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Delay in transferring patient to mental hospital ends in suicide
Depressed patient waits at least 10 hours before hanging himself
Thursday, May 27, 2010 | 2 a.m.
MountainView Hospital
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A man who went to a hospital for help with his depression ended up killing himself there after a string of errors that compounded his problems, a state investigation has concluded.
The 59-year-old man, seeking help at MountainView Hospital, said he was depressed and having suicidal thoughts. He volunteered to be transferred to a mental hospital, but after waiting at least 10 hours, he hanged himself with his belt, investigators found.
The patient arrived at MountainView’s emergency room at 11:20 a.m. May 19 and met with an intake coordinator for a mental hospital who was at MountainView to process the transfer. The patient said he had not taken his medications for weeks and was easily overwhelmed, frustrated and worried about his finances and the state of the nation, the investigation report said. He reported mild paranoia and delusional thoughts, and said that in addition to seeing signs of Armageddon in the world around him, he’d had flashbacks to Vietnam. He told the intake coordinator that he tried to commit suicide three years ago, but “the rope broke,” the report said.
What happened next, according to the investigation, was the step-by-step mismanagement of the man’s care:
• A MountainView social worker and case manager failed to read the intake coordinator’s report.
• A doctor failed to complete discharge paperwork, delaying the man’s voluntary transfer to a psychiatric facility.
• The man somehow changed into his street clothes, in violation of hospital policy — and obtained his belt.
• A technician who was supposed to monitor the man via a camera in his room failed to check on him when he lingered in the bathroom.
Twelve hours after telling the intake coordinator of his suicidal thoughts, the man was being lowered from a shower rod with his belt around his neck. Hospital staff tried to revive him before pronouncing him dead the next morning.
Richard Whitley, administrator of the Nevada State Health Division, said the death was the unfortunate outcome of a combination of errors.
“In isolation (the errors) maybe would not have led to this tragedy,” Whitley said. “But in total, in looking at it, you can see how the dots connected to have this outcome.”
The case was investigated by the Health Division’s health care quality and compliance bureau, which licenses hospitals and investigates complaints. The 38-page report, made public Wednesday, documents interviews with key people who knew about the man’s care.
MountainView officials said they take patient safety seriously and are investigating the matter. They said they offer their sympathies to the patient’s family and could not comment further because of privacy laws.
The Health Division will assess a penalty for the violations found during the investigation. It also notified the Joint Commission, which accredits hospitals, and the Centers for Medicare & Medicaid Services, the government’s insurance payer, which also conducts investigations into complaints. The two agencies could investigate the case.
The man’s hospital roommate told investigators that the patient had been depressed about a divorce and losing his job as a heavy-equipment operator. After being admitted to MountainView, the man’s mood improved. He had completed his assessment with the psychiatric hospital’s intake coordinator and was just waiting for his discharge from MountainView.
He was “feeling as if things were starting to look up for him due to the help he was going to have dealing with his depression, and he was looking forward to his transfer to a mental health facility,” the roommate told investigators.
The patient became increasingly agitated, anxious and depressed when the transfer was delayed by so many hours, the roommate said.
The transfer never came.
A case manager noted at 1:18 p.m. that a physician was called to do the discharge summary. Another note at 5:58 p.m. indicated that the doctor still had not arrived to do the paperwork.
The intake coordinator, who had assessed the suicide risk, said the social worker was to follow up with the physician and arrange transportation to the psychiatric hospital, the investigation found. The intake coordinator said that because of the suicide risk she “assumed the facility would watch the patient closely,” the report said.
But neither the social worker nor the case manager read the intake assessment.
The doctor said he had not been notified that a psychiatric assessment had been completed. He said that if anyone had told him the patient had suicidal ideas combined with a past attempt, he would have placed the patient on suicide precautions. He expected the intake coordinator, social worker or case manager to notify him of the assessment.
MountainView’s medical records document no evidence that a self-harm risk assessment was completed by the emergency room staff, a failure in policy and procedure, according to the hospital’s director of emergency services. But his nursing care plan included suicide risk.
