DEL.ICIO.USJustice Department says conditions at Atlanta facility violate patients' constitutional rights
The Atlanta Journal-Constitution
Published on: 06/04/08
An "unabated" failure to correct dangerous conditions at the state mental hospital in Atlanta has caused preventable deaths, injuries and illnesses for patients, federal investigators have found.
In a blistering 65-page letter to Gov. Sonny Perdue, the U.S. Justice Department detailed "critically deficient" conditions at Georgia Regional Hospital/Atlanta. Investigators have inspected two other state hospitals, finding comparable problems, and plan to visit another next week.
Continually failing to address hospital fatalities and violence, the letter said, caused similar deaths to multiply and left patients vulnerable to sexual assaults and other attacks.
Federal investigators, the letter said, found that medical and nursing care "substantially depart from generally accepted professional standards." They also determined that the hospital provides inadequate psychiatric treatment; uses seclusion and restraint, including sedatives, inappropriately; and fails to "adequately protect its patients from harm."
"The harm," the letter said, "can be fatal."
"We have concluded," the letter added, "that numerous conditions and practices at [Georgia Regional] violate the constitutional and statutory rights of its residents."
The Justice Department gave state officials 13 pages of necessary corrective measures, including the hiring of substantial numbers of medical and support staff members. If the state does not act by late July, the department said it could file suit to force the changes.
The department's letter, obtained Wednesday by The Atlanta Journal-Constitution, resulted from an investigation that began in April 2007. The inquiry's findings — unnecessary patient deaths, abuse by staff members, uncontrolled fighting among patients, overuse of medications, poor planning for patient care after discharge, shoddy or nonexistent investigations of serious incidents — echo a series of articles in the Journal-Constitution, "A Hidden Shame," published in 2007.
The newspaper reported that at least 136 patients died under suspicious circumstances at the seven state hospitals from 2002 through late 2007. In addition, the newspaper said, state officials substantiated nearly 200 cases of patient abuse by hospital employees during that period.
Officials at the Georgia Department of Human Resources, which operates the hospitals, said the Justice Department findings were not surprising.
"We were already working on many of these [problems]," Gwen Skinner, head of the state's mental health division, said Wednesday. Georgia Regional has increased its nursing staff, as well as the number of hours of patient treatment, she said. A commission appointed by Perdue to study the state's mental health system issued a report Wednesday documenting problems in hospital care, community psychiatric services and state funding.
Skinner acknowledged "a sense of urgency" in correcting problems at Georgia Regional. But asked about the Justice Department's contention that immediate changes were required, Skinner said, "It speaks for itself."
A spokesman for Perdue, Bert Brantley, said the governor has already put more money into mental health and "is definitely determined to make progress."
"We are confident in the plan of action and the steps we're taking," Brantley said. "There's definitely some momentum toward making changes."
A Justice Department spokesman in Washington, Jamie Hais, declined to comment.
A tone of indignation, however, infused the agency's letter to Perdue.
By tolerating a chronic shortage of nurses, the letter said, Georgia Regional "routinely compromises" patient care. The adolescent unit is "highly dangerous," the letter said, quoting one staff member as saying patients "would be safer outside" the hospital and another who described "continuing clinical chaos."
"Many of these deficiencies," the letter said, "stem from a system that does not have clear, specific standards of care or an adequate number of trained supervisory, professional and direct care staff."
Deaths highlighted
Again and again at Georgia Regional, a 352-bed facility on Panthersville Road that opened in 1968, investigators documented a failure to respond to danger signs about hospital performance or at-risk patients.
In 2006, the letter said, federal regulators cited Georgia Regional for poor mental health treatment, nursing and health care. Last year, consultants hired by the state reported similar concerns. And, the letter said, the Journal-Constitution series reported that patients "often suffer preventable injuries and illnesses, some of which have been fatal."
"We found that these same conditions remain unabated, despite [Georgia Regional's] notice of the deficiencies," Grace Chung Becker, acting assistant attorney general in charge of the civil rights division, wrote to Perdue.
The hospital failed to react when staff mistakes resulted in patient deaths, the letter said.
It cited the February 2006 death of Sarah Elizabeth Crider, a 14-year-old Cobb County girl whose case was highlighted in a Journal-Constitution article. The day before she died, the letter said, Crider complained of stomach pain and had nausea and vomiting.
