SC State Hospital To Undergo JCAHO Review After Patient Demise

South Carolina State Hospital Historical Marker

The South Carolina state psychiatric hospital, historically called “Bull Street” for decades in the past, Brian (state) Hospital in Columbia SC, recently had a sad and tragic occurrence, a suffocation death of a patient apparently undergoing a hands on restraint for out of control behavior by multiple staff.

In a recent article written by Avery G. Wilkes of The State newspaper of Columbia SC, entitled: “Suffocation Death of SC Mental Health patient under review by group that accredits hospitals,” published July 17, 2019, the sad story of this tragedy is detailed. In this article, there is described the possibility that some of the staff involved in this patient’s restraint event, were not adequately trained in these highly complicated and at times, hazardous to all involved, events. I will try to comment on my own experience with these events below. In any case,

The results of such investigations are made public. This is not a closed process with no transparency. Sometimes the public can be overly suspicious that transparency is not being followed by officials at the state or hospital levels when the media note that officials could not and would not discuss details of these reviews at first until the results are determined and made public. An article published September 8 ,2017 by the Wall Street Journal authored by Stephanie Armour entitled: Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge: The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations,” gave a cursory overview of this issue which was taken up by the U. S. House of Representatives in 2018 with a request for documentation (House committee probes CMS, Joint Commission over accreditation process,” published in Modern HealthCare magazine). Unfortunately I have not been able through my searches to find left over record by that Commerce Committee of the House as to what eventually came of the initial inquiry.

But it is my opinion and experience, that one of the reasons the Wall Street Journal found that only 1% of hospitals nationwide are ever de-accredited is that wealthy private hospitals are de-accredited less than the state psychiatric hospitals. Medical hospitals are now usually huge conglomerates and rarely are penalized at such a level. Small poorer community hospitals seem to be more vulnerable to such review based censures. And they are closing across the nation now anyway for reasons of declining revenues but that is another story for another day. Suffice it to say that state psychiatric hospitals, as maligned as they still are, operate in a far more regulated and highly scrutinized environment than private psychiatric hospitals or units/services within large wealthy, private, or university medical center based entities.

States’ governmental laws regulating their health care facilities, as well as private hospitals, require investigations and review by various bodies locally and nationally, deaths of patients by unnatural causes. Local review bodies include legislative oversight committees, the states’ own departments that oversee state psychiatric and private medical/psychiatric hospitals, national bodies such as the Joint Commission for the Accreditation of Hospital Care Organizations (the famous “JCAHO”), CMS (the federal agency for Medicare and Medicaid)C etc. Investigations such as these are very important since failure and loss of accreditation by these bodies can result in loss of ability to receive reimbursements from various insurers, especially the federal ones, Medicare and Medicaid. And for state psychiatric hospitals, this is extremely important. State psychiatric hospitals serve mostly poorer patients on Medicaid and Medicare or the uninsured, and loss of these operating funds means that the state legislatures’ budgets then have to make all the lost funds until the hospital which has lost such accreditation and funding can regain such. This always involves submitting to the mandates the hospital must put into place. This process is always lengthy, detailed and usually requires “corrections,” “actions plans” etc. It is not a trivial event then when a state psychiatric hospital has such a tragedy, and when a “deficiency” is found. The investigative review process is arduous. It requires no questions asked cooperation by the hospital staff and leaders. Staff are subject to detailed interviews and scrutiny. Hospital policies are reviewed and the review personnel check to make sure that the policies are indeed followed and fully implemented. If there are deficiencies found, then the corrective actions are imposed and possible penalties such as loss of accreditation are imposed.

Now there are wealthy(ier) private psychiatric inpatient systems that have been de-accredited in the past few years and I would be remiss in my own ethical standards if I did not mention a couple of them. One was the Timberlawn Hospital of Dallas TX that in its heyday was truly a very good inpatient treatment facility. I had a former mentor from my long ago training days who migrated to work there and did exemplary work with adolescents. But the leadership and ‘mission’ of the facility changed a decade or so ago and it went rapidly downhill, quality of care suffered and tales/rumors of its bumblings, then deaths and such, began to emerge. It underwent investigation, lost accreditation which was a genuine shock to many who knew it in its heyday, and closed only a very few years ago. Another chain of psychiatric inpatient centers in the Boston area garnered such scrutiny, was loudly hectored in the media for a variety of missteps, some of them quite major and involved a lot of financial misdoings and lost its accredited standing also. So this does happen with some monied, strongly capitalized psychiatric inpatient entities, but I feel it does not happen enough and helps the explain the findings in 2017 of the WSJ article/expose.’

At this point I would like to comment on my own experience with at least the aftermath of a state hospital-based investigation regarding the patient death undergoing a take down manual restraint.

After serving as stint for approximately 4 1/2 years is the first psychiatrist at a newly established Native American tribal mental health clinic and substance abuse services, and in the approaching twilight of my psychiatric practice career, I was looking for a more balanced and salaried position for essentially the rest of my career. As I had started out my post residency and fellowship practice career in a the North Carolina state hospital helping to start a new 44 bed acute relatively short-term adolescents psychiatry unit, I made the decision to apply for a position that my current state hospital site of employment. I initially applied through a locum tenons psychiatry job placement firm. I had a few long-term friends, fellow psychiatrists I had known through professional contacts over the years who worked there as well. I had some knowledge that this state hospital provided excellent high quality care and I was eager to apply and see if things would work out for all parties.

