An investigation into a man’s suicide at Central Regional Hospital found that staff members were not checking patients as they should and a record of patient monitoring had been falsified.
The state Department of Heath and Human Services said that a hospital nurse resigned before an internal investigation was over, and “personnel action” was taken against two other employees after a patient was found hanging in his bathroom last March. The two employees were not demoted, suspended or dismissed, DHHS said.
DHHS operates Central Regional in Butner and two other psychiatric hospitals – Cherry in Goldsboro and Broughton in Morganton.
A record of patient checks “included entries by staff that checks were conducted when the video surveillance confirmed otherwise,” DHHS spokesman Cobey Culton said in an email.
The death put Central Regional at risk of losing federal money. Inspectors determined patient safety was at risk. But the federal Centers for Medicare and Medicaid Services declared the hospital back in compliance in late May.
DHHS did not release the patient’s name, but an autopsy report confirmed he was Harold Jason Campbell, 42, of Macon County.
Before dawn on March 28, Campbell was found hanging by his belt, which was wedged between his bathroom door and door frame. He lived in the part of the hospital called the forensic unit, which is for people who are found not guilty of crimes by reason of insanity, have been found incompetent to stand trial, or are criminal defendants receiving court-ordered mental health evaluations.
Another Central Regional patient attempted suicide in a similar fashion in 2009, using a sheet.
Bathroom fixtures and door handles were scrutinized as potential suicide hazards at Central Regional before it opened in 2008.
According to records of the investigation into Campbell’s death, hospital staff members were required to check on him every 30 minutes. No one checked on him between 12:29 a.m. and 1:38 a.m., and no one checked between 1:38 a.m. and 2:51 a.m.
When they made their rounds, two nurses and a therapeutic staff support member did not go into Campbell’s room to check on him, but walked by the room or looked in without going in. Hospital policy requires workers to go into rooms to make sure patients are alive and in their beds. The investigators found hospital staff was not trained to do patient rounds according to hospital policy.
Immediately after Campbell died, the hospital removed all full-length bathroom doors in patients’ private rooms. DHHS officials decided patient privacy could be maintained without the doors, said Mark Benton, deputy secretary for health services. The agency is considering various options for replacing them, he said.
The state recently finished construction of a new Cherry Hospital, which Benton said has breakaway bathroom doors. DHHS is considering putting sensors on doors to semi-private bathrooms in the new Broughton Hospital under construction. Bathrooms in private patient rooms at Broughton will have no doors.
Campbell was charged in 2006 in Macon County with killing his mother.
According to local news reports, Campbell was charged with murder for shooting his mother and attempting to burn her body. He called 911 to report it. He told the dispatcher who asked about his mother’s condition, “She’s dead, ma’am. Just please send the police to lock me up.”
He was ruled not guilty by reason of insanity in 2011 and was committed to Central Regional. According to court testimony, Campbell thought his mother was trying to poison him. Campbell told a doctor at a state psychiatric hospital he was receiving computer messages directing him to kill his mother, according to a 2011 report in the Asheville Citizen-Times. A doctor found Campbell had a delusional disorder at the time of the killing.
A request from his doctors that he be allowed to spend unsupervised time outside the hospital brought Campbell back to court in February.
Brad Tisdale, of Macon County, Campbell’s lawyer for the hearing, said Campbell was allowed up to four hours unsupervised time at the hospital and doctors were asking that he be able to leave the hospital without supervision, with the time expanding gradually as Campbell demonstrated his trustworthiness.
Campbell was dejected when the judge denied the request, Tisdale said.
One of Campbell’s doctors testified in court that even if Campbell did everything perfectly, it would be 10 years before he was close to being released from the hospital, Tisdale said. “After the judge’s ruling he (Campbell) felt like it might never happen.”
After Campbell died, Central Regional told doctors to evaluate patients for suicide risk after life-changing events, and determine whether the patients should keep their belts and shoelaces.
The nursing staff was told that making notes on patient care before it is completed, or when it isn’t done at all, is falsifying a document.
The nursing staff was also trained to enter patients’ rooms while doing their nightly rounds. That training is ongoing, Benton said.
“It’s not a once and you’re done,” Benton said. “We take patient safety incredibly seriously.”