An on-call physician did not document whether she examined the girl, who died of an infection caused by a severely impacted colon that went untreated. The letter said impaction is a well known side effect of many of the antipsychotic drugs prescribed for Crider.
Three days later, the letter said, a 33-year-old patient died at the same hospital after his "medical concerns were mishandled," including the failure to monitor his bowel functions. And that December, 59-year-old Michael Webb died after more than two weeks without a bowel movement — information never flagged on his medical chart, the letter said.
Georgia Regional's "failure to critically review the first death, which should have led to corrective actions that could have prevented the second and third fatalities, compounds the tragedy of these three deaths," the letter said.
The hospital's staff, investigators found, "often fail to provide even the most basic care, opting instead for a reactive approach in which patients' medical needs are addressed only after problems develop."
Observations
Similarly, investigators documented a failure to break a pattern of physical assaults and aggressive behavior. The adolescent unit, the letter said, is "particularly disturbing."
Investigators touring the unit observed a patient tearing a water cooler from the wall before he was forcibly restrained by staff members. A week earlier, in September 2007, six patients started a disturbance on the adolescent unit, throwing tables and chairs, crashing through a secure door to the building's lobby and breaking furniture. One patient used a piece of broken plexiglas to cut his neck before staff members could react. What investigators now call a "melee" was controlled only after hospital officials summoned DeKalb County police.
Investigators said they found "troubling patterns" of patient aggression on adolescent and adult units: repeat victims, repeat assailants, multiple assailants ganging up on a single victim. Assaults frequently caused serious injuries that required emergency room treatment, the letter said, including broken bones and head wounds.
"The repeated and significant level of violence on the units suggests a fundamental failure to address the root causes of patients' aggression," the letter said, "and demonstrates a failure to intervene adequately to prevent future incidents."
Violations found
In many cases, investigators found, hospital officials simply don't investigate incidents — or, if they do, they conduct woefully inadequate inquiries.
In one case, investigators found documents had been removed from the medical file of a patient who had attempted suicide. The documents described irregularities in the patient's care: Staff members had failed to watch the woman as a doctor had ordered, and one had gotten into a shouting match with the patient shortly before the suicide attempt.
Removing the documents from the file was "highly irregular," the Justice Department letter said. "Equally disconcerting," the letter added, was hospital officials' failure to investigate why the documents were removed.
Repeatedly, investigators documented situations in which hospital employees violated standard procedures. They cited the case of a patient who has been admitted to Georgia Regional 107 times; her treatment plan has rarely varied, and no one has assessed why she repeatedly returned to the hospital.
Patients routinely are discharged to places such as homeless shelters, motels and bus stops, the letter said, noting that the U.S. Supreme Court ruled in a 1999 case that shelters, for instance, were "inappropriate discharge locations."
State officials are more than familiar with that case. Georgia Regional, the Justice Department letter said, "is the very hospital where, nearly a decade ago, the United States Supreme Court made clear that the unnecessary institutionalization of persons with disabilities violates the law."
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More on ajc.com
- Mental health system may cut back, privatize (08/21/2008)
- Georgia mental patients in 'jeopardy' (08/01/2008)
- Mental patients in 'jeopardy' (07/31/2008)
- State agrees to widen housing options for mentally ill (07/02/2008)
- Mentally ill gain housing options (07/02/2008)
- Budget fix shifts millions from mental health (06/30/2008)
- UGA staff to write state mental health report (06/25/2008)
- Demand action on mental health care (06/19/2008)
- Perdue may divert funds from children's mental health (06/12/2008)
- Mental care funds at risk (06/12/2008)
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Comments
By simplexity
Jan 14, 2009 10:50 AM | Link to this
I was there in 08/08 and basically, it was just a crack house. (YES, AFTER THE DOCS LEAVE IN THE EVENING; THE WARD BECOMES A CRACK HOUSE). The "employees" instigate fights between the patients for "fun" and "entertainment". Blatant homosexual activity. Fighting going on all day long. A male counselor pulled out his penis and "waved" it at me... Other female patients complained of being raped while under sedation... A person is safer on the streets than in that hospital. Sorry, but that's just the way it is.
