Sunday, August 03, 2008
News, In this Issue...

The patient in room 34

Gov. Perdue has agreed to transition most mentally ill patients out of state-run facilities. But private care may be just as bad.

shutterstock.com

By Stephanie Ramage

The patient in room 34 had been admitted around noon that day. One of the people whose job it was to watch him would later say that she first saw him in the private mental health facility’s dayroom—a kind of common room where the patients were allowed to mix and mingle—when she started her shift just before 3 p.m. She noticed that he wasn’t mixing and mingling. He was very quiet. Two years later, in a deposition, she would say she remembered seeing him there because he was in a wheelchair, something that set him apart from the other patients. She also remembered that he looked younger than the other patients, and that he had fair hair.

She did not know much about the patient aside from these basic things. She did not know, for example, that he had become a paraplegic in a diving accident when he was about 19 years old, or how in the aftermath of the accident he had eventually begun restoring classic cars. Piece by piece, day by day, he put them back together, and the parts catalogues piled up in his room in the home he shared with his mother. The young woman probably didn’t know that on the day he was admitted, at the age of 34, he was in the middle of restoring a 1957 Chevy. Or that he had become the go-to guy for his friends who needed their brakes replaced but were low on cash. Or that he had painfully weathered a breakup with his girlfriend a couple of years before the day he rolled into the private hospital where the young woman worked northeast of Atlanta's suburbs. 

As long as his health was good, he was OK. It could be plausibly said that being a paraplegic gave him enough to worry about without some added illness. So when he became sick, as he had about 16 months before, with a urinary tract infection, it depressed him. During that earlier infection, he had been admitted involuntarily to a different facility, but had calmed down, and had stayed of his own volition to complete some therapy.

At the time of his admission to the facility where the young woman worked, the patient had yet another urinary tract infection, and he was so depressed that he had threatened to kill himself. His frantic mother had taken him to an emergency room, where doctors signed papers for an involuntary commitment to the private mental health facility. His mother was afraid he would hurt himself, and she wanted to take every precaution to make sure that would not happen.

But the young woman whose job it was to watch him didn’t know any of that. She was 25 years old, and had only just graduated from a small college with a degree in psychology. She had never used her degree, had never been formally trained in the actual work of a mental health technician, aside from the training she had picked up in the little more than two months that she had worked at the facility. Before that, she had waited tables and worked at a golf course. She had a cousin who worked at the facility, and she had several friends who were nurses there. She earned little more than $10 an hour.

It was her job, on Aug. 4, 2005, to check on the patient in room 34 at least every 15 minutes. She probably did not know that her job is one that has always been part of the mental health field, or that in the 19th century, some inhabitants of London would give their profession on certain legal paperwork as “Bethlehem watcher,” meaning that they were employed by the Royal Bethlehem Hospital, later known simply as “Bedlam” Hospital, to watch the patients and make sure they didn’t hurt themselves or each other. As long as people have cared enough about the mentally ill to protect them from themselves, there have been those who are paid, albeit very little, to watch them. She was one of these.

And so, every 15 minutes, beginning at 3 p.m., she checked on the patient in room 34. She indicated having done so by initialing the time slot on a sheet of paper on a clipboard used for that specific purpose. Then, at 6:45 p.m., the initials changed to those of another mental health technician, a 59-year-old man who had worked at the facility for eight years, and had worked in low-level positions at other mental health facilities since the ’70s.

Who’s watching the patients?

The young woman, whom we will call Candy, may have gone to dinner at 6:45 p.m.
“I don’t recall,” she would tell an attorney in September 2007, when he asked her why the initials changed, and then she would say that it was likely that she had gone to get something to eat. She and the man, whom we will call Bob, usually split the unit’s 26 patients between them. She would take half as her patient load, and then, when she went to dinner, he would cover for her, and vice versa.

From 6:45 until Candy returned at 8 p.m., it was Bob’s initials that filled the blanks on the patient’s check sheet.

Candy may or may not have known that Bob, who earned a little more than $11 an hour, had been written up just nine days before that night for spending too much time in the nurse’s station. On July 26, his boss had noted in his personnel file, “…will spend most of his time in the milieu with the patients, and not in the nurses' station … will only be in the nurses’ station when it is required to do a specific task. He will demonstrate that he understands that the most important part of his job is to be in close proximity to the patients, observing them for safety, and meeting their individual needs.” There was also a note in the file that read, “Gets off on belittling staff and patients,” and another that stated, “Goes out of his way to make patients miserable.”

Between 8:15 p.m. and 9 p.m., neither Bob nor Candy initialed the time slots under the name of the patient in room 34. That portion of the sheet is blank. Candy would say later that she had gone to feed a patient who had been refusing to eat.

