Federal report details psych patients death, says Parkland violated rights

Mona Reeder/Staff Photographer

Jane Pena is still looking for answers in the February 2011 death of her son, George Cornell, at Parkland Memorial Hospital in Dallas.

By MILES MOFFEIT Staff Writer mmoffeit@dallasnews.com

Published: 25 June 2011 11:17 PM

George Cornell refused to take another injection, and struggled with attendants. So three Parkland Memorial Hospital psychiatric technicians pulled his arms across his chest and wrestled him face-down to the floor of the solitary confinement room. A nurse pumped him with an anti-psychotic and a sedative. While Cornell resisted, the techs kept him pressed down for as long as 15 minutes. Those were among his last breaths. Cornells rights were repeatedly violated minutes before his February death in Parklands psychiatric emergency department, according to the U.S. Centers for Medicare & Medicaid Services.

A federal inspection report obtained by The Dallas Morning News provides the first public, in-depth look at what happened to Cornell, a 49-year-old who suffered from schizophrenia and heart problems. His case has triggered an upcoming broad federal review of the hospitals patient-care practices. Cornell was restrained twice for as long as 25 minutes total without a doctors order. The restraints occurred without close monitoring by a nurse, and without effective training of the technicians who subdued him, CMS investigators found. Such aggressive methods not only violate government standards but best practices promoted by mental-health organizations nationwide. Texas regulations prohibit holding patients face-down except to reposition them and for no longer than a minute. This looks really bad, and this is a major institution, said Dennis Borel, executive director for the Austin-based Coalition of Texans with Disabilities. We know in this field that certain restraints are inherently dangerous, yet they continue to use them? This is not one single screw-up, this is a series of mistakes. The use of so many risky measures from isolation to physical restraints to repeated injections adds up to serious violations of human rights, said Borel, who read the CMS report. You have to ask: Do they have a culture that says this is OK? Dr. Peter Breggin, a New York-based psychiatrist and former consultant for the National Institute of Mental Health, also raised questions. Seclusion and restraint is almost never a proper response, he said. What that human being needed above all else is one-to-one contact with somebody empathetic. Parkland officials have repeatedly declined to answer questions from The News about the report and Cornells death. But they delivered a list of corrective actions to CMS, saying they will revise their procedures and retrain staff physicians, nurses and techs to conform with regulations on properly restraining patients. We welcome this examination and it will receive our full attention and cooperation, a hospital news release said of the pending CMS review. A spokesman for UT Southwestern Medical Center, whose doctors staff the psychiatric ER, refused to talk about Cornells case. We do not comment on pending investigations, said Tim Doke, the spokesman. Parkland could face a variety of sanctions, from fines to the rarest of punitive measures, a loss of Medicare and Medicaid funding. These deficiencies have been determined to be of such a serious nature as to substantially limit your hospitals capacity to render adequate care and prevent it from being in compliance, CMS wrote to Parkland CEO Ron Anderson regarding the Cornell case. Other violations The 19-page CMS report offers another window into breakdowns of medical supervision at the Dallas County public hospital. The Cornell review is the ninth time in five years that CMS has cited serious patient-care failures at Parkland. An inspection last year found that the hospital, in six of six cases sampled, violated the rights of patients who complained about medical treatment. In addition, the agency this year cited Parkland for violating patient Jessie Mae Neds rights when a botched knee-replacement surgery led to nearly a dozen follow-up surgeries and an amputation. In recent weeks, federal and state regulators have focused on Parklands treatment of psychiatric patients. Since February 2010, three psychiatric patients have died, with Cornells death the most recent.

