Federal investigators looking into how Rex Hospital treated a violent mentally ill patient found that the staff improperly kept the patient immobilized in restraints for extended periods and subdued him with a Taser stun gun on two separate occasions. But the Raleigh hospital will not lose federal funding over the incident because it has changed its policies.
The federal probe was the first time Rex has been placed on “Immediate Jeopardy” status and put at risk for losing hundreds of millions of dollars federal funding. In March and April state investigators reviewed the hospital’s internal policies to determine if Rex should be disqualified for payments from Medicare and Medicaid, the federal insurance programs for the elderly, poor and disabled.
Investigators from the N.C. Department of Health and Human Services, which administers the programs, initially concluded that Rex staff failed to provide a safe environment for the patient, the result of poor communication between nurses and security staff. Their findings said Rex staff failed to make sure that the restraints were not used as a means of coercion, discipline, convenience or retaliation.
Rex’s qualification was restored April 24, after the hospital made internal changes, such as stripping security guards of Tasers, requiring intensive training for doctors and staff, requiring physicians to review patient restraint decisions every 24 hours, and other policies.
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The 2-1/2-week-long episode lays out in stark detail the dangers hospital workers face when treating mentally ill patients admitted to hospitals, the consequence of a chronic shortage of space in psychiatric hospitals in the state. In January, WakeMed Health & Hospitals in Raleigh closed its emergency room to non-serious cases for 3-1/2 hours because its ER overflowed with 65 psychiatric patients. Such patients routinely wait for days or weeks in hospital emergency departments, requiring round-the-clock “sitters” and backup from security guards, until they can be transferred to a mental health facility.
“This was a patient who really should not have been in any hospital emergency department,” said Linda Butler, Rex’s chief medical officer. “The problem is, if we had not restrained this patient and he had run out into the parking lot and been hit by a car, we would have been in trouble.”
Butler said Wednesday that the situation was so volatile that one of the nurses caring for the patient asked to be reassigned. As part of Rex’s assessment of the situation, hospital officials are considering following the lead of other hospitals and adding an armed police presence.
Rex typically has up to a dozen mentally ill patients admitted at any given time, Butler said, and in December psychiatric patients logged 900 hours at the hospital. In March, mentally ill patients spent 2,261 hours in Rex as they awaited a transfer or a discharge.
It’s not clear whether Rex’s new policies would have resulted in different treatment for the mentally ill patient who was stunned, a 24-year-old man with a history of psychosis and paranoia and incarceration.
“None of our co-workers did anything wrong,” Butler said, noting that none of the doctors or employees involved in the episode was reprimanded.
Patient #5, as he is identified in public documents by the Centers for Medicare and Medicaid Services, was unlike other psychiatric cases, requiring intensive monitoring.
“Most patients, you can see when they’re escalating,” Butler said, referring to a violent mood swing. “This patient could be lying very quietly and within a split-second launch an attack at someone.”
The Rex probe was triggered by four anonymous complaints, likely lodged by hospital staff but possibly filed by another patient, a relative or a lawyer, or even the same person multiple times. The subsequent investigation, detailed in a 281-page report, reveals confusion and fear at the hospital as the patient abused nurses with racial slurs, punched health care staff and spat at them, and vowed to kill hospital employees and his own family.
Among his grievances, Patient #5 complained that he had been tortured by black people and that black people were forcing him to stay in the hospital. All six hospital employees he attacked were African Americans.
In the most violent incident, the patient bolted out of the emergency room and lunged at a security guard. The guard required treatment in Rex’s emergency room after the patient nearly ripped off his eyelid. In another incident, the patient head-butted a security guard and it took about 10 security officers to get him into restraints safely.
“Our staff had never been put in a position to have to manage such a volatile, violent patient in order to prevent harm to other patients and staff,” Rex President Steve Burriss wrote to federal and state health authorities on April 8. “We believed that we had policies and procedures in place to meet the letter of the law and the needs of our mental health patients and those requiring restraints, but those policies had not been tested by the extreme circumstances we experienced in dealing with this particular patient.”
If Rex had failed to appease federal and state investigators, the hospital would have fallen out of compliance with federal conditions for receiving payments from Medicare and Medicaid. Such an outcome would have deprived Rex of about 39 percent of its annual revenue, or about $275 million, based on fiscal year 2014 reporting.
Rex is part of Raleigh-based Rex Healthcare, which is owned by Chapel Hill-based UNC Health Care. Rex released the investigative report Wednesday.
No room at Cherry
According to the report, Patient #5 had recently completed a 30-day jail stay for making phone threats against his father. He was first taken to UNC Health Care Crisis and Assessment Service at WakeBrook, a behavioral health facility in Raleigh, but WakeBrook was full and the patient was becoming violent and required a higher level of care.
Cherry Hospital, a state psychiatric facility in Goldsboro, was also full, so the patient was taken to Rex on Jan. 24 and stayed until Feb. 10, when a bed at Cherry became available.
At various times during his stay at Rex, Patient #5 was kept in restraints on both arms and legs, and forced to wear an apparatus alternatively called a spit guard, spit mask or spit hood. The patient requested the body restraints at times, but also complained about the safety measures as he cycled up and down through emotional extremes.
“Staff did not know how to approach the patient and realized they were out of their league,” the Emergency Department director told investigators. “The staff and security did not know how to deescalate patient.”
The director was not identified in the report, and Butler would not provide a name. The director raised the most serious concerns in the federal investigation, describing the situation as tragic and a “catastrophic communication failure. ... This has been a call to action like you don’t know.”
The director told investigators that nurses should have loosened the patient from his restraints more often.
“I think the staff were terribly afraid of him,” the director told investigators on March 19. “The nurses and security were not working together.”
Concerns about restraints are a recurring theme in the report, but most Rex employees felt that immobilization was necessary.
“I believe he remains in imminent danger to himself and others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room, given there are no beds ... ,” Psychiatrist #3 wrote on Feb. 1.
“I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically.”