Probe uncovers issues with mental patient’s care

By Marshall Allen

Tuesday, April 20, 2010 | 2 a.m.

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.