‘She should still be alive’
Woman’s death at Gahanna mental health facility raises concerns
The pressure felt crippling for Brant Cummins, and time was running out.
His mother, Susan Cummins, had tried to kill herself.
The Cincinnati woman was taken to a local hospital, and Brant and his dad, Tim, had only a few days to decide where to send her next.
Bringing her home was too risky. And they had no idea what facility would give her the best long-term mental health care.
“It was definitely rushed and frantic and scary,” Brant said.
Susan couldn’t go to one place because of insurance issues and another facility was full.
But then Tim and Brant turned to The
Woods at Parkside, located in Gahanna. It was a place they had contacted prior to Susan’s suicide attempt and whose marketer had been calling them on a regular basis.
Susan was admitted to Parkside on March 7, 2020.
“What a mistake that was,’” Brant said, sobbing.
On April 10, Susan was found lifeless in her room. The 65-year-old had killed herself.
“Susan should be here, experiencing the kids with me, watching them grow,” Tim said. “That was all taken away from me. She should still be alive.”
‘No suicide risk plan was implemented’
Two months after her death, records from a state investigation stated that the Parkside staff had not conducted a proper assessment of Susan’s mental health history and needs, which meant that they did not treat her as being a high risk for suicide.
Family attorney Mike Mezher said that Mercy Health-clermont hospital records provided to Parkside indicate that Susan was admitted to Mercy Health after she had made a suicide attempt.
Parkside, in its own “Root Cause Analysis” of the incident, filed with an accrediting organization called the Joint Commission, and later submitted to the state, acknowledged that it did not take Susan’s past history into account, that “no suicide risk plan was implemented.”
In January, the Cummins family filed a civil lawsuit in Franklin County Common Pleas Court, naming Parkside, its parent company, Oglethorpe, Inc., the Ohio Department of Mental Health and Addiction Services (which oversees the facilities) and a number of individuals as defendants.
The ODMHAS later was dismissed as a defendant, and the Joint Commission, which is an Illinois-based organization that accredits hospitals and mental health facilities, was added as a defendant.
Four deaths in three years at Oglethorpe’s Ohio mental health facilities
Susan’s death was not the only incident in Oglethorpe-owned mental health facilities in Ohio.
In the course of a months-long investigation, The Dispatch reviewed hundreds of public records obtained from the state through requests made under the state’s Open Records Law.
The review found that since July 2018, four patient deaths, including Susan Cummins’ suicide, have been investigated by the state in three Oglethorpe facilities in Ohio. In addition to Cummins’ death at Parkside, there have been two deaths at Ridgeview Behavioral Hospital in Van Wert County and one at Cambridge Behavioral Hospital, which has since closed.
In all four deaths, the state cited the facilities for policy violations and put Cambridge on a probationary license in November 2019.
The Dispatch contacted attorneys for Oglethorpe for comment. They did not respond directly to the request, but instead filed a motion for an emergency gag order in Franklin County Common Pleas Court, requesting, among other things, that The Dispatch be barred from publishing this story so as not to prejudice a jury pool. The Cummins’ civil case against Oglethorpe is scheduled for trial in January 2023.
That motion, which Dispatch attorneys argued to the court was unconstitutional, was denied by Franklin County Common Pleas Judge Kim J. Brown.
The Dispatch then reached out again to the Oglethorpe attorneys and received an emailed response.
“We are aware of Mr. Cummins’ allegations and vehemently disagree with his claims against Parkside and their employees and staff regarding Mrs. Cummins’ suicide and death,” the statement read. “It remains our intention to continue to fully defend the appropriateness of the care and treatment that Mrs. Cummins received from Parkside through their employees and staff.”
State officials, who are responsible for regulating about 2,300 mental health and addiction-treatment facilities, said they could not comment on Oglethorpe or Parkside because of the pending lawsuit.
But they expressed confidence in their system of oversight, even as they said they were hoping to hire more employees to help with the licensing and inspection process.
One expert said the demand for mental health services and the growing number of facilities in Ohio that provide different forms of treatment have made it almost impossible for state regulators and families in need to navigate it all.
“Crisis might be too strong of a word, but we have been putting up with this far too long in the mental health system,” said Keith Warren, as associate professor at the Ohio State University’s College of Social Work whose expertise is residential treatment for substance abuse.
“Standards for mental health services are very weak. Standards for residential programs are very weak. Information on these programs is every weak. And enforcement mechanisms for these services are very weak.”
Warren said the state needs more public transparency that cites violations, investigations or major incidents at mental health facilities.