The man was transferred to a camera-equipped room for 24-hour observation, but was not placed on suicide watch. A monitor was assigned to continuously observe 10 rooms containing 12 patients, but the view was obscured when the man went into the bathroom.
The chief nursing officer told investigators that the hospital has no policy for how much time can elapse after a patient goes into the bathroom without being checked. The nursing officer said nurses should be notified within three minutes of at-risk or suicide-watch patients entering the bathroom. A camera technician told investigators he’s been at the hospital four years and has never been given a policy on the matter. And MountainView’s vice president of quality and risk management could not locate any written policy for the monitoring of patients on camera beds, the investigation said.
The man’s belongings were taken from him, including his clothes, and he was supposed to be transferred in a hospital gown to the psychiatric hospital, the report said. His clothes were brought to the fourth floor at 4:30 p.m. in preparation for his discharge, and somehow he obtained them and put them on.
The nurse assigned to care for the man on the overnight shift said the patient was in street clothes when he arrived at 7 p.m. At 8 p.m., the patient asked about the delay and the nurse noted that the doctor still needed to complete the paperwork. The nurse did not call the doctor to ask about the delay.
At 11 p.m., the nurse and charge nurse decided to cancel the transfer and the patient was informed. Ten minutes later a nursing assistant found the patient hanging by his neck in the bathroom.
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Nice work by all the Hospital employees!!! THEY SHOULD ALL BE FIRED!
Nevada healthcare, once again exporting the cost, in this case to the next realm of eternity.
The person came to the provider, admitted needing help and why, and nobody did their job....
Its really not good enough that the system failed this man.
Wow. Might just as well have left a cyanide capsule and a glass of water with the poor man.
What has become of human compassion?
I would like to hear from some of the staff at this hospital about what it's like to work here, and whether staffing meets needs. Or is it overcrowded and are its workers overwhelmed?
Why is this country so full of people who must assign blame for every unfortunate thing that happens to anybody? The steady increase in the "find somebody to blame" attitude has made this country a worse place to live in, and we're all afraid of being sued. In other countries people make jokes about us because of it.
This article does not have enough information to conclude whether staff members were irresponsible, uncaring, etc., or whether they are simply so busy and overworked - another American characteristic that keeps growing - that it's inevitable that something like this will happen occasionally.
Those of you who are so quick to condemn should be judged by others the same way - harshly, and without all the facts.
I think healthcare providers reflect the attitude of our society. No one re4ally seems to care. This isn't the first example we have heard about carelessness and a lack of empathy. Health care professionals aren't the only ones who seem to have adopted the cynical, dispassionate attitude toward human life, look around-a complaint about poor service, poorly made goods with dangerous substances, medicines on the market which have to be recalled. Even diapers which burn newborns. Americans have gradually devalued human life. Why is that?
This is a very sad confirmation of the piece published by the Sun last Sunday about the dreadful quality of hospital care in Las Vegas. If a sequential readmissions don't kill you for initial botched care, incompetence during a behavioral health emergency may.
Gunowners4Obama,
You ask, "Why is this country so full of people who must assign blame for every unfortunate thing that happens to anybody?"
Would you agree, at least, that when these sorts of tragedies occur, an investigation should be held to determine what went wrong, where was the breakdown?
And in doing that, wouldn't it seem appropriate and logical to hold people, or institutions, or processes, accountable so the tragedy doesn't repeat itself?
Such accountability is the equivalent of assigning blame, or at least identifying what went wrong so it can be addressed and hopefully not happen again.
What a sad way and place to die of depression!
Tom,
I really like the fact that The Sun reporters monitor stories and comment when appropriate. It gives the readers the idea that we are having a conversation instead of just leaving a comment.
That said, I do think that accountability is important, but I don't often think anyone is actually held accountable.
This man went to professionals for help and did not receive it because of the staff that did not feel they needed to go beyond what their job required. If someone would have taken 5 minutes out of their day to find out why this Doctor hadn't arrived, this man would still be alive today. But no, they only think they should do what their job requires and nothing else. I don't know how these people sleep at night.
