their answer, the defendants acknowledged that Gates was found bleeding from a neck wound. but denied he was found lying on the floor or that he died on the way to a hospital.
"It is specifically denied that Gates was not supervised and was allowed to roam freely without any supervision," the answer states, adding that "all liability against defendants for wrongful death are denied."
As reported previously on this blog, a second suicide at Belmont was detailed in a state inspection report. In that case an unnamed patient hung himself. The state cited Belmont for multiple deficiencies including lack of staff and failure to have facilities designed to prevent suicides.
In fact state inspectors declared a state of imminent danger when they visit in early November of last year.
Monday, February 12, 2018
By Walter F. Roche Jr.
A Philadelphia behavioral hospital has been cited in the suicide death of a patient and a host of other violations of state requirements' many involved in the treatment of patients with Electro Convulsive Therapy (ECT) ,in a recently released report..
The report on the Belmont Behavioral Hospital was first made public without an approved corrective action. The agency normally posts inspection reports only after the submission of an approved plan of correction.
"An approved plan of correction is not on file," the report stated.
Mark Schor, a Belmont official, said the facility did submit a plan of correction and that state officials had accepted it.
The latest version of the inspection report posted today shows that several parts of the corrective action plan have been accepted while others have not.
Schor also said the hospital is in the process of building a 250-bed state-of-the-art replacement facility, scheduled to open in late 2019.
According to the report, based on a Nov. 9 visit to the hospital, inspectors declared a state of immediate jeopardy after discovering numerous violations of anti-ligature requirements, rules set to minimize the risk of suicides.
The failure to comply with those requirements "resulted in the suicide death of one patient," the report states.
The patient was pronounced dead on April 24 of last year.
"The patient was found hanging from a loopable point on a bathroom anti-ligature door," the report states, adding that in addition the hospital failed to request an autopsy report and forms on the disposition of the body were not completed.
The hospital failed to provide a safe setting, the report continues, adding that a hospital psychiatrist "did not document the observations and special precautions" needed for the patient.
The facility did immediately change its policy to require that all patients with a suicidal risk be observed by staff every seven minutes. As a result the state of immediate jeopardy declared at 12:14 p.m., on Nov. 9 of last year was lifted at 7:46 p.m.
In its corrective action plan Belmont said they had designated a patient safety officer and that policies and procures for ECT treatment were reviewed and revised.
Belmont is part of the Acadia Health Care LLC, a company that operates some 579 treatment facilities.
Other findings by the state Health Department surveyors included the failure to properly monitor patients who had undergone ECTs. During the visit two patients were observed in the treatment area without any staff present.
Still other violations included medication carts left unlocked and unattended and failure to maintain complete records showing how many vials were used on ECT patients. There was "no documented evidence of how many vials were delivered to the ECT room," the report states.
Inspectors also cited failure to respond to grievances within a seven day limit and failure to secure patient records to ensure confidentiality. They observed 166-pages of patient related data in open view.
Inspectors also said Belmont "failed to ensure a sufficient number of nursing staff were available to meet the nursing needs of the patients."