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Even with troubled histories, psych hospitals face few sanctions

Parents may never know that the facility treating their child has had serious patient care issues

On its consumer website, a high-profile accrediting organization displays its “Gold Seal of Approval” next to the names of almost every Georgia psychiatric hospital that admits children or teens for crisis care.

The Joint Commission, which sets quality standards and conducts inspections, says patients and their families should rest assured by seeing the shiny emblem it awards. “By earning our Gold Seal,” the commission says on its website, “you’re telling your staff, competitors, community and each and every patient that comes through your doors that you have placed an emphasis on quality of care.”

Above all, the commission says, the seal demonstrates a facility’s “devotion to patient safety.”

Yet, some Georgia psychiatric hospitals that display the Joint Commission’s seal have troubled histories with government regulators and law enforcement agencies. Their investigations have determined the hospitals failed to meet even basic patient protection standards, with some of the lapses contributing to patients’ deaths, The Atlanta Journal-Constitution found.

Regulators appear to impose few sanctions, though, even when government inspectors discovered cases of abuse, negligence or shocking systemic problems. Instead, government regulators routinely rely on hospitals to correct their own deficiencies and accrediting organizations say they partner with hospitals to help them improve.

Meanwhile, the hospitals continue to admit vulnerable psychiatric patients with little public notice of the failures.

At Ridgeview Institute Monroe, which admits adults and children, two patients died by suicide in 2018 while hospitalized, according to reports by the Monroe Police Department, which investigated the cases. A 22-year-old mother of two, hospitalized because she was suicidal, wasn’t being monitored every 15 minutes as ordered and was able to use a zip-up jacket to hang herself in the bathroom, police reported.

By the time state inspectors showed up nearly two months later, they documented failures that caused “serious harm” to a patient. The state agency reported that the facility had corrected its deficiencies by firing staff who didn’t follow policies, hiring new workers, conducting patient safety training and adding new policies. With the actions, the survey found, the hospital was back in compliance, suggesting a safe atmosphere had been ensured.

Then, about eight months later, a 46-year-old man who also was to be monitored died by hanging himself at Ridgeview, too. The police investigation found that forms showing that both patients were checked every 15 minutes weren’t accurate. Video reviewed by police found the 22-year-old woman had been left unmonitored for more than an hour, while the man was alone in his room, with no checks, for 90 minutes, according to police records.

“Once again Ridgeview Institute has put more effort into covering up their own neglect of patients . . . by attempting to debrief a certain version that only protects the big office and by fraudulently documenting care of patients,” the police investigator concluded after the second death.

Ridgeview’s parent company did not respond to the AJC’s requests for an interview.

Few patients would ever know that the hospital has had serious patient care issues. Public inspection reports posted on the state’s website, for the public to review, don’t reveal the deaths, and Ridgeview Institute Monroe has a Gold Seal of Approval.

‘Collaborative’ approach

State and federal regulators are supposed to enforce standards to ensure the quality and safety of patient care. The oversight system has multiple players.

Hospitals can voluntarily seek accreditation with a nonprofit such as The Joint Commission, which imposes extra standards. But the accrediting organizations can become part of the official system, too, because the federal government can authorize them to do some compliance checks on its behalf.

In Georgia, state inspectors at the Department of Community Health, working on behalf of the federal government, usually handle the most serious complaints. But the state agency often refers less serious ones to accrediting organizations.

Credit: Monroe Police Depart

Credit: Monroe Police Depart

Most psychiatric hospitals in Georgia turn for accreditation to The Joint Commission, a nonprofit that is the nation’s oldest and largest standards-setting and accrediting body for health care. The Joint Commission does an in-depth review of hospitals every three years to identify patient safety risks by studying past cases, current care, the physical plant and credentials.

Hospitals can lose their accreditations if they don’t meet standards. The federal government can also remove hospitals from Medicare and Medicaid programs, which makes it almost impossible for them to operate. But that’s extremely rare. Accrediting organizations and government inspectors operate under a collaborative philosophy of allowing facilities to correct any problems they uncover because shutting down any hospital creates a cascade of problems.

“We continually partner with accredited organizations to maintain accreditation because they provide vital health care services that their communities need,” said Lisa DiBlasi Moorehead, field director for The Joint Commission’s Psychiatric Hospital Accreditation Program.

Some advocates say more careful monitoring of the hospitals is needed to protect vulnerable children and adults, whose family members are usually barred from staying with them during treatment. In Georgia, families may take their children to ERs at a pediatric or general hospital when they fall into a mental health crisis. If they are seriously ill, most will get transferred to a psychiatric hospital for crisis care.

How we got this story

With rates of depression, anxiety and suicide rising among children in Georgia and across the nation, The Atlanta Journal-Constitution explored whether kids in crisis could get the medical care they needed to get better. The AJC studied years of hospital admission statistics, inspection records, police reports, court records, recordings of state government hearings and public health data to try to understand how Georgia’s system worked. The AJC also interviewed mental health providers who work in the system, families whose children needed crisis care, hospital executives in multiple states and policymakers who are looking for solutions.

Readers who would like to share their own experiences related to behavioral and mental health services for children and teens can email investigative reporter Carrie Teegardin at cteegardin@ajc.com.