In a way, this does not surprise me at all...the medical establishment here in Vegas astounds me and it is the main reason I have continued to see my Doctor in California. My husband sees a Doctor here in Vegas and I have gone in to pick up scripts for him from them...they are the most rude and unhappy people I have ever met. Even the Doctor is as bad as his front staff. They don't care about patients, they only care about how unhappy they are at their jobs. A smile & a better attitude goes a long way.
The man did not just become depressed. Where is a record of treatment from Metal Health, did he have a case worker? Had he been perscribed drugs that he did not take? where was his family? While the hospital had many mistakes where was everyone eles in his life? RIP fellow, depression is a horrible placed to be.
Mountainview is not a psychiatric hospital and hospital ERs are not the appropriate place for psychiatric patients to be held. The docs and nurses at that ER are trained to take care of heart attacks, strokes, trauma and other physical ailments. I agree there was some breakdown of communication, but with all the news about our over-crowded emergency rooms during the last few years, is it really surprising that paperwork wasn't completed very quickly? How many ER patients were there that day? The system is distressed and the needs of psychiatric patients will never be adequately addressed in ERs.
The employees at MountainView are good people who are dedicated to patient care. This patient was being treated medically with underlying psychiatric issues. The vast majority of patients in southern Nevada come in to the ER with some altered mental condition, which speaks to a larger issue of the lack of funding in this state to appropriately care for the mentally ill. MountainView is an acute care facility that provides medical attention. Not psychiatric care.
Several readers point out that MountainView is not a psychiatric facility, which is true. But the breakdown doesn't appear to have been in the patient languishing in E.R. waiting for help. As the story notes:
The patient "met with an intake coordinator for a mental hospital who was at MountainView to process the transfer."
It was after that paperwork was begun that the transfer process collapsed, based at least on my reading of the investigation that Marshall has reported.
Readers also are correct that acute hospitals are having to deal with many mentally ill or unstable patients who are part of their daily patient mix.
So, how do we address THAT issue? I'd love to hear some constructive ideas.
"At 11 p.m., the nurse and charge nurse decided to cancel the transfer and the patient was informed. Ten minutes later a nursing assistant found the patient hanging by his neck in the bathroom."
Do we really need to look any further?
hey he showed us,respect to the victim and family,i'm thinking about holding my breath until i get my way next time
There but for fortune go you and I
I've experienced the awful state of mental health care in Las Vegas personally and recently. I've been trying to get help in diagnosing my 5 year old son, who has had issues with agression toward his peers, the inability to control himself, hearing voices, and threats to hurt himself. With his insurance, we have only one option when it comes to mental health. That practice (with multiple locations in the valley) has only a few doctors on staff who treat children, so after 3 acute incidents at school, I called in an attempt to get an emergency appointment. Their definition of an "emergency appointment" was 3 weeks out. They advised me to bring him in for an emergency triage the following day, which I did. After waiting in the waiting room for 45 minutes, they advised me "we are really sorry, but we didn't realize that he is a child, and we don't have anyone who IS WILLING to see children." WILLING?!?! Soooo, no one bothered to read his file before you told us to come in for emergency triage..? If you had, you would have known that he is only 5!!!
At that point, I said, in my most controlled but forceful voice," my son threatened to kill himself and injured another student at school. I don't care who you have to call, but someone WILL see my son today."
Finally, the clinical director saw him, and recommended I take him immediately to Spring Mountain Treatment Center, which by the way, is one of only 2 facilities in Vegas that see kids. After 6 days of inpatient treatment, he came out just as he went in.
I am STILL struggling to find a quality caregiver who not only treats children, but actually listens as opposed to just throwing different drugs at him.
Relax guys - the hosptital's CEO will be conducting a televised press conference where he will address the public, explain the mistakes, offer an apology, and take responsability.
