Suicide In Wellstar Douglas Hospital

From the AJC:

Hospital cited in patient suicide
ER fell short in monitoring a homeless man who hanged himself in Douglasville, according to a federal report.

By ANDY MILLER
The Atlanta Journal-Constitution
Published on: 02/25/08 A Douglasville hospital failed to meet patient safety standards when a homeless man committed suicide in its emergency department, federal regulators have found.

The patient, evaluated as a suicide risk by WellStar Douglas Hospital staff, was not properly monitored for two hours and was then found hanging in his seclusion room, said a federal investigative report. The death occurred Oct. 31.

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The report was obtained this month by The Atlanta Journal-Constitution under the Freedom of Information Act.

Douglas Wayne Brown, 45, was in a seclusion room — typically used to manage a very agitated patient — a total of 22 hours, waiting for a transfer to another facility for treatment of alcohol and psychiatric problems, according to the report from the federal Centers for Medicare and Medicaid Services.

The report, based on an inspection by state surveyors in mid-November, does not describe whether the WellStar Douglas emergency room was crowded when the patient died.

A suicide in a hospital emergency department is extremely rare, health care officials said. Brown's death also renews questions about the capacity of general hospitals and psychiatric facilities in Georgia to handle the rising demand for mental health services.

Acute-care hospitals recently have complained that overcrowding in the state-run psychiatric hospitals have caused an increase in ER waiting times for mental health patients before a transfer.

That overcrowding was documented in a series of articles last year in the Journal-Constitution, which also described persistent problems and errors in medical care at the seven state mental hospitals.

More than 90 percent of hospitals have run into difficulty in transferring patients to a state hospital, according to a new Georgia Hospital Association survey. The average wait time: 20 hours.

WellStar Douglas Hospital tried to have Brown transferred for mental health treatment, but two facilities refused to accept him, according to the federal report.

The report said ''only two non-hospital facilities'' were contacted, but did not say how many should have been called.

WellStar Health System officials, citing patient privacy rules, declined to identify the other hospitals contacted. They also declined to comment on the suicide itself, or on a police report that Brown ''was waiting for a bed'' at WellStar Cobb, an Austell hospital that has a behavioral health unit.

After Brown's death, the Douglasville hospital changed its policies on monitoring mental health patients and repaired its seclusion rooms, and is now in compliance with federal Medicare rules.

An executive with the five-hospital WellStar group said the system gets 500 to 600 mental health patient visits a month in its emergency rooms. But it's difficult to transfer them because there are not enough private or public psychiatric beds in Georgia, said Nancy Craney, executive director of behavioral health for the WellStar system.

Nationally, emergency rooms are increasingly having backups of all patients, including those with mental health problems, said Dr. Sandra Schneider, a Rochester, N.Y., emergency medicine physician. A suicide, though very rare, can happen when nurses get overwhelmed with a heavy patient load, said Schneider, a board member of the American College of Emergency Physicians.

Brown, described in the police report as homeless, was judged a moderate risk of suicide after arriving at the Douglasville hospital Oct. 30. He was also intoxicated, and had a history of alcohol abuse, the report said. An ER physician filled out a form to have Brown evaluated in a mental health facility.

Hospital policy required that there be continuous observation of patients in seclusion via camera, with in-person checks at least every 15 minutes.

After more than 18 hours in seclusion, Brown showed signs of anxiety in the afternoon of Oct. 31, and was given a medication used for alcohol detox. The federal report said ''there was no evidence that the patient was assessed and/or observed'' from 3 p.m. till after 5 p.m., when he was discovered hanging from a ceiling grate, a sheet around his neck.

Attempts to reach Brown's relatives were unsuccessful.

The Medicare report added that a week after Brown's death, a second suicide-risk patient in the same hospital remained in seclusion for two days and three hours before being transferred. ''The patient remained in seclusion although the behavior was calm,'' the report said.

The Medicare agency, in a Dec. 5 letter to WellStar Douglas' administrator, said deficiencies found in its inspection ''have been determined to be of such serious nature as to substantially limit your hospital's capacity to render adequate care.'' The hospital was also cited for fire safety violations.

The ruling that the hospital had not met Medicare's ''Conditions for Participation'' was lifted later in December after WellStar Douglas launched a policy of stricter monitoring of mental health patients, made their seclusion rooms safer, and educated staff on risk factors for suicides.