“The oversight at these facilities is notoriously inept and lacking,” said Darren Penn, an Atlanta attorney who represented the family of Sarah Reum, the 22-year-old who died by suicide at Ridgeview Monroe. Penn said national chains that operate psychiatric hospitals increase profits by cutting costs, especially staffing, frequently leaving patients like Reum without the care and monitoring they need. “As a result,” he said, “people needlessly die.”

Penn said the regulators and accrediting organizations don’t have the resources to adequately oversee day-to-day operations at the hospitals.

The Georgia Department of Community Health declined an interview request from the AJC and has not responded to written questions submitted to the agency.

Blistering report

Conditions found by inspectors inside the Lakeview Behavioral Health psychiatric hospital were deadly for at least one patient and disturbingly inadequate for many others.

One patient died in 2019 after nurses failed to provide CPR on a patient for 34 minutes until EMS arrived. The patient collapsed after being injected with medications to calm him after he became aggressive with staff, while also complaining of chest pain.

Inspectors found that shortcomings at the hospital were systemic and put other patients at serious risk, according to a blistering inspection report. Patients were not even given adequate psychiatric evaluations to justify their diagnoses or plans for treatment, reports show. The hospital is part of the Riverwoods Behavior Health System.

Credit: Department of Community Health

Credit: Department of Community Health

The inspectors called out the management of the hospital and its medical director. They failed to provide oversight to ensure patients received proper care. Some critical staff members didn’t even have the required credentials, inspectors found.

On top of the death case, inspectors found a juvenile patient who had been combative had bruises all over his body after a short stay at the facility. The investigations also found an 11-year-old sent for treatment for aggression after a brain tumor surgery didn’t get care for a rare physical disorder. Also, a confused woman was discharged to a homeless shelter even though records indicated she wasn’t stable and had been brought in by family. What’s more, the shelter wasn’t notified of her issues, a situation the Gwinnett homeless shelter director indicated was a pattern.

Lakeview was raided by police in 2019 but police announced no charges. In 2020, Gwinnett police investigated two Lakeview security guards for assault after video showed them beating a patient who refused to take medications. A series of civil lawsuits have been filed against the facility alleging poor care, including a sexual assault of a minor girl.

Credit: Natrice Miller / Natrice.Miller@ajc.com

Credit: Natrice Miller / Natrice.Miller@ajc.com

Allegations at Lakeview followed findings in 2017 by government inspectors that Riverwoods Behavioral Health had failed to implement follow-up care, which the inspectors said harmed three patients — they all died by suicide within 48 hours after being discharged by the hospital in Riverdale.

The Riverwoods facilities are operated by Tennessee-based Acadia Healthcare. The company did not reply to interview requests.

In late 2020, The Joint Commission imposed a preliminary denial of accreditation. But within four months, the Gold Seal status of accreditation was restored, the commission’s website shows.

Case closed, no fines

Public inspection reports don’t suggest frequent, widespread problems at The Ridgeview Institute in Monroe. But reports filed by the Monroe Police Department tell another story.

The department carefully investigated the two suicides in 2018. Officer Gina Holbrooks said in a report that Sarah Reum “cried out for help almost every opportunity she had with any employee.” But the facility responded to her death by falsifying documents regarding the care of patients, “who ALL should be Ridgeview’s sole purpose for existing.”

Police were called to the facility over and over again after the deaths, the AJC found, for dozens of incidents including thefts of patients’ property, violent incidents, allegations of sexual assaults and of the unwillingness of the facility to release patients.

The facility admits both adults and children and numerous reports involved minors, including one incident described as a “riot” in the adolescent unit. In September 2021, local police arrested a therapist working at Ridgeview for forcing a 17-year-old patient into sex, allegations the police found were backed up with recordings on her phone.

Credit: Natrice Miller / Natrice.Miller@ajc.com

Credit: Natrice Miller / Natrice.Miller@ajc.com

The facility repeatedly blocked police from entering to investigate complaints, the AJC found. Parents called local police because they couldn’t get information about their children or get them released. Just before Christmas in 2021, a Monroe police officer arrested one staff member caught lying about a patient’s wishes to leave the hospital.

“This is an ongoing issue,” the officer wrote. “It would appear that The Ridgeview Institute is holding certain patients with medical insurance against their will while refusing services to those who are not privately insured.”

The state of Georgia has posted a dozen inspection reports on its website for Ridgeview Monroe. On most visits inspectors said they found nothing wrong at the hospital when checking on complaints. Inspectors did find deficiencies related to medications and the handling of a special diet. Just this year, the facility was found to have failed to properly investigate an abuse allegation.

Credit: Department of Community Health

Credit: Department of Community Health

Five inspectors arrived nearly two months after the 22-year-old mother died inside Ridgeview. Internal documents obtained by the AJC found they clearly documented the gross failure in Reum’s care and found more problems, too. Every unit of the facility had been chronically understaffed, including the adolescent unit, according to the internal reports. Violence was common and conditions were dangerous for both patients and workers.

But when the investigation was finished, the hospital’s coming back into compliance closed the case. Federal regulators told the AJC they imposed no fines.

An apology found in the records came not from the facility but from the woman who hanged herself when she was supposed to be on suicide watch. “I’m sorry to everyone,” Reum wrote in pink marker on a note that police found in her room. “This pain is hurting.”


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