“You have to file a public records request to learn about these problems and that is wrong,” Warren said. “That information shouldn’t be kept from the public. If there have been issues that rise to citations and violations, people have a right to know before deciding where to send someone in need of help.”
The issue of whether the state’s mental health and addiction facilities are being regulated well enough caught the attention of at least one state lawmaker.
After learning of Susan Cummins case, Rep. Adam Bird, R-new Richmond, contacted The Dispatch and said that he plans to study the system more and will consider introducing legislation.
“The hope is we can find something we can do legislatively to bring relief to another family in the future and keep this from happening again,” Bird said.
“If the issue is there is not enough inspection or regulation, or enough finances to hire inspectors, or enough follow-up, those are all certainly issues to be looked at,” he said.
‘She loved people’: Susan Cummins remembered by family
Tim Cummins, 62, met his future wife at a shoe store she managed in a suburban Cincinnati mall. They were married in 1988 and had two children, daughter Kia, 29, and Brant, 27.
Tim and Brant remember Susan as a devoted wife and mother who was thoroughly involved in her children’s lives.
She was artistic, with many of her paintings gracing the walls of the family’s comfortable home in the Kenwood neighborhood of northeastern Cincinnati.
And they remember that she could cook.
“Her cooking was second to none,” Tim said. “She could take a simple piece of cod, just with lemon juice and butter, and it would turn out delicious, cooked perfectly every time.”
Tim and Susan would visit Brant at the University of Cincinnati on football game days and sometimes offer to cook for his fraternity buddies, preparing hundreds of meals.
She also sometimes would drop off food for Brant.
“We had a group chat at school, called, `The Susan Cummins Secret Society of Lasagna,’” Brant said. “We had to keep it secret so people wouldn’t eat our leftovers.”
Brant also recalled his mother as one who deeply cared about people, both her children and others.
“She was involved in my life and got to know all my friends; she loved people,” he said, once again fighting emotions. “One of the beautiful things about her, you know, we live in such a fastpaced life, but she would slow things down, ask open-ended questions, and she would actually get to know you.
“She took time to care and have an authentic relationship, and that was just the beauty in her.”
At the same time, there was a darkness in her that she kept well hidden from her family.
Tim remembers a few of what he calls “episodes,” when Susan would get “massively depressed.” Usually, her parents – who lived nearby – would come over, and she soon would recover, Tim said. The first one he can recall was
nearly 30 years ago, but it wasn’t until more recent years that Tim realized the severity of his wife’s mental illness.
Tim was pursuing a busy career as a sales representative, which often involved travel. He said he was unaware that his wife had begun seeing a psychiatrist and had been prescribed medication. She handled all the bills, he said, and kept her struggles secret.
In 2015, both of Susan’s parents died within a two-month span, and Tim and Brant said that’s when she could no longer hide her problems.
She began drinking, often to excess. “Looking back, I see things that happened, and now I understand what was going on, but back then, I didn’t know,” Tim said. “When her parents passed away, the cushion was gone.”
In 2018, Tim persuaded her to go to Beckett Springs, a mental health and addiction treatment hospital in West Chester, near Cincinnati.
She would spend two or three weeks there and then return home and begin drinking again. This happened four or five times, Tim said.
Then, on the morning of Feb. 27, 2020, Tim went to work, and Brant, who was living at home at the time, checked on his mother. She was unconscious, having overdosed on a drug sometimes used to help with major depressive disorder.
Susan was treated in the intensive care unit at nearby Jewish Hospital, then sent to Mercy-clermont in Batavia, east of Cincinnati, for several days of recovery and evaluation.
At that point, the clock was ticking for the Cummins family to decide where Susan could get longer-term mental health care.
And that raises the question of whether families have enough information to make a good decision.
State officials from the Ohio Department of Mental Health and Addiction Services told The Dispatch that they have made it a priority to help guide families to the right treatment for their loved ones.
They cited their Careline (1-800720-9616) and the Ohio Crisis Text Line (text keyword 4HOPE to 741 741) as resources, as well as the websites mha.ohio.gov or Findtreatment.gov.
They also suggest contacting local National Alliance on Mental Illness (NAMI) offices, or county Alcohol, Drug Addiction and Mental Health Services (ADAMH) boards.
“Ohio supports services that are person-centered and tailored to everyone’s unique needs – there is no “one-sizefits-all-approach” to wellness,” Jodi Snider, the ODHMAS chief of licensure and certification, said in written responses to Dispatch questions.
“At (ODHMAS), our goal is to empower families with information and resources needed to help them find the right facility for their loved ones.”
