This is a tragic story and this death is totally unacceptable. The problem here is that there usually are not enough staff to spend the time you really need to spend with adolescents. The adolescent patient is very time-consuming, as they are not adults and do not fully understand the situations they find themselves in. They rarely think before acting and sometimes they choose to act out instead of thinking. Dealing with adolescent psychiatric patients can be both a blessing and a curse. In my ten years working with this population, I have seen many, many success stories. Yet it is the near-misses and the actual misses that I actually remember vividly. Although I have never been a party to any teenager getting injured, I know that it does happen. What do you think about this story? Let me know if you have any information to share on this topic, won’t you?
My heart goes out to all the people involved in this tragic loss. The child will never live her life, the family will never get to integrate her into their midst, the people who were charged with keeping her safe will have to live the rest of their lives knowing that they failed and in failing cost a young girl her life.
BY BLYTHE BERNHARD • firstname.lastname@example.org > 314-340-8129 AND JEREMY KOHLER • email@example.com > 314-340-8337 ©2010, St. Louis Post-Dispatch | Posted: Sunday, August 1, 2010 10:00 am |
The charge nurse found Alexis Evette Richie alone in a small room at SSM DePaul Health Center, motionless and sprawled facedown on a bean bag chair.
Minutes earlier, the 16-year-old foster child had tried to hit, scratch and bite staff members in the adolescent psychiatric ward. Two aides grabbed her arms and took her down a hall and into a small room called the “quiet room.”
They held her facedown in the chair while a nurse injected a sedative into her hip. Alexis continued to struggle and then went limp.
The nurse and the two aides left without checking her pulse or making sure she was breathing.
Charge nurse Iris Blanks checked on her minutes later and didn’t think Alexis looked right. An aide helped Blanks roll the girl over. Alexis wasn’t breathing. Her pulse was faint.
It was 12 minutes after she stopped moving before anyone tried to revive Alexis. By then it was too late.
“Why did they leave her like that?” Blanks wailed over the phone to her daughter that night, according to a police report.
The “little girl,” she said, “didn’t have to die.”
The medical examiner agreed, concluding that Alexis had suffocated on the bean bag chair. Her death on Oct. 26 was ruled a homicide.
Alexis’ death came less than two years after the Bridgeton hospital had been warned by the state and federal regulators that patients weren’t safe. In January 2008, a patient with doctor’s orders for constant supervision died alone after five days in seclusion. That led to a state inquiry that uncovered instances of improperly secluding and restraining patients and failing to report deaths to authorities.
A health inspector was already investigating an operation in which a urologist removed the wrong kidney from a patient.
Last week, officials with SSM Health Care, the St. Louis-based corporation that operates DePaul and several other hospitals, said they could not speak about specific patient cases because of federal privacy laws. “The desire to defend ourselves and paint an accurate and full picture does not outweigh our patients’ right to privacy,” they said in a statement.
They said safety is the first and most basic promise that they make to patients and cited the training throughout SSM that empowers all employees to protect patient safety.
In early 2008, DePaul was required to explain to state inspectors how it would improve patient safety.
It satisfied the state by passing a full inspection. Its written improvement plan included suspending certain surgeries until surgeons earned proper credentials. DePaul also promised to continuously monitor patients in seclusion and make sure all its behavioral health employees were trained in first aid and restraining patients.
As is the case in most instances when hospitals are found to be unsafe, nothing was done to alert the public.
Even though DePaul had updated its safety procedures, many things went wrong the night Alexis died. Patients held facedown need extra care to make sure their breathing isn’t constricted, according to standards established by a national group that credentials hospitals. Failing to check on a patient after giving a sedative is a breach of basic care because the drugs can slow a patient’s breathing.
A state health inspector especially wanted to know what caused the 12-minute delay before CPR was started on Alexis.
“I don’t think they knew what to do,” one aide said.
The government found — again — that DePaul patients were in immediate jeopardy. A federal agency placed a three-paragraph legal notice in the Post-Dispatch classified section indicating that DePaul was scheduled to be “terminated” from the Medicare program because it was “not in substantial compliance with Medicare Conditions of Participation.”
There was no explanation of why.
And, once again, neither the state nor the hospital alerted the public that inspectors had determined DePaul patients might be in danger.
At least two of these episodes at DePaul were so-called “never events” — a list of 28 serious errors or incidents that the health care industry agrees should never occur at a hospital, from baby abductions to wrong-site surgeries.
How often these occur nationwide is unknown. Only about half the states, including Illinois, mandate reporting of never events to state authorities.
Missouri does not, but hospitals can voluntarily report to the Missouri Center for Patient Safety, a nonprofit group in Jefferson City created to study never events. It plans to release general figures on medical mistakes — without naming hospitals or doctors — sometime next year.
Even among states that require hospitals to report never events, compliance is spotty. A report by the U.S. Inspector General for the Department of Health and Human Services in 2008 acknowledged that many errors go unreported.