P.S. Don't hold your breath.
the WHOLE system needs overhaul. my mother has cancer and went to UMC where she receives treatment from a cancer doctor. Many times she has waited DAYS just for her doctor to SIGN paperwork. I have lived in many a state and have never heard of such delays until I moved to Vegas. The education system here is a joke and it reflects on all basic services and lack of common sense I see hear over and over.
(yesterday I was at Fry's and the computers went down, the teenagers and adults struggled to do basic math it was the most ridiculous thing I had ever seen). Vegans always complaining about the President and the education system here is the real joke it. Someone actually stated that each country has their own measurement system they had never heard of the metric system. I tried hard not to chuckle because the eduction system here is a joke producing ignorant adults not knowing the difference between state, city, or national affairs.)
"The intake coordinator, who had assessed the suicide risk, said the social worker was to follow up with the physician and arrange transportation to the psychiatric hospital, the investigation found. The intake coordinator said that because of the suicide risk she "assumed the facility would watch the patient closely," the report said."
This intake coordinator is employed by the psych hospital. Did she actually communicate this risk to hospital staff??? say "was to follow up..." and "assumed" does not say that she actually communicated.
"But neither the social worker nor the case manager read the intake assessment."
"MountainView's medical records document no evidence that a self-harm risk assessment was completed by the emergency room staff..."
No wonder they didn't read it. It wasn't in the patient's chart!
The problem here is that the psychiatric hospital's intake coordinator did not do her job well. You don't show up in the ER and assess that a patient is suicidal and NOT tell the doctors and nurses. You have to tell them AND write it in the patients chart which she also apparently did not do.
So much of this story bashes Mountainview and not enough focuses on the poor performance of the psych hospital employee.
The handling of mental health emergencies is difficult and expensive. How the patient was treated depended upon what conditions he had upon arrival. If he had an underlying medical condition (other than his mental health condition) the hospital would have been obligated to keep him there until that condition was stabilized. Barring that, the procedure would be to transfer him to a proper facility to give him care.
Whether or not he was assessed as a risk to himself or others the risk of a sudden change in mental status is so great that one-to-one monitoring is essential. There appears to have been a lapse in the monitoring protocol when the patient went to the restroom and was out of sight. Other hospitals actually place observers sitting in the doorway of the room whose sole responsibility is to keep an eye on the patient. While not infallible and more expensive than video monitoring it probably would have saved this man's life.
Additionally, the story doesn't indicate if he was evaluated by a psychiatrist at Mt. View to determine what level of care he needed. The psychiatrist is usually the one who determines whether the patient will be admitted to inpatient mental health care or is safe enough to discharge with medications to follow-up as an outpatient.
Ultimately I suppose one could hang some blame on the participants here. However, at some point in time in your 59 years on this earth you have to assume some responsibility for your actions, or failures to act, i.e. taking your meds.
JenniferMKC....while I hope there really are no serious conditions your son suffers from, did you try the old fashion way of a good "butt whippin" after causing trouble at school?
That always cured me from a few issues I had as a child from time to time.
Yeah, beating a child with mental issues is ALWAYS a good idea. Maybe he should be locked in a closet until he stops hearing voices. That will help. Way to be sensitive, Noindex.
Sounds like the ball was dropped and then kicked all over the field on this one.
I retired from a community based clinic within the Veterans Administration and I can tell you with ALL sincerity this would NEVER have happened at a VA hospital.Even a patient coming in for their periodic check up receive what we called a mini-mental with each visit.Fail the questions,and you are referred to psychiatry within the office immediately and then reviewed.If the outcome of that visit warrants transferring to the main hospital, he/she is not allowed to leave and is watched while the ems/police arrive for transporting. The VA takes issues of this nature extremely serious. It's sad to see the end results of what can happen when someone is screaming for help because he/she is afraid of what they may do. To know hospitals brush something like this aside makes me so angry.