Concerns with The Woods at Parkside
Tim and Brant Cummins said they made their decision to send Susan to Parkside partly because of the persistence of the Parkside representative and partly on the suggestion from a staff member at one of the other facilities that they contacted that could not take her.
Tim said he Googled Parkside, and at that time, in early 2020, it had a 4.35 rating from user reviews.
There is no database families can turn to, or anywhere to find a listing of past deaths or state disciplinary actions searchable by facility or provider.
Had they known about it, Tim and Brant could have checked a database kept by the nonprofit organization Kaiser Health News. It reveals that every year from 2016 to 2020, the federal Centers for Medicare & Medicaid Services penalized Parkside 1% of reimbursements.
Facilities are penalized for being in the bottom 25% of hospitals in the hospital-acquired condition rankings. That is a measure of infections, falls and other complications that occur in each facility.
The Dispatch independently verified the Kaiser Health News information with the Centers for Medicare & Medicaid Services.
Susan Cummins died by hanging herself on the interior doorknob of her room.
The risk involving the doors in patients’ rooms had been raised in an inspection years earlier.
State records show that in a May 2017 inspection by the Joint Commission, the commission cited the facility for “ligature risk and self-harm risk” in its patient rooms, a situation the commission listed as widespread with a high likelihood to cause harm.
According to state records, a followup inspection in June 2017 resulted in Parkside being considered compliant. The records do not indicate what happened between then and Susan Cummins’ death in April 2020.
According to Parkside’s analysis of Susan’s death in a report filed to the Joint Commission, Susan’s room did not have ligature-resistant door handles. Such hardware would consist of a handle with rounded edges, preventing someone from tying anything to it.
According to newsletters found on the Joint Commission’s website, the group in 2017-2018 underwent a review of its suicide-prevention policies and clarified its recommendations.
The result is that the commission would cite a facility that lacked ligatureresistant hardware only if it was considered a “secure or locked inpatient psychiatric facility.”
State officials confirmed that they did not consider Parkside such a facility, either in 2017 or in 2020.
Facilities that were not locked, though, still would require a comprehensive safety plan if patients were considered at high risk for suicide, according to the newsletters.
Officials for the Joint Commission declined to comment, citing the pending lawsuit.
Not the only one
The world changed soon after Susan was admitted to Parkside, with the COVID-19 pandemic causing most healthcare facilities to prohibit visitors.
Tim Cummins said he was able to visit Susan there only once, a week into her stay. He came away feeling that she was doing well, even making friends, who called her, “Mama Sue.” After that, he was limited to phone or video calls.
The family said her medical records from her treatment at Parkside support what Tim felt, that Susan at first was doing fairly well. But that changed after a few weeks, they said. In therapy sessions, she reported feeling more anxious and depressed.
Mezher, the family attorney, said, “The hardest part for me is the two- to three-week struggle she had where she was crying out for help and not getting the proper treatment.”
Meanwhile, Tim said there was little communication from Parkside about his wife’s treatment plan and said it was difficult to reach staff members.
Records provided by the state show that a member of Parkside’s patient intake unit noted that Susan had attempted suicide in the past 30 days. However, the same records show that two different Parkside employees, a nurse and Susan’s assigned counselor, both rated Susan as a low risk for suicide after she denied having recently attempted suicide.
The nurse filled out a detailed assessment, called the Columbia-suicide Severity Rating Scale, and on it, she reported zero suicide attempts and rated Susan as “low risk.” According to the scale, that means treatment consists of standard precautions and observations.
If either staffer had reported that Susan had attempted suicide recently, Susan would have been considered high risk, according to the suicide rating scale, and that should have triggered more precautions.
In the report of their investigation of Susan’s death, state officials criticized Parkside staff members for not rating Susan as a high risk for suicide.
Records show that the state accepted Parkside’s corrective-action plan in the wake of Susan’s death, and on Aug. 7, 2020, an investigator noted that Parkside had conducted, “all trainings relevant to the findings.”
In May 2021, the state re-certified Parkside for a period of three years.
Susan’s death was the last of four deaths at Oglethorpe-owned facilities since 2018.
Oglethorpe, Inc., is based in Tampa, Florida. Its website lists 12 facilities that it operates in five states, including three in Ohio: Parkside, Ridgeview and Georgetown Behavioral Hospital in Brown County. The Georgetown facility opened in 2020 and was praised by state surveyors at the time for its policies for patient care.
Records show that two patients died at Ridgeview in 2018, one in July and one in August. Both were found unresponsive in their rooms. The causes of death were not included in the state report.