Missouri health officials in the past year have found 11 cases of hospitals with such serious problems that patients were considered to be in immediate jeopardy.
While those inspection reports are public records, they are difficult to access.
The state is too strapped for cash to put its inspection reports online, said health department spokesman Kit Wagar.
It’s another way that Missouri patients are in the dark. Earlier this year, the Post-Dispatch highlighted failures of hospitals to report when they discipline doctors. Reporting of serious disciplinary actions is mandatory, yet the newspaper found just eight reports a year by Missouri hospitals, a number experts said was low.
Some states provide much more detailed information about problems at hospitals. California and Minnesota — two states that require hospitals to report never events — publish reports online that name the hospital and infraction.
“If you have routine regular public reporting, I do think that builds public trust,” said Louise Probst, executive director of the St. Louis Area Business Health Coalition, which represents local employers’ interests in the health care debate.
SSM executive Robert G. Porter said in an interview Thursday that the company would support an effort such as Minnesota’s in which there is open sharing of information by all hospitals, so long as it didn’t create a culture where people were afraid to report mistakes.
“If health care workers were fearful that any mistake they made would be automatically publicly scrutinized, what incentive would they have to openly and honestly report errors — or even near errors — so that we can learn from them and improve?” SSM said in its statement.
Becky Miller, who directs the Missouri patient-safety nonprofit group, said the issue is also about lawsuits. “A lot of these safety issues can be very litigious events, so there is a reluctance to openly talk about them and to report them,” she said.
The federal agency U.S. Centers for Medicare and Medicaid Services, or CMS, investigates most cases of an unexpected patient injury or death reported to it.
The agency’s website, Hospital Compare, has some information for patients but none about never events.
CMS has the authority to cut off federal funding to any hospital that fails to fix a serious problem, essentially shutting it down.
It rarely wields that power. Each year, CMS cuts off two to four hospitals out of more than 6,000 nationwide. No St. Louis-area hospital has ever been terminated, according to CMS; DePaul came close after Alexis’ death.
Five days in seclusion
When a patient dies during or soon after being secluded or restrained at a hospital, it’s a red flag that could signal negligence. That’s because those patients need constant supervision for their protection.
Hospitals must report the deaths to CMS as a condition of participating in Medicare and Medicaid. But DePaul didn’t report two such deaths in January 2008.
Few details are available about one of them: the death of an 87-year-old cardiac patient who had been in wrist restraints, according to an inspection report.
The second death involved a patient who was supposed to get continuous, one-on-one supervision in a room apart from other patients.
On the fifth day of seclusion, an aide reported seeing the patient, who had a history of seizures, “slithering around on the floor like a snake” and falling when he tried to stand up, according to the health inspector’s report. When the shift ended, the aide reported that the patient was asleep.
No one checked for at least 12 minutes after the aide left. A staff member on rounds found the patient dead on the floor.
The aide who had been monitoring the patient later told an investigator that it wasn’t the first time that a patient needing “one-to-one” monitoring had gone unsupervised. A nurse said the staff was short because of budget cuts.
Investigators warned that DePaul psychiatric patients were in “immediate jeopardy.” In addition to the failures involving the two deaths, the hospital did not always document reasons for restraining patients and did not always check the vital signs of restrained patients as required.
The hospital promised to review all restraint episodes every week and retrain its staff on restraints.
In their statement last week, SSM officials said they “regularly monitor and review our staffing levels to ensure we are providing safe patient care.”
A troubled life
Alexis was abused and abandoned in her short life.
Her medical and foster-care records indicate that after Missouri child-welfare officials removed her from her home at age 7, she bounced around foster homes and institutions.
Around age 11, she tried to kill herself by running into traffic. She was admitted to DePaul on Oct. 16, 2009, after stabbing a teacher at Evangelical Children’s Home with a pencil.
In therapy at DePaul, Alexis said she knew she needed to behave. She wanted to go home to her foster family in time for her 17th birthday on Nov. 4.
She could be cheerful and attentive — but was often angry or tearful, according to the records. Being around younger girls would trigger flashbacks of when she was 7 and a family friend sexually abused her.
She was constantly seeking attention, primarily from boys, and was often defiant to staff.
Staffers sometimes encouraged other patients to ignore her — a therapeutic tactic.
Nurses and aides sedated and restrained her several times during her 10-day stay.
The day before she died, Alexis removed a screw from a window panel in the nursing station, taunting workers with it. She wouldn’t calm down. An aide named Leon Harriel held her down. She got shots of two drugs, Ativan and Geodon, according to her medical records.
After she quieted, Alexis was asked whether she felt safe while she was restrained.
“Safe,” she answered.
The next night, when Harriel told Alexis to go back to the girls hall for bedtime, she cursed him and said, “I’ll kick your ass.”
He told her he was going to get a shot to calm her down. That made her angrier. [read more here]