Bob would say that he was not aware that he was supposed to be covering for Candy from 8:15 until 9 p.m. In turn, Candy would concede that she had not directly told Bob to cover for her, but thought he was in earshot when she told their supervisor. She also admitted that she had not handed Bob the crucial 15-minute time-slot sheet for the patient in room 34. She had instead put it down on a work station near where Bob was standing at the nurses' computer.

During that 45 minutes, the nurse whose job it was to administer medication to the patients found Bob in the nurses’ station, and told him that there was no photograph in the file of the patient in room 34. Patients were usually photographed when they were admitted, something that helped to make sure that they were kept track of and given the right meds. Photographing the patients and printing out their photos was a duty that Bob had taken upon himself. Camera in hand, at 9:07 p.m. he made his way to room 34. He saw that the patient had pulled the covers up over his head. He called the patient’s name a few times. There was no response. He went over and pulled back the blanket and saw that the patient had a bungee cord tightly wrapped around his neck and that he was not breathing.

"He was ashen," Bob would tell an attorney two years later.

“I feel sorry for the mental health care workers and for the people they care for”

The patient in room 34 had a name, of course: the name that was printed on his chart, the name that Bob had called just before he found him not breathing and ashen with a bungee cord around his neck. But the lawsuit that resulted from his death, which was settled in July of this year, included an agreement of confidentiality. The Sunday Paper obtained the court documents of the case in exchange for reassurance that the paper would honor the agreement.

In nearly every instance of abuse or neglect among the mentally ill, there is an overwhelming concern for privacy. The stigma of mental illness is so great that most grieving families would prefer that the identity of the person they have lost remains anonymous, more than they wish for the exposure of those people or institutions involved in some way in the loss.

It's pertinent to the case that the bungee cord was one that the patient used to secure his legs to his wheelchair. Anything that might provide a way for suicidal patients to hurt themselves is always, as a matter of policy in any mental health facility in Georgia, removed upon that patient’s admission. But for some reason, no one had removed it from the wheelchair.

When police were summoned to take a report on the patient’s suicide, an investigator talked with Bob.

“I asked if he had noticed if [the patient] had a bungee cord around his legs,” the investigator wrote in the report, “and he said he did notice and thought it strange he would have it, but that considering his condition, it was not that abnormal.”

Shortly before the case was settled last month, damning reports about Georgia’s state-run mental health facilities prompted Gov. Sonny Perdue to announce that under a newly formalized agreement with the U.S. Department of Health and Human Services Office of Civil Rights, mentally ill and developmentally disabled Georgians will be transitioned out of state hospitals. The hope is that most will be enrolled in outpatient, community-based treatment programs. But it’s likely that many will end up at private facilities like the one where the patient in room 34 ended his life with a bungee cord.

“Obviously, this is going to take some focus by the state on these private centers and even on these community-based programs,” says Bert Brantley, spokesman for Gov. Perdue. “We are not just forgetting about these patients.”

According to Eric Spencer, executive director of the Georgia chapter of the National Alliance on Mental Illness, an outside agency is needed to reform Georgia’s private facilities as well as its public mental health care system.

“You have to remember that the state system is really a bunch of private enterprises that get Medicaid, Medicare and Peach Care public funding,” he says. Public or private, he says, “most insurance does not give parity to mental health and physical health. When my dad had a heart problem, he was in the CCU [Cardiac Care Unit] for three days, and then three days more to recover, and insurance paid it. When my daughter had her break from reality, she was in and out of the hospital in a couple of days. Which is more important, the heart or the mind?”

Most private facilities in Georgia are accredited by the Joint Commission on Accreditation of Healthcare Organizations, and must meet its guidelines. But the front line positions like those occupied by Bob and Candy are not licensed, and therefore they are not closely regulated either by the state or any professional organization.

William A. Anthony, executive director of the Center for Psychiatric Rehabilitation at Boston University believes that ignorance about the effectiveness of mental health care is at least partially to blame.

“People, unless they have experienced severe mental illness, don’t know people can recover,” he says. “Mental illness is not a life sentence, but obviously they need good care, and as a society we have not invested in that. I feel sorry for the mental health care workers and for the people they care for. We pay a lot of money to the people who watch our money, but we pay very little to the people who watch our people.”

The patient in room 34 didn’t die on Aug. 4, 2005. He was declared brain dead, but he survived on a ventilator for more than two weeks. The private facility has since changed its policies. It now avoids the issue of whose turn it is to watch the patients by assigning all 26 to just one mental health technician. SP