I'm just curious, if you people hate this town and all it's issues so much then why do you live here? I am from Las Vegas, born and raised, and damn proud of it. I am so sick and tired of people bashing my hometown. You don't like it? LEAVE! You were probably part of the problem to begin with. I am a young adult who has received an excellent education in this state. I have a college degree and a normal day job. And guess what? You think the healthcare in other parts of the country is so superior? My mom died in a hospital in California. We are just an extreme example of a larger issue. Do me a favor- next time, before you post so freely, pretend like it's your hometown.
"The man did not just become depressed. Where is a record of treatment from Metal Health"...
Metal Health will drive you mad.
Quiet Riot
I agree with Boomer. This was just sensless, tragic and sad.
Hospitals usually have psychiatric staff available for on call situations and it sounds as if the patient was evaluated by both psychiatric professionals and staff. All emergency room personnel are trained in how to deal with mental health issues in emergency situations. Medical professionals in an ER-nursing staff, social workers and physicians will tell you this. Staff personnel do not need to be mental health experts but need to be responsive to written assessments, suicide precautions and it sounds like the hospital had all those in place. It is not pointing fingers if the report claims professionals did not read the psychiatric assessment, follow up with the physician and find out why the patient was not transferred. All these questions should be asked and hopefully the hospital will make changes to ensure the safety of future patients is assured.
There is a larger problem in our state and we are not alone. We are clearly a community making decisions about the quality of service we want to provide our citizens. Mental health services is one of many areas we as a state chose to cut to a bare bones budget.
Quality of life decisions on a state level affect all services, private and public. It is not surprising to hear about problems with health care in our state. It is one of the areas we choose not to value for the uninsured, the veterans, the mentally ill, and the indigent.
How do we change that?
I'll bet the hospital will still demand full payment for their "services".
What did the spoon say to the fork as they were side by side companions in the silverware drawer.
Mental health and mental patients pose the same aspect of health care as do any other patients.
Doctors who and nurses and auxiliary personnel in hospitals who walk over patients instead of walking with patients will cause more mental problems for the patients, their coworkers, and, if aware of the local health care givers, the community as a whole.
There are persons in the community who are religious fanatics who donate money to any cause in the name of god and the two holy ghosts regardless of the circumstances. Judges and wives of judges do the same dance with the devil because they are the leaders the community looks to for development of the right thing to do!
"The patient had flashbacks to VietNam". This is truly unfortunate considering the extensive outpatient/inpatient facilities available to vets from the VA Southern Nevada Health Care System.
I can speak from personal experience that if you are in crisis, and present at the VA Mental Health Clinic on Owens Ave you will see a mental health professional that day. Action will be taken to help you.
A word for all the vets out there. Mental Health counselors are available at these VA Clinics:
VA North Clinic, 916 W. Owens, Las Vegas
VA Henderson Clinic 2920 N. Green Valley Pkwy, Suite 215
VA Pahrump Clinic, 2100 E. Calvada Blvd.
VA Inpatient psychiatric facilities are also available in Las Vegas and Loma Linda CA.
VA personnel can be reached by the VA Central phone system at 702-636-3000 ask for the Mental Health Clinic.
http://www.lasvegas.va.gov/services/ment...
Well, of course he didn't get service. He forgot his chicken at home.
Truly sad....
Thank you WordSmith10!! I love our town and I hate to see people bashing it!! Very well said!
"Readers also are correct that acute hospitals are having to deal with many mentally ill or unstable patients who are part of their daily patient mix.
So, how do we address THAT issue? I'd love to hear some constructive ideas."
There are two kinds of pysch patients: insured and uninsured. If a psych patient is insured, meaning Medicare or a private insurance, they will transfer to a psych facility usually the same day if their medical condition is stable. The uninsured patient has to wait for a bed at Rawson-Neal for hours or days. The beds at Rawson have been reduced and the staff is required to take furlough days.
The best solutions would be to have more beds available at Rawson-Neal and cancel the furlough days for the staff.
Quote: MountainView officials said they take patient safety seriously and are investigating the matter. apperently not!
Quote: But neither the social worker nor the case manager read the intake assessment. as above!
And healthcare workers want more money and less hours? I hope whoever was involved in this, will be fired, including the administrators.