Negligence, Deaths at NY Pilgrim Psychiatric "Hospital"
Circare
President, CIRCARE: Citizens for Responsible Care & Research, a Human
Rights organization
Tel. 212-595-8974 FAX: 212-595-9086
vera...@erols.com
FYI
Pilgrim Psychiatric Center is a NYS hospital that consistently
fails to provide acceptable standards of care to its largely aged,
disabled patients. Several years ago the U.S. Dept of Justice
found that numerous untwoard injuries and worsening of patients'
conditions as a result of its sub-standard, negligent patient care.
After a shut down of its research unit-- following a state invetigation
which found violations in patient protection requirements -- Pilgrim
is once again a center for psychiatric research, though its
sub-standard care has not improved. NY Newsday reports (below)
that researchers at Pilgrim do not bother to obtain informed consent
from relatives of deceased patients before removing their brains.
Furthermore, we have found that Institutional Review Boards (IRB)
at Pilgrim & the NYS Research Foundation for Mental Hygiene (NYSFMH)
gave approval to drug experiments involving high risks for
patients--without obtaining their informed consent-- as required
under Federal regulations. For example, "Academic Detailing for
Clozapine Utilization," a research project involving the schizophrenia
drug clozapine, was approved without requiring researchers to obtain
informed consent: NY Newsday reports that a patient given clozapine
at Pilgrim died of neuroleptic malignant syndrome, a fatal side-effect
of the drug.
Meanwhile, NYS officials & Pilgrim administrators keep mum as
patient deaths irreversible injuries due to neglect are being
investigated.
~~~~~~~~~~~~~~~
New York NEWSDAY
Deaths Bring Review Agencies investigate Pilgrim State after 3 die,
1 paralyzed
by Jamie Talan Staff Writer
State and national oversight agencies are investigating recent
incidents at Pilgrim State Psychiatric Center to determine whether
three patients who died Easter weekend and a fourth who is now
paralyzed from the neck down received adequate medical care and
whether their tragic outcomes could have been prevented.
Clinical privileges of three doctors who examined Michael Bernstein,
the patient who is now a quadriplegic, have been suspended, which
means they have no access to patients. Suffolk's Third Precinct
also is investigating actions leading to the patient's paralysis.
"There are some real concerns here," Dr. John Oldham, chief medical
officer for the New York State Office of Mental Health, said of
the four cases. His agency, which oversees care at all psychiatric
facilities and in-patient psychiatric units in the state, has
assembled a panel of independent medical experts to review the
episodes.
One patient died of a potentially lethal side effect of an
anti-psychotic medicine. A second patient with a history of swallowing
foreign objects died from internal injuries after she ingested a
pen; it was removed, but the injury remained untreated for two
days. A third patient died of a massive infection following a burst
appendix. His relatives say that he had complained for several
weeks of stomach pains. The patient who is now a quadriplegic was
initially termed "malingering," and 17 hours passed before he was
transferred to Southside Hospital in Bay Shore for treatment.
Administrators at Pilgrim said they could not comment on cases
under investigation, but the institution's director, Alan Weinstock,
said each case is being reviewed. He did say Friday that a root-cause
analysis has been done on two of the incidents to learn if there
was a problem in the delivery of medical care. He wouldn't identify
the two cases, saying only that reports will be filed after the
investigations are complete. "I expect that there will be policy
changes," Weinstock added. According to a nurse who asked not to
be identified, a recent memo to staff stated one change: Cervical
collars will now be available in the main patient building.
Also conducting an investigation is the Joint Commission on the
Accreditation of Healthcare Organizations, a national accrediting
group, which sent an investigator to the psychiatric facility in
Brentwood June 15 to interview staff involved in these incidents
and to collect medical records. The organization oversees the
delivery of medical care at hospitals throughout the country,
formally inspecting each facility every three years. If the agency
finds serious fault with the treatment these patients received,
Pilgrim could lose its accreditation status.
Investigators from a third agency, the state-funded Commission on
Quality of Care for the Mentally Disabled, also arrived in June to
conduct an investigation. It is a nonprofit watchdog agency that
keeps tabs on psychiatric and mentally retarded patients in the
state.