By simplexity
Jan 14, 2009 10:49 AM | Link to this
I was there in 08/08 and basically, it was just a crack house. (YES, AFTER THE DOCS LEAVE IN THE EVENING; THE WARD BECOMES A CRACK HOUSE). The "employees" instigate fights between the patients for "fun" and "entertainment". Blatant homosexual activity. Fighting going on all day long. A male counselor pulled out his penis and "waved" it at me... Other female patients complained of being raped while under sedation... A person is safer on the streets than in that hospital. Sorry, but that's just the way it is.
By simplexity
Jan 14, 2009 10:48 AM | Link to this
I was there in 08/08 and basically, it was just a crack house. (YES, AFTER THE DOCS LEAVE IN THE EVENING; THE WARD BECOMES A CRACK HOUSE). The "employees" instigate fights between the patients for "fun" and "entertainment". Blatant homosexual activity. Fighting going on all day long. A male counselor pulled out his penis and "waved" it at me... Other female patients complained of being raped while under sedation... A person is safer on the streets than in that hospital. Sorry, but that's just the way it is.
By Robin Davis
Jul 3, 2008 8:35 AM | Link to this
Robin Gary Davis
822 Burns Walk Court
Lilburn, Georgia 30047
678-683-5584
March 10, 2008 To Whom It May Concern:
My name is Robin Davis. I am 48 years old. In 2003 I was married, owned
a home, was the Director of Operations for Pless Security in Atlanta and was involved in Body Building. In 1986 I became interested in Politics and Rep. for state representative in Kennesaw Georgia District 38. Although I didn't win I stayed active in following the laws of Georgia. That all changed over night when I had a stroke in November of 2003. After 4 weeks in the hospital, 6 months in Rehab I lost my job and went on disability , my wife divorced me, I lost my license, had to learn to walk and talk again, I lost my home and moved into an apartment alone and went into a deep depression. My 72 year old mother and my step dad became the only support I had.
After 3 years of watching me lose the will to live my mom researched many options for assistance what she found was there wasn't any. Then she found "Just" People, after meeting with the director and explaining to them my story she was told I wasn't a candidate for their program, I didn't meet the criteria. My mom convinced her to just meet me and maybe I could bring something new to the program. She agreed, I am no longer lonely, I don't feel isolated or segregated. I live in the community with Just People. I have a job as a driver with the program, I cook for the Gwinnett Guys every Friday night, I am the Chairman of the Human Rights Community , a
member of the Board of Directors and a back up support person for the staff on property .My parents have stopped worrying about what will happen to Robin if something happens to them.
I have a few questions:
Where do we get a copy of the laws/guidelines for the MRWP?
Who wrote the policies and procedures for the MRWP?
Isn't it our right to live where we want to live? What happen to Freedom of Choice?
How to I get in front of the Board that governs the policies for the population I work with, live with and consider my family?
How can I help the system understand what people like me and my friends go through everyday to fit in?
Recently our agency was told "you have no business employing people with disabilities as companion sitters to work with your consumers". I though we had the right to work in the field of our choice if we were capable? Just People employees 6 people in jobs that they do well at and are qualified based on their skill level and ability .Sounds like the waiver program has some discrimination problems of its own to me.
I still have limited feeling in my right side, my speech is impaired and I can not longer write. But I have found a place where a person with my disabilities fits, free of discrimination. I have a home, friends, and a job. I am a happy, productive person, living in the community of my choice like all American Citizens should be allowed.
Sincerely,
~1i(\f ))AV\~
Robin G. Davis, Chairman Human Rights Committee
By Robin Davis
Jul 3, 2008 8:34 AM | Link to this
Robin Gary Davis
822 Burns Walk Court
Lilburn, Georgia 30047
678-683-5584
March 10, 2008 To Whom It May Concern:
My name is Robin Davis. I am 48 years old. In 2003 I was married, owned
a home, was the Director of Operations for Pless Security in Atlanta and was involved in Body Building. In 1986 I became interested in Politics and Rep. for state representative in Kennesaw Georgia District 38. Although I didn't win I stayed active in following the laws of Georgia. That all changed over night when I had a stroke in November of 2003. After 4 weeks in the hospital, 6 months in Rehab I lost my job and went on disability , my wife divorced me, I lost my license, had to learn to walk and talk again, I lost my home and moved into an apartment alone and went into a deep depression. My 72 year old mother and my step dad became the only support I had.