In a December 2018 report triggered by the deaths, the state cited Ridgeview for a number of violations, including inadequate nurse training, prescribing unsafe medications, and failing to report hundreds of incidents as the state requires.
In October 2019, a 41-year-old woman died at Cambridge, one day after she was admitted. The state report revealed that the patient was combative with staff and refused to leave her wheelchair from the evening of Oct. 29 until she collapsed on the floor and was declared dead late in the afternoon of Oct. 30.
According to state records, in placing Cambridge on probation in November 2019, officials cited Cambridge for numerous violations, including incomplete or unsigned documents and administering medication despite not obtaining a signed consent to do so. Cambridge
closed in March 2020.
Also, in March 2021, Oglethorpe Inc. agreed to pay $10.25 million to settle a federal class-action lawsuit alleging Medicare fraud totaling more than $223 million. As part of the agreement, Oglethorpe did not admit to any wrongdoing.
Ohio’s mental health department seeks to add staff
State officials expressed confidence both in providers and in their oversight, even as they are seeking to add staff to help in this area.
“We expect compliance by all of the facilities we regulate,” Snider wrote in her responses to The Dispatch. “Overall, the majority of licensed/certified providers operate with minimal incidents over time. Part of the department’s role as an oversight authority is to ensure compliance with all rules and regulations governing the operations of these facilities.”
Of the approximately 2,300 facilities that ODMHAS regulates, 526 fall into categories in which outside groups such as the Joint Commission accredit a facility. The state accepts that accreditation as meeting its own requirements for licensure and certification.
Snider said that her department has 29 employees: four supervisors and 25 surveyors. Of those, she said, three employees are devoted to responding to complaints and serious incidents: One who has a dual role as a private psychiatric hospital licensure supervisor/surveyor and two surveyors.
She added that when a complaint or incident involves one of the 526 facilities that are accredited, the accrediting agency sometimes works with the state to respond.
And she said that the state is currently looking to hire more staffers to inspect facilities and investigate complaints and incidents.
Bird, the state representative, said he plans to have a meeting with ODMHAS officials to learn more about this issue.
Snider defended her department and providers in general.
“By nature, Ohio’s behavioral healthcare services system serves some of the most vulnerable, at-risk individuals, who often have complex histories of substance use, mental illness and trauma,” she wrote. “As is the case in any healthcare setting, while every effort is made to ensure safe, therapeutic environments for patients and staff, there are no fail-proof guarantees; no provider is immune from incidents.
“We value the life of every Ohioan, and we grieve with family and friends who have lost loved ones to suicide and addiction. We are focused on ensuring that prevention, harm reduction, treatment, and recovery resources and supports are available, visible, and accessible for Ohioans of all ages, and we promote strategies for organizations and trainings to build workforce competency to prevent suicide attempts and unintended deaths for Ohioans.”
“By nature, Ohio’s behavioral health-care services system serves some of the most vulnerable, at-risk individuals, who often have complex histories of substance use, mental illness and trauma. As is the case in any healthcare setting, while every effort is made to ensure safe, therapeutic environments for patients and staff, there are no fail-proof guarantees; no provider is immune from incidents.”
Mourning a loss
None of that, of course, is much comfort to the Cummins family.
They are approaching their second Christmas without Susan, who, true to her creative, artistic nature, always had the house decorated seasonally.
“On holidays, she would go all out,” Brant said, slipping into the present tense. “I wish you could see the house at Christmas, this place explodes into a winter wonderland. It’s quite the sight to see.”
Father and son both are dealing with guilt. Tim questions why he didn’t recognize the severity of Susan’s problems sooner, and both kick themselves for sending her to Parkside.
And both are angry. That’s why they decided to talk with The Dispatch about their ordeal.
“We need transparency,” Brant said. “We can’t let another family go through this.”
Tim said, “It’s going to be hard seeing this in the paper, and I understand why people don’t want to talk about it. But on the other hand, if I put my head in the sand like an ostrich like I’ve always done in the past, nothing is going to change.”
He said a friend of Susan’s recently asked him if he thought the family would win their lawsuit. He said he was taken aback.
“No one wins these things,” he said. “We’ve already lost. What the hell am I going to get? I just want to see justice.”
Susan had been scheduled to go to Beckett Springs for outpatient treatment upon her discharge from Parkside.
But some where along the line there was lack of communication.
Because the week after his wife’s death, Tim endured a final insult when Beckett Springs called and asked him: Where is Susan? kgordon@dispatch.com @kgdispatch mwagner@dispatch.com @Mikewagner48
Jodi Snider
Ohio Department of Mental Health and Addiction Services chief of licensure and certification