I’m was not prepared by the two-way exchange that I was given during the several week application and review process. I was prepared for essentially one way process in which I would furnish information and references about myself and to be judged regarding meeting the qualifications for employment at this facility and providing evidence, references and the best representation of my qualifications that I could. Instead, toward the end of the application and interview process which lasted more than one interview session and multiple visits to the hospital, I found myself being informed by the CEO psychiatrist of the hospital, of the relatively recent traumatic experience that the hospital itself had gone through. He did so for the purpose of complete transparency and honesty so that I would know fully what the hospital had gone through and be exposed to any possible negative information about the hospital organization, its own level of confidence etc. As he began to relate the history of the death of the patient within the previous two year period, I was floored by his openness. Gradually I came to understand that this incident had been traumatic for everyone involved and was witness to the extraordinary links to which the clinical leadership and staff involved at all levels, went to in order to be cooperative with the ensuing mandatory investigations, the patient’s family and the media to the extent that they were permitted by the confidentiality laws. There was no hiding of the incident, no minimizing, no bureaucratic obstruction etc. It did turn out that part of the basis for mandating corrections and deficiencies based on the circumstances of the death by virtue of the physical nature of the episode of manual restraint of a truly aggressive and supremely uncooperative patient were erroneous. I was permitted to find out and review the incident myself and learned with confirmation from the CEO that for instance, the initial pathology exam was erroneous and efficient and that a repeat exam later on in the process essentially demonstrated that the cause of death was a previously unknown cardiac condition of the patient and not the air of the hospital staff in affecting the physical restraint and control measures. But this was not accepted or validated by the investigators and sanctions were imposed including the loss of accreditation for the hospital that lasted approximately a year and a half.

I was simply ethically amazed that the hospital clinical leadership worked actively with the investigators and without any protest whatsoever submitted to the corrective actions in a dutiful accepting way seeing them as an opportunity for positive change. By the time I arrived on the hospital’s staff, the changes had been actively implemented and I was exposed to the most detailed and helpful training course in physical restraints procedures that I had ever witnessed at any hospital at which I had practiced in the past. The hospital had contracted with an outside training and consulting agency in another state and at great expense to itself, instituted a mandatory training policy for every single staff member who has any sort of clinical contact with the patient population, from behavioral nursing assistants on up through psychologists and psychiatrists without exception. This training is mandatory and is repeated annually for all clinical staff and stands witness to the openness, cooperation and commitment to high quality of patient care.

So when I read of other hospital organizations undergoing such thorough reviews and investigations by outside bodies have more appreciation for the difficulty of the task that is endured by both the reviewer in investigators and by the hospitals themselves mutually. I also am somewhat dismayed when I read accounts of hospital organizations who seem to resist these investigations and outside reviews in an almost reflexive defensive manner. I can understand usual human reactions in which we all get defensive about having our professional actions critiqued and criticized and if need be, having to submit to a professional disciplinary action especially if it involves public censure and procedures that create a negative image in the eyes of the public who cannot ever fully appreciate how difficult these processes are.

I hope that this small effort at sharing and observer’s long-term perspective and experience can help any reader more fully understand these very difficult and periodically inevitable said events and their aftermath.

The AntiPsychiatry Movement

I wish to comment of the “AntiPsychiatry Movment” as this month there has occurred a little known but imporant anniversary this very month of May at the time of this writing, May of 2018. First I will set the stage a bit laboriously by outlining the several main fields of focus for this movement. At least one of these “anti-psychiatry” movements was well placed, needed, healthily revolutionary and far sighted, Some of the others have been dismal flops, misguided lunatic efforts in the service of lunatic philosophies, and/or instrumental in generating monstrous new social problems.

There have been three forms of the “anti-Psychiatry” movement over the last half century or more.

In the USA the movement has focused on treatments that were, and/or seen as abusive, cruel or inhumane. These villified treatments concerned mostly the first few decades of the use of ECT, or electoconvulsive treatment, and psychiatric medications. In the last few decades ECT was refined to a point that its visually frightening quality of causing gross, big time seizures of muscles with all the scary “herking and jerking,” as I always term it in lectures, so that medications suppressed and eliminated those aspects that gave it a “bad” reputation. ECT was the only effective treatment for psychotic or serious mental illness for more than two decades until the advent of psychiatric medications commenced in the 1950’s and 1960’s Ritalin has long been the focus of certain advocacy groups as the second prong on the American anti-psychiatry groups as far as treatments.

The second main front on the anti-psychiatry movement has been the focus on the social phenomenon of institutionalization, or the inappropriate use of the state hospitals, large asylums, to house the chronically mentally ill for incredibly long periods of time, or lifelong, turning psychiatric hospitals into convenient warehouses for the mentally ill, keeping them out of the sight and awareness and social responsibiity of the rest of American society and of other western societies as well. Psychiatric hospitals became de facto prisons since hundreds of thusands of persons were confiend to hospitals lifelong for not only grossly obvious psychotically bizarre behaviors but also petty offenses such as being poor, chronically inebrited etc. These latter “status offenses” as they were called in more modern times when applied to juvenile offenders were more common the 1800’s than is commonly known.

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Joint Commission Snubbed

This past week, for this health care provider, the unthinkable happened: a hospital rebelled,  and refused further accreditation review by the long-dominant and supremely influential arbiter of hospitals and their national rankings. The Joint Commission for the Accreditation of Healthcare Organizations is, as far as I know, an independent organization that has been around since before I ever dreamed of becoming a physician. To say any more about its history, development, and evolution would reveal my ignorance unless I scurried off during the writing of this post and did some hours of Internet search engine based research…

The story line is that the state of South Dakota has taken the unprecedented stand of declining having the Joint Commission to review and help the state reinstate the accreditation for the state psychiatric hospital of South Dakota! Continue reading