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StumbleProbe uncovers issues with mental patient’s care
Sources say woman at psychiatric hospital died after being left untended
Tuesday, April 20, 2010 | 2 a.m.
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State investigators found problems with the care received by a woman who died this month at Rawson-Neal Psychiatric Hospital in Las Vegas, officials said Monday.
Ben Kieckhefer, spokesman for the Nevada Department of Health and Human Services, said he could not provide details, but that the hospital submitted a plan of correction to address the deficiencies.
Two sources familiar with the incident told the Sun that the patient was supposed to receive constant, one-on-one care and died April 4 when she was left untended.
Harold Cook, administrator of Nevada’s Division of Mental Health and Developmental Services, which operates the 212-bed facility near Oakey and Jones boulevards, said on April 13 the woman went into cardiac arrest, and Rawson-Neal staff performed CPR before she died.
The death appears to have been caused by pre-existing medical conditions, and there’s no indication the death was related to the medical care the patient received, he said at the time.
Kieckhefer said Cook would not comment for this story because the inspection process is not yet complete.
Cook said patient privacy laws prohibit him from discussing whether the woman’s condition required constant monitoring.
About half a dozen Rawson-Neal employees have been temporarily reassigned during the investigation into the woman’s death, according to state officials.
The sources requested anonymity because speaking about the issue could hurt their reputation in the medical community.
According to the two sources, the woman, who was obese, was administered medication to calm her when she began acting psychotic. But because there are no medical doctors on weekend duty, she may not have been properly examined, the sources said.
Providing constant one-on-one observation of patients has proved difficult in the wake of state budget cuts, said one of the sources, a former clinical employee at the hospital.
“Many times a so-called one-to-one is not one-to-one,” the former employee said. “A one-to-one employee is giving attention to three people.”
It’s unknown why employees did not monitor the patient, but by the time they found her dead, her body was cold, the sources said. She had been dead so long that employees questioned why anyone would perform CPR, one source.
Nevada’s Bureau of Healthcare Quality and Compliance, which licenses the hospital, has been investigating the woman’s death and will issue a public report of its findings.
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Sounds like a regretable accident. This doesn't happen all the time.
How many will have to die in this Hell Hole beofre anything is done? this is not an accident, this is neglect. There needs to be an undercover investigation of this entire operation. No one will belive the neglect, abuse, and poor care that comes from all levels.
So a patient is supposed to be constantly monitored, but isn't, and dies as a result? And Marshall Allen writes it isn't because of the medical care?
You can bet if the same thing happened at UMC, it would have been a much larger, splashy article. But because it happened at a state facility, clearly it isn't about the medical care. Yeah, right.
This is a state psychiatric hospital, not a general acute care hospital. Why is a psych patient who needs one to one observation for medical issues NOT transferred to a medical hospital? Doesn't make any sense.
Hi vegasmorgan - I did not say that the patient did or did not die because of medical care. At this point it's unknown why the patient died. Harold Cook said it was due to an unavoidable medical problem, and that it did not have anything to do with patient care. Others say that is not the case. But the facts are not yet known. A state investigation revealed problems with the patient's care, but again, this has not been made public yet, so we don't know the facts.
This is the same hospital that recently was forced to reinstate a nurse that it had fired because the nurse was reporting medication errors and other misconduct of another nurse. The supervisor the nurse was reporting the misconduct to was a friend of the nurse doing the misconduct so the nurse trying to protect the patients was therefore fired. If this hospital spent less time keeping people employeed because of who they are friends with and more time ensuring that they have the best employees possible to take care of the most vunerable of our population......I don't know just a thought.
This hospital is a disgrace and needs to be exposed for what it is. When a psych patient is one-on-one, it means that they are to be within arm's reach of a staff member at all times. In matters not if it is for medical or for psych, most often the one-on-one order is for psych reasons. If they are to be one-one-one regardless of the reason, it means just that. Additionally, nurses at any time can have a medically compromised psych patient sent out to the medical center. Therefore, the death is a result of negligent care. It is true that any employee who is a patient advocate does not last. There are many employed by this hospital, including a doctor who should be in jail for what they are involved in. No one has any real idea what goes on here. Cook is sitting in his office hundreds of miles away with no clue of what is going on here. Again, how much are the citizens of this state going to continue to allow such substandard care in this place before taking action? It appears that no one cares about the mentally ill in Nevada. We have regressed in the care of the mentally ill. Rapes and deaths happened prior to deinstitutionalization. No wonder those who really need the care have an intense fear of being hospitalized. They truly are safer wandering the streets unmedicated or locked up in jail.