Bernstein, 34, the patient who is now a quadriplegic, fell over a
swinging half-door at a nurses station on May 9. He was paralyzed
from the neck down by the time he arrived at Southside Hospital 17
hours later. According to Bernstein's chart, he told doctors that
a therapy aide pushed him, causing the fall. The aide disputes
Bernstein's account. Pilgrim administrators notified Suffolk police
because of the allegation and the seriousness of the injury.
Two doctors who saw Bernstein at the scene of the fall, on the
floor complaining of numbness, wrote in his chart that he was
malingering.
Experts in spinal cord injuries who either saw or were read
Bernstein's medical records say that had the compression on his
cord been tended to immediately, he may not have progressed to
where he is now: paralyzed from the neck down and dependent on a
ventilator for his every breath.
The two physicians who dealt with Bernstein after the fall-Dr.
David Adler and Dr. Rafael Almanzar-were removed from patient care
duties within days of the incident, pending an investigation. A
third doctor who saw Bernstein the morning after the fall-Dr.
Niharendu Paul-was also told that his clinical privileges were
suspended pending an investigation, according to Roger Klingman,
press officer for OMH, who said the three actions were the direct
result of the Bernstein incident. The doctors are appealing the
actions, which range from three to six months. None of the doctors
returned calls seeking comment. Klingman said that it was the first
time in his five years with OMH that he had witnessed suspension
of physicians' clinical privileges at Pilgrim.
None of the doctors involved with the cases of the three patients
who died have been removed from clinical duty.
The events also raise concerns about the rights of mental patients
and their relatives. In one case, the family was not notified of
a patient's death and learned of it only when a reporter called
two weeks later. Another patient's family learned of his death when
a psychologist called to ask permission to donate the patient's
brain to science.
A review of hundreds of pages of medical records provides details
about the three patients who died within 36 hours of one another:
Marcus Jackson, 37, of Brooklyn, began taking a new antipsychotic
medication, Clozaril, on March 15. A doctor's note in his chart
that day reads, "Hold Clozaril if BP 90/60 or less." On March 29,
Jackson's blood pressure began to fluctuate, dropping to 90/60 from
150/90 the week before. He also was shaking with chills and tremors.
His psychiatrist decided to hold all medications, including Clozaril,
until he could be examined by an internist.
Later that afternoon, a slight fever developed, and his blood
pressure hadn't improved. An internist on the ward evaluated him
and wrote a prescription for an antibiotic, noting in the chart
"upper respiratory tract infection," followed by a question mark.
That evening, Jackson's blood pressure fell even lower, and his
fever climbed to 104.7.
The next day, his temperature returned to near normal and so did
his blood pressure, and a psychiatrist wrote an order to resume
the Clozaril. That afternoon, he was noted to be "lethargic" and
in a "stupor." His temperature climbed to 102 and his blood pressure
dropped to 90/70. He was given Tylenol, and again a decision was
made to stop Clozaril.
It was another 24 hours before the psychiatrist found Jackson
"delirious," and transferred him to Southside Hospital. He remained
there, attached to a ventilator and in critical condition, until
his death on April 23.
While his death certificate reads "acute respiratory distress
syndrome," Dr. Pamela Weinberg, Pilgrim's clinical director, said
an autopsy showed his death was caused by neuroleptic malignant
syndrome, the name for the condition that is a side-effect of
antipsychotic medication.
NMS is a condition that can be reversed if the medicine is stopped
soon enough and treatment immediately implemented, according to
Dr. John Kane, chief of psychiatry at Hillside Hospital-Long Island
Jewish Medical Center in New Hyde Park. Kane is an expert on the
condition, and he responded to Jackson's case at Newsday's request.
A 31-year-old Nassau County woman diagnosed with borderline
personality disorder swallowed a pen, one of many such incidents
over a period of years.
The woman, whose family asked that she not be identified, had been
in and out of psychiatric hospitals since she was 16 and had many
times engaged in self-injurious behavior, such as cutting her
wrists, banging her head and swallowing objects, according to family
members and medical charts. On March 26, she swallowed a pen, and
a Heimlich maneuver was performed; Weinberg said that she reached
into the patient's throat to remove the pen. It took another two
days, during which she complained of back pain, before she was
transferred to Southside Hospital. There, surgeons found an abscess
extending from the pharynx to the trachea. Her condition worsened
over the next three weeks and she, too, died April 23.
