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Federal investigation: State hospital caused patient’s death

By Andrea Ball - American-Statesman Staff

Unnecessary restraints and poor medical care killed a woman who was strapped down for 55 hours at Terrell State Hospital last year, a federal investigation has found.

Ann Simmons, who died at the Northeast Texas psychiatric hospital in February 2012, died of a pulmonary thromboembolism because she was held in restraints for too long and failed to receive proper nursing care, according to a report by the Centers for Medicare and Medicaid Services. Poor nursing practices continue to endanger patients, placing them “at risk of potential harm, serious injury and subsequent death,” the report states.

Medicare’s investigation into Terrell State Hospital was launched in April after the American-Statesman inquired about Simmons’ death. Though her cause of death raised questions about the medical care the 62-year-old Pittsburg woman received, no one outside of the agency that runs the hospital had investigated.

Now the Department of State Health Services says it might close Terrell’s medical unit, which would require doctors to send some sick patients to local hospitals. Officials say they will scrutinize every patient restraint and develop a policy on how to prevent pulmonary emboli, which are associated with long periods of immobility and dehydration.

“We made immediate changes, and our main concern right now is strengthening our policies and retraining staff,” said Carrie Williams, spokeswoman for the State Health Services Department, which oversees the hospitals. “We’ve got to maintain our foundation of safety and stay focused on the patients.”

The findings of federal investigators confirm the suspicions of Ann Simmons’ husband.

“It makes me sad that she was basically left to die,” said Bob Simmons. “I knew that’s what happened.”

The Statesman’s review of about three dozen other deaths in the state’s 10 psychiatric hospitals showed that fatalities are rarely investigated by anyone other than the hospital in which the patient died and the state agency that runs it, leading to questions about the integrity and objectivity of such reviews.

When the Statesman brought the Simmons case to Medicare’s attention in April, federal officials discovered they had no record of it.

On April 24, a team of Medicare investigators unexpectedly showed up at the hospital to examine Simmons’ records and those of several other patients at the hospital. On May 24, Medicare ordered the State Health Services Department to improve care at Terrell by June 17 or risk losing $4.6 million in federal money, about 9 percent of the hospital’s annual budget.

Medicare investigators will now conduct a review of Terrell’s overall operations. When that is finished, the federal agency could terminate the hospital’s certification, thereby freezing its federal money; it could decide the hospital is in compliance with federal standards and end its investigation; or it could give the hospital more time to resolve its problems.

During their visit to Terrell, investigators found that patients were kept in restraints even when they were calm, cooperative or sleeping, the report states; that records showed no evidence that such patients were regularly moved, bathed or physically assessed; and that patients were being restrained for hours without a doctor’s permission.

Simmons, for example, was supposed to be restrained for 24 hours because she was pulling out a nasal gastric tube being used to administer fluids. But staffers inappropriately left her in wrist and upper body restraints for an additional 31.5 hours, even when she was smiling, chatting with nurses and watching television, the investigation found.

Bob Simmons says that’s what he saw when he visited his wife at Terrell. Ann Simmons was relaxed and lucid, yet was in restraints, he said.

“I’m glad they inspected, followed up and found out what happened,” he said. “Hopefully, it will prevent other people from dying.”

Medicare’s report also stated that other patients were unnecessarily restrained. Several of those restraints involved nasal gastric tubes, which provide liquids and nutrition to patients who refuse to eat or drink. The tubes are inserted through the nose, down the throat and into the stomach.

The Medicare report states that staffers kept one patient in restraints for five hours after she pulled the tube out. Another woman was drugged before her tube was inserted, though records indicated she was not uncontrollable or harming herself or anyone else.

When an investigator asked an employee if restraints were used as a convenience for the staff since the patients pulled out the tubes so often, the staffer answered, “Well, yeah, I guess you could say that.”

State officials say the tubes will no longer be used at Terrell.

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