Parkland fired its director of psychiatric nursing just over a week ago. The hospital did not disclose a reason for the firing. The new details surrounding Cornells case surfaced during a surprise inspection of Parkland in early May after reports in The News about his death. The hospital had failed to notify regulatory agencies of the incident as required, authorities said. After reviewing records and interviewing staff members at Parkland over several days, health regulators cited the hospital for violating three federal standards. One pertained to failures in nurse supervision. The others involved improper use of restraint and seclusion. Federal and state regulations place strict limits on such methods because they can lead to physical and psychological trauma, research has shown. Pushing patients to the floor stomach down known as a prone position can compromise movement of the diaphragm or block airways, leading to asphyxiation or cardiac-related deaths. Cornell may have been particularly vulnerable. He had complained of chest pain in recent weeks, his mother said. He was overweight, smoked, had an irregular heartbeat and suffered from hyperlipidemia a condition of elevated cholesterol and blood fat linked to heart disease. He also was taking three prescription medications. Dr. Jeffrey Barnard, Dallas Countys chief medical examiner and a UTSW physician, concluded in his April autopsy report that Cornell died of natural causes: an irregular heartbeat due to an enlarged heart during psychosis from his schizophrenia. He noted multiple rib fractures, saying they were consistent with CPR. Barnard also documented two abrasions on Cornells forehead injuries that the CMS report said were not mentioned in hospital records at the time he was admitted. Barnards report did not address whether restraint practices were factors in Cornells death. It noted that Parkland staff reported he was held down to receive an injection in a seclusion room. But unlike the CMS report, Barnards report didnt delve into the nature and duration of Cornells restraint. After The News provided Barnard with a copy of the CMS review, he said he planned to reinvestigate Cornells death. Placed in solitary What was known before the CMS report is that Cornell left his Oak Cliff home, where he lived with his mother, sometime after midnight on Feb. 10, running to a nearby fire station. A station employee told The News that Cornell showed up winded and saying something about his chest, but refused an offer to take an ambulance to Parkland. Cornell also said he feared that people had been watching him. The employee called Dallas police to have Cornell taken to Parkland. He arrived at the hospital at 2:04 a.m. According to hospital records and Barnards report, the psychiatric staff characterized Cornell as agitated or combative shortly after he arrived. To control him over the next hour, the staff techs placed him in solitary confinement twice, the second time after he banged on a door and pulled up floor tile. He also was injected twice with three medications a total of 10 mgs of Haldol, 3 mgs of Ativan and 50 mgs of Benadryl, an antihistamine. Haldol is an anti-psychotic, and Ativan is a sedative.

When the techs took him to the second isolation room, he fought back and they had to restrain him. Two minutes after they left him alone, he was found blue and unresponsive, according to medical records. He was pronounced dead at 3:56 a.m. after resuscitation efforts failed. Irregular heartbeat The CMS investigative report, drawing on reviews of hospital records and interviews with staff members, fills in gaps of information unavailable in the autopsy report and medical records released to Cornells family. None of the medical staff is identified. Aside from detailing the restraint of Cornell and the breakdowns in supervision, it reveals that at least one staff member knew of Cornells problematic medical conditions before he was restrained. A physicians note timed at 2:23 a.m. documented his irregular heartbeat: cardiovascular positive for palpitations patient is nervous/anxious. A nurses note said he was placed in seclusion at 2:30 a.m. Another note, timed at 2:34, said Cornell resisted having his blood pressure checked. I am refusing medical treatment and I want to leave right now, Cornell was quoted as saying. The nurse wrote that he was not following verbal redirection from staff. The techs told the CMS team that they had to place Cornell in seclusion twice. The second time, the report said, he was kicking, yelling and swinging his fists. Both times, the techs acknowledged, they pulled his arms across his chest and held him face-down to receive injections. The first time, the techs estimated, they kept him down for up to 10 minutes. The second time it was for as long as 15 minutes, according to the report. At some point during that last takedown, the nurse left the room to make notations in his chart. A physician, who acknowledged that he didnt write any orders to restrain Cornell, told the inspectors that he walked in during the second takedown and ordered the techs to let the patient up. The CMS report doesnt make clear the range of medical tests or treatment Cornell was provided before he was placed in isolation or restrained. It also doesnt address why the techs restrained him for so long and without a doctors order. A staff member responsible for training employees on safe restraint techniques who was not present the night of Cornells death told inspectors that the techs were taught not to place patients in prone positions. If they do, the patients are to be quickly repositioned on their sides. When inspectors followed up with two of the techs to ask them what position they should place a patient in during a takedown or to give an injection, one didnt answer. The other said, on their stomach. Bans on restraints Since the late 1990s, government agencies and mental-health advocates across the country have strived to reduce and ultimately eliminate seclusion and restraint in hospitals and other facilities.