Guy Delaney, 41, of East Massapequa had been in and out of psychiatric
hospitals most of his adult life. His diagnosis: paranoid schizophrenia.
His brother, Stephen Delaney, had seen him several times in March,
during which time Guy complained of stomach pains. The patient's
brother said he reported the stomach pains to a staff member, who
responded that it was probably from something Guy had eaten. On
April 9, about 5:30 p.m., Guy Delaney asked the ward nurse for
Tylenol. A physician found him shaking with chills, and his abdomen
was sore and distended, according to medical charts. The doctor
noted he had an "acute abdomen" and transferred him to Southside
Hospital. His family was notified that Delaney was being taken to
the hospital to evaluate stomach pains. "It seemed like a routine
exam," his brother Stephen recalled.
At Southside, doctors diagnosed a burst appendix. Following surgery,
Delaney needed to be put on a ventilator. He remained in critical
condition until he died April 24.
The patient who is now a quadriplegic, Michael Bernstein, arrived
at Pilgrim Psychiatric Center in early November. He'd been in and
out of psychiatric facilities for more than 20 years. His main
symptoms were an explosive temper and manic behavior, according to
his psychiatric record. As a teenager, he tried twice to kill
himself with high doses of medicines. His recent stay at Pilgrim-he'd
been there once several years ago-was triggered after he threatened
a staff member at a residential facility in Massachusetts, according
to the medical records.
From November to mid-February, Bernstein received extra injections
of medicines 18 times to control his outbursts, triggered mostly
over issues of food and cigarettes, and had been put in restraints
or in seclusion an equal number of times due "to his assaultive
behavior toward staff and peers," reads a summary report in his
chart.
Pilgrim doctors had him on a daily regimen of six different medicines
to control his mood and behavior.
On April 17, his behavior still problematic, Bernstein was transferred
to a special unit for the more violent patients-the Behavioral
Treatment Unit.
Doctors believed they could figure out a way to manage his temper,
says a social worker who worked with him and who asked not to be
quoted by name.
A therapy aide's notes give this account: On May 9, three weeks
after he arrived at the behavioral unit, the aide caught Bernstein
smoking in his bedroom, which is not allowed. Angered at the
punishment-24 hours without cigarettes-Bernstein followed the aide
to the nursing station. Bernstein grabbed the aide's arm with one
hand and, with the other, reached for the nursing station phone-and
fell over a swinging 3-foot door.
A nurse came out from the nearby medication room to find Bernstein
on the floor, saying that he couldn't get up because his arms felt
numb, according to her note in the patient's chart. Dr. David Adler,
an on-call psychiatrist, arrived and examined Bernstein, who was
still on the ground. Cold water on his body produced a reaction,
and Adler wrote into the chart that he believed Bernstein was
"malingering." A few minutes later, Bernstein repeated his symptom
to Dr. Rafael Almanzar, an internist at the facility. He too saw
no evidence that Bernstein's "arms were numb," as he wrote in the
chart.
"No apparent injuries present except for mild redness over right
cheek," he continued. Adler and Almanzar discussed the case. "It's
our impression," Almanzar wrote, "that patient was malingering to
deflect attention to the fact that he was caught smoking in his
bedroom." About 8:30 p.m., according to notes on the chart, Bernstein
was given cold compresses for the scratch under his eye. No other
medical care was recorded that evening.
The next morning Bernstein's complaints broadened to include back
pain and inability to bend his knees, according to the chart. A
therapy aide reported at 6:30 a.m. that Bernstein "refuses to get
up or strip his bed." Dr. Niharendu Paul helped Bernstein into a
wheelchair about 7:15 a.m., and the patient was in the day room
when the next nursing shift arrived 15 minutes later. A note was
recorded in the chart at that time to give Tylenol as needed.
According to the nursing notes, Bernstein had trouble moving his
arm for a blood pressure reading, and he couldn't move his lower
body. He was alert but his speech was slow. The ward doctor saw
him that morning and called in the associate medical director, Dr.