After 3 years of watching me lose the will to live my mom researched many options for assistance what she found was there wasn't any. Then she found "Just" People, after meeting with the director and explaining to them my story she was told I wasn't a candidate for their program, I didn't meet the criteria. My mom convinced her to just meet me and maybe I could bring something new to the program. She agreed, I am no longer lonely, I don't feel isolated or segregated. I live in the community with Just People. I have a job as a driver with the program, I cook for the Gwinnett Guys every Friday night, I am the Chairman of the Human Rights Community , a
member of the Board of Directors and a back up support person for the staff on property .My parents have stopped worrying about what will happen to Robin if something happens to them.
I have a few questions:
Where do we get a copy of the laws/guidelines for the MRWP?
Who wrote the policies and procedures for the MRWP?
Isn't it our right to live where we want to live? What happen to Freedom of Choice?
How to I get in front of the Board that governs the policies for the population I work with, live with and consider my family?
How can I help the system understand what people like me and my friends go through everyday to fit in?
Recently our agency was told "you have no business employing people with disabilities as companion sitters to work with your consumers". I though we had the right to work in the field of our choice if we were capable? Just People employees 6 people in jobs that they do well at and are qualified based on their skill level and ability .Sounds like the waiver program has some discrimination problems of its own to me.
I still have limited feeling in my right side, my speech is impaired and I can not longer write. But I have found a place where a person with my disabilities fits, free of discrimination. I have a home, friends, and a job. I am a happy, productive person, living in the community of my choice like all American Citizens should be allowed.
Sincerely,
~1i(\f ))AV\~
Robin G. Davis, Chairman Human Rights Committee
By ByeByeBJWalker
Jun 17, 2008 12:56 PM | Link to this
Why is BJ Walker still head of DHR? If Perdue is such a great and compassionate governor why does he put up with such overwhelming incompetence at the top that is causing horrible consequences for the most vulnerable members of our society? Is it because the mentally ill don't vote so they don't have a voice? That's a good Christian for ya. Stop having prayers for rain on the front porch and go to WORK man!
GA's mental health system is broken. That's not news. It's been going on for a long time. You can't continue to make budget cuts and siphon money from the mental health system to go to other programs and still have it work. The building is on fire, folks. Stop running around screaming that the building is on fire because we can all see that. Stop screaming and do your jobs! Hook up the hoses, put up the ladders and put the fire out! Hire a friggin' fire chief will ya? Heck, you copied Michigan's state report on mental health so why don't you copy everything else they are doing? Can't be worse than what they are doing in Atlanta which is NOTHING.
By dave
Jun 9, 2008 1:43 PM | Link to this
Its real simple. You have an overcrowded hospital where the majority of the care is delivered by people who make barely above minimum wage. Good people trying to do an impossible job. Govenor Purdue has significantly cut funds for inpatient treatment and closed hospitals so the ones that are open are overwhelmed. I hope the DOJ does take control and demand that the state spend some funds on treatment.
By Michael
Jun 9, 2008 7:52 AM | Link to this
IMO this should also be a criminal investigation. Although I have never been, I think prison isn't as bad as what these people have to endure. Even worse, they are not even criminals..for the most part - I do not know, just an assumption.
One more thing, I am appalled to know that up until 10 yrs. ago people with disabilities were allowed to be institutionalized in Georgia.
By Valerie
Jun 8, 2008 5:13 PM | Link to this
The State hospitals are turning the mentally ill out into the streets without treatment with the suggestion that they seek outpatient care. In my community it is non-existent. My son 22 has been hopitalized 3 times in the last year and our only option is to care for him until he realizes that he is sick and seeks help on his own. Or so I am told by state officials. I pray that we can keep this up. It is taking an enormous financial and emotional toll on our family. No one will help us not even the governor. We don't want to turn him out on the street and don't want to be homeless ourselves. I wonder how many other families have been forced to make this choice.
By Debra
Jun 7, 2008 7:08 AM | Link to this
As a nurse, I have to say that these problems arent specific to this hospital. Most mental health facilities are experiencing similar problems. Not enough nurses in general or staff needed. The state is also lacking in mental health facilities. When it comes to discharge, where does one send a homeless individual? If they have been living in a shelter, discharging them back to it seems appropriate. Not all homeless individuals are psych patients. As someone who has worked with many homeless individuals in the healthcare field, many choose this lifestyle. It may be hard for people to believe and most would like to blame the system but this isnt always the case.
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