Five months after federal regulators blamed Terrell State Hospital for the death of a patient, state leaders say they are overhauling operations at the 10 psychiatric facilities in Texas.
They’re making top bosses visit patients throughout the state; regularly inspecting how well doctors are performing; and revamping the way they identify and solve problems. They also say they have tackled major deficiencies identified during two federal investigations at Terrell State Hospital, such as substandard nursing care and filthy conditions.
What the state has not done is change the very thing that triggered months of federal scrutiny in the first place: A lack of independent oversight in the way the hospitals review the death of a patient. But that may be on the way.
“The reviews are thorough, but we’re looking at how we can make them more rigorous and objective by adding a layer of outside review,” said Carrie Williams, spokeswoman for the Department of State Health Services.
Death reviews are internal assessments of how and why patients die in state psychiatric hospitals. In April, the American-Statesman published a report stating that those reviews regularly cleared doctors of any mistakes or lapses in medical care even when those same reports pointed out clinical problems.
The Statesman focused on the case of Ann Simmons, a 62-year-old Pittsburg woman who died in 2012 at Terrell State Hospital after spending 55 hours in restraints. The death review found no faults in the medical care that she had received. Medicare — which investigated after learning about the case from the American-Statesman — disagreed. The federal agency ruled that Simmons died because of Terrell’s faulty medical care. Since then, the hospital has been ordered to make extensive changes by Oct. 18. The conflicting conclusions of the hospital and Medicare raised some basic questions. Would the state re-examine any of its previous death reviews? Would it change its procedures?
The answer is maybe. Williams said state administrators are exploring ways to bring independent scrutiny to hospital death reviews, but that she could not provide details because those discussions are ongoing. The goal is to ensure the hospitals are not the only ones evaluating their work, she said.
It is impossible for the public to know exactly how death review committees come to their conclusions. The investigations are conducted by hospital employees and the Texas attorney general’s office has ruled that all records of them can be kept secret.
But last year, the Department of State Health Services mistakenly gave the American-Statesman more than three dozen administrative death reviews, short summaries about a patient death provided to state leaders. Those documents formed the basis of the Statesman’s April report.
The summaries do not provide extensive information about the way the committees conducted their investigations, such as listing the people they interviewed or the documents they examined. Instead, the reviews generally contain the patient conditions, causes of death, and what, if any, clinical problems might have occurred.
The amount of information in the summaries varies. Some committees detail the conditions in which patients arrived, their evolving medical problems, their treatment and the circumstances surrounding their deaths. Others say nothing about the patients other than the fact that they existed.
Those familiar with the death reviews paint a picture of investigations that are limited in scope and identify problems without making doctors take responsibility for them.
Disability Rights Texas, a federally funded advocacy group, regularly examines such reviews. In general, hospital investigators do take a close look at the circumstances around a patient’s death, said Robin Thorner, a supervising attorney with the group. When the committees note flaws in care, they make recommendations for improvements, which can include new training and policies.
But those changes almost always seem to be directed toward nurses and other direct care staffers, Thorner said. Doctors, she said, “almost always get a free pass.”
And even when the committees find inadequate medical care, documents show that they usually tell state leaders that reviewers found no failures in clinical care.
In 2010, for example, a patient died after swallowing an unnamed object and doctors noted that they should consider a patient’s history before changing treatment. In a 2007 case at Rusk State Hospital, reviewers stated that they were not recognizing the signs of delirium. In 2006, reviewers at Wichita Falls hospital found that patient records did not accurately reflect the patient’s medical condition.
In all three cases, reviewers found no evidence of improper medical care.
Dr. Sidney Weissman, who reviewed the death reviews for the Statesman’s April report, said the documents he examined did not seem to get to the heart of why a patient died. The Simmons case is a good example, he said.
“Here, they did not pursue further understanding but simply wished to say that they did not have a problem,” said Weissman, a psychiatrist and professor at Northwestern University’s Feinberg School of Medicine.
State officials say they’ve used their experience with Terrell to make reforms aimed at protecting patients at all 10 psychiatric hospitals.
Hospital system leaders will conduct in-depth assessments at each hospital once a year, Williams said. In the past, state leaders have relied mostly on information provided by hospital superintendents.
“They’ll be walking through the hospitals, eating a meal with patients, going through the admissions process, talking to patients and staff at all levels, walking around campus, reviewing the environment,” she said.
The state has also hired several people to improve hospital services, Williams said. One new hire is focused on how the hospitals handle unusual incidents, such as escapes, unexpected injuries and serious incidents of violence. Another new staffer is regularly pulling medical charts to double check the quality of care at the hospitals.
The hospital division is also changing the way it tracks systemwide data. The state already collects volumes of information in areas such as abuse, neglect, restraints, medication errors, admissions and injuries. But that information hasn’t always been used to improve conditions at the hospitals. Now the state is going through it more carefully, tracking problems, developing solutions and communicating more effectively with the hospitals, Williams said.
“It’s a constant cycle, moving us toward being better hospitals,” she said
Additional changes are taking place at Terrell State Hospital because of two Medicare investigations prompted by the Statesman’s report: one into the Simmons case, the other into overall conditions at the hospital.
The federal agency cited problems in about a dozen areas, including nursing care, laboratory, food, anesthesia and respiratory services. Medicare regulators also said the hospital’s infection control and its environment for patients were inadequate; and that the hospital is failing to follow federal, state and local laws.
If the hospital doesn’t fix its problems, it could lose $4.6 million in Medicare money, about 9 percent of the hospital’s $49 million budget.
While the hospital is still working on the broad changes it is required to make by next month, the facility has already closed its 20-bed medical unit, agreed to review all medical restraints and stopped using nasal gastric tubes. Other changes included cleaning the hospital “top to bottom,” halting a high school program that allowed students to prepare blood slides headed to a laboratory, and changing the jobs of nursing managers to focus more on patient care than administrative duties.
In June, superintendent Joe Finch quit after state officials told him they wanted a leadership change at the troubled hospital and that they would fire him if he didn’t resign.
In July, the facility fired a nurse involved in Simmons’ case after the Office of Inspector General accused her of falsifying documents that unnecessarily kept Simmons in restraints. The nurse has disputed that version of events, saying that a doctor signed off on her actions.
WHAT WE REPORTED
The Austin American-Statesman first reported in April on the case of Ann Simmons, a woman who died at Terrell State Hospital in 2012 after being in restraints for more than two days. That report raised questions about whether those restraints contributed to her death and whether hospital officials had objectively assessed the circumstances around it. Federal regulators opened an investigation and concluded that poor medical care killed Simmons. Since then, Terrell State Hospital’s superintendent has resigned, a nurse charged with caring for the woman has been fired, and a federal investigation has found a number of other problems that are now being addressed.