A recent article in The Boston Globe highlighted problems with one of the Commonwealth’s major providers of mental health care. In a piece entitled “Staff Failures Cited in Deaths at Arbor Psychiatric Centers,” reporter Chelsea Conaboy describes three patient deaths that occurred at Arbor facilities in the last few years. The “staff failures” were basic: failure to follow emergency response policies, and in one case, a patient suffering from unexplained head trauma and multiple bruises.
Unfortunately, the problems uncovered by the Department of Mental Health (DMH) are not new. Our firm represents the family of a patient who died at Arbor Fuller Hospital in Attleboro in December 2007, because of some of the same problems recently reported. The most significant include the failure of the hospital staff to conduct regular safety checks on patients, and the inadequate emergency response when a patient is in distress.
In two of the more recent cases reviewed by the DMH, patients were found unresponsive, and there was an inordinate delay in bringing emergency equipment and beginning resuscitation. The hospital chain–owned by a Fortune 500 corporation called Universal Health Services based in King of Prussia, Pennsylvania–claims that it responded to the deaths by implementing new policies and retraining its staff.
Coincidentally, that’s exactly what Arbor and UHS told the state investigators in 2007, when they were being investigated on account of our client’s death in the Attleboro facility. She, too, was found unresponsive and there was a delay in response, including a lack of proper resuscitation. An extensive DMH investigation revealed a security videotape that showed a 40-minute gap between the time a staff member noticed a problem with the patient and the time he reported to it to his supervisor. And even when the problem was reported, and the nursing supervisor saw the patient unresponsive, the staff was shown walking calming around the floor, with no regard for the urgency of the situation. The DMH interviewed 16 people and issued a lengthy and damning report.
It would seem that if the hospital had responded properly to that tragic event, a similar situation would not have been repeated–TWICE–a few years later. And there’s no doubt that UHS was aware of the incident: two staff members were fired and a nursing supervisor demoted, all on the order of the company’s CEO. Policies were supposedly rewritten, and staff was supposedly retrained.
So why does the Arbor system continue to have multiple violations and patient deaths? Without question, many of these mental health patients are challenging to care for. But they need caring and compassionate staff who understand and are trained and equipped to deal with those challenges. Arbor’s track record of poorly trained staff who are at best overworked and indifferent to their patients’ needs, and at worst in blatant violation of corporate policies should concern anyone who cares about mental health care in Massachusetts and elsewhere.