The federal government has enacted measures to curb or ban restraint-and-seclusion practices in health care facilities . Texas requires facilities to monitor patients closely and consider any patient risk factors before using restraints. Still, restraint practices have persisted in general and psychiatric hospitals statewide. During the last five years, the Texas Department of State Health Services has investigated 15 cases of patients who died in restraints or within 24 hours after being released, the agency said. At facilities like Parkland that receive Medicare and Medicaid funding, the federal government requires training on how to respond to agitated or aggressive patients. Most programs emphasize de-escalation strategies that use empathy and peer support instead of physical responses. The Joint Commission, which accredits Parkland and more than 4,000 other hospitals nationally, has reviewed Cornells death and worked with the hospital to improve practices. Robust assault Mental-health leaders pressing for the elimination of restraint and seclusion called Cornells death a red flag. Its very sad theres been a lot of work going on with these issues, but in a case like this you realize a lot more work is still to be done in the mental-health field, said Lynda Frost, director of planning and programs for the Hogg Foundation for Mental Health at the University of Texas. The foundation coordinates programs aimed at preventing coercive interventions. The News read to Breggin, the New York psychiatrist, the medications Parkland administered to Cornell and the medications he already was prescribed. The psychiatrist questioned whether the mix of drugs factored into his death. Cornell had been taking two anti-psychotics ziprasidone and quetiapine which Breggin said arent usually combined because of a risk for cardiac complications. In addition, he was taking an anti-depressant, Wellbutrin. Cornells mother said she had checked his medication bottles and it appeared he took his pills before going to Parkland. Adding the two injections he received at Parkland with those drugs is a recipe for trouble, Breggin said. You want to know if such a person can handle such a robust assault. Cornells mother, Jane Pena, said she wonders why the Parkland staff didnt contact her she was the only emergency contact listed in Cornells records before taking such brutal steps. It just makes me sick this didnt have to happen, she said. They wouldnt have had to do all that. She could have calmed her son, Pena said. Pena said she sent an email to Parkland CEO Anderson on June 6, but has received no response from him. In the four months since her sons death, no one from the hospital has contacted her to explain why or how he was locked in a seclusion room and restrained. Additional medical records were released to her last week. Also, the hospital sent her a $379.01 bill for trying to resuscitate her son. That was the deductible after Medicare paid Parkland $1,426.37. WHAT THEY SAID: Inspectors findings

This is how Parkland Memorial Hospitals psychiatric emergency department staff violated George Cornells rights just before his death in February, according to inspectors with the U.S. Centers for Medicare & Medicaid Services: A doctor failed to issue a written order to restrain Cornell, who was restrained twice while being held to the floor in a prone [facedown] position and medicated each time with Haldol, Ativan and Benadryl. The hospital failed to ensure that three technicians who held Cornell down were competent to physically restrain him in a prone position. And training for one of 9 personnel was not current. A registered nurse failed to monitor the physical condition, the safe application of restraints and the psychological well-being of [Cornell] during and after being physically restrained two times within approximately 35 minutes. And no documentation was found indicating [Cornell] had abrasions to his forehead on admission. Parklands response The hospital takes seriously its obligation to protect and promote each patients rights, Parkland officials told CMS. Among the changes the hospital says it is making as a result: Revising its procedure to clearly define types of restraints and to reflect that the prone or supine positions are not to be used except in cases where the patient is being transitioned from one position to another position, and in no event for more than one minute in duration. Physicians, nursing staff and psychiatric technicians will be educated on the content of the revised restraint procedures. Nurses will be re-educated on supervision procedures. Medical chart audits will be conducted in the psychiatric emergency department weekly for 16 weeks for all patients placed in restraint or seclusion to verify physician orders are present and compliance with procedures. SOURCE: U.S. Centers for Medicare & Medicaid Services