Paul Vitulli, to evaluate the patient.
By the time Vitulli arrived, he knew the situation was serious,
according to the record. He wrote in the chart that the patient
had to be sent to the hospital to rule out "upper body" and "lower
body" paralysis. At 11:15 a.m., he ordered a transport for the
patient to Southside Hospital.
By the time the ambulance arrived at Southside at 12:47 p.m.
Bernstein was paralyzed, according to Michael Sacca, a spokesman
for the hospital. He was in critical condition, Sacca said, but
was still able to breathe on his own and speak. Seven hours later
Bernstein was sent to University Hospital at Stony Brook. Sacca
said that Bernstein needed a more intensive trauma unit and an MRI
scanning machine, both of which are available at Stony Brook.
The next day, May 11, Bernstein underwent an extensive surgical
procedure to reconstruct the spine. According to a family member,
the orthopedic surgeon who operated on Bernstein, Dr. Fred Orcutt,
told them that the patient had fallen on his head and suffered a
compression fracture of the spinal cord at the C3-C4 vertebrae.
Orcutt said that Bernstein may yet regain his ability to breathe
on his own. Orcutt refused to comment to a reporter.
Three experts said that spinal cord injuries call for immediate
medical attention. In Bernstein's case, they said that paralysis
may have been prevented had the patient's neck been stabilized at
the time of the fall, and he received immediate help.
"Sometimes things can progress because of compression to the cord,"
said a leading spinal cord specialist in New Jersey. He, along with
the other two, asked not to be identified because of the potential
for legal action. "If you relieve the pressure or whatever is
causing the compression, that's important.
You can prevent the damage from occurring." A family member said
Pilgrim officials told Bernstein's closest living family member,
an aunt, that he'd become paralyzed because of "a congenital spinal
defect." Indeed, Orcutt told family members that Bernstein had a
slight narrowing of the spine, a fairly common condition called
spinal stenosis. But Orcutt told Bernstein's relative and a
lawyer-Steven Mantione, hired by the family to represent Bernstein-that
if he didn't have stenosis his injury might not have been as severe.
Pilgrim administrators notified the Suffolk Police department's
Third Precinct within a week of the incident. "At this point there
is no proof that an altercation occurred," said Thomas Groneman,
a detective. The therapy aide refused to speak to a reporter. OMH's
Klingman said that the aide resigned from Pilgrim after the incident.
Police have not interviewed Bernstein. "We are still investigating,"
Groneman said.
While the tubes in Bernstein's throat interfere with his ability
to speak, on a recent visit he tried to respond to visitors.
Ultimately, three words were formed with enough force that a whisper
came through: "I was pushed." Bernstein's parents are dead, and
his sister killed herself when they were teenagers. "It was a tragic
life to begin with . . . and now this," a relative said.
Bernstein's doctors told relatives that his recovery will be more
difficult because of his psychiatric history. Stony Brook is
considering transferring Bernstein back to Southside until a nursing
home placement can be found.
According to OMH's Klingman, Pilgrim is conducting its own
investigation of the events that led to Bernstein's paralysis.
By law, Pilgrim administrators must report deaths and serious
injuries to the independent New York State Commission on Quality
of Care. The watchdog agency screens all deaths and selects suspicious
cases for further investigation. That represents about 10 percent
of all deaths, according to Gary Masline, a lawyer at the commission.
Masline said it could take up to a year before the investigation
of the events leading up to the three deaths and Bernstein's injury
is complete and findings are made public. According to agency
figures, 11 Pilgrim patients died in 1999, and an equal number of
deaths were already logged in the first four months of 2000. The
three deaths that occurred in April have been flagged for review.
A fourth, a man who died of cancer, was also flagged because of
its proximity to the other three, according to OMH officials.
Mental health experts acknowledge the difficulty in tending to the
medical needs of psychiatric patients. In the case of the 31-year-old
woman who died after swallowing a pen, for example, there was a
long history of self-harm in which she had received medical
intervention. In fact, her medical record shows the following: Six
months earlier she had swallowed a toothbrush, and many trips were
made to Southside before a CAT scan discovered the location of the
bristles, which then were removed in surgery. In early March she
had a number of swallowing episodes, including a pen cap that she
said had passed in a bowel movement. She was then assigned one-on-one
supervision, from March 7 to 13.
She continued to act out and show severe signs of depression;
according to a note in her chart, she was upset about the closing
of her ward and worried about where she might be transferred. On
March 24, she refused to eat or take her medicines and lay on her
bed, hugging her pillow.
"How many times did someone save her?" her father asked. He said
he believes she would have needed round-the-clock monitoring to
prevent such incidents. He loved his daughter and was devastated
by her death, but also devastated by her life-in and out of hospitals,
often harming herself, always deeply troubled. "It is an impossible
situation," he added.
Certainly, treating psychiatric patients for their medical ills
poses difficulties. "Providing good medical care to people with
severe mental illness is an ongoing challenge," said Dr. E. Fuller
Torrey, a schizophrenia expert and executive director of the Stanley
Foundation, an organization devoted to funding psychiatric research.
Nevertheless, the medical needs of psychiatric patients should be
a top priority, says Dr. Stephen Scharfstein, medical director of
the private Sheppard Pratt Psychiatric Hospital in Baltimore and
a leading expert in schizophrenia. He was asked by a reporter to
respond to the records that Pilgrim compiled on the incidents for
the Commission of Quality Care.
"Although psychiatric patients can have medical complaints that
are complicated and confusing," he said, "they must be worked up
completely and in a timely way to prevent a potentially life-threatening
problem.
"These patients are always vulnerable to improper care because
their psychiatric symptoms can confuse the diagnosis of medical
symptoms...But that's why doctors working with psychiatric patients
need to be extra vigilant. When a patient complains of a medical
problem, you have to go all out-immediately." Oldham, of the State
Office of Mental Health, said, "There are always concerns about
whether there is the right kind of clinical management, and in
these facilities it's much more problematic. The clinical challenges
of those remaining in [state institutions] are quite daunting. That
doesn't mean there shouldn't be an adequate standard of care.
"Patient safety is a high priority to us," he added.
The Pilgrim incidents also raise concerns about the processes in
place to keep willing families involved in their loved one's care.
In the case of Marcus Jackson, his family was never notified of
his death. Since his mother died in 1998, Jackson's maternal uncle,
Nathaniel McFarland, had been his only relative to visit. McFarland
said he told his nephew's doctor that he should be contacted should
he need anything. He left his address and phone number, he said.
That call never came.
Marcus Jackson was buried alone. McFarland was informed by a reporter
that his nephew had died. The hospital had autopsied Jackson and
removed his brain for a research project on schizophrenia, according
to staff members who asked not to be identified.
Delaney's family also learned of his death in an indirect way.
Delaney had received frequent visits from his brothers and sisters
and he spoke almost daily with his mother, who is frail and elderly.
Given the closeness of the family, it was a shock when Stephen
Delaney received a call from a Pilgrim psychologist asking for a
donation of his brother's brain to science. Weinstock said it's
Southside's role to notify family members when a Pilgrim patient
dies there. A note in the Pilgrim record indicates a staff member
called Southside with Stephen Delaney's phone number.
The family did decide to donate Guy's brain after the researcher
explained that the study would help unravel the mysteries of
schizophrenia.
Lawyers at the Mental Hygiene Legal Service, a state agency that
represents the rights of mental patients, have put together a report
detailing each of the cases and submitted it to the head of the
agency, Sid Hirschfeld. The agency is also now representing Bernstein.
"We are waiting to see whether the hospital takes appropriate
actions," Hirschfeld said. "Our concern is that the hospital does
a thorough and fair investigation and, if things occurred here,
that procedures and policies should be put in place to prevent
future incidents." Pilgrim is the last remaining state psychiatric
hospital for adults on Long Island. While the red brick buildings
on the sprawling campus in Brentwood once held tens of thousands
of mental patients, today there are about 625 patients.
Taking care of the medical and psychological needs of these patients
are 29 medical doctors and 39 psychiatrists, as well as social
workers, nurses and therapy aides.
Copyright Newsday, Inc. Produced by Newsday Electronic Publishing.