The Dallas Morning News

Psych safety woes shared

Suicides, assaults, sex misconduct found at multiple area facilities

- By SARAH MERVOSH and SUE AMBROSE Staff Writers

He had a history of attempting suicide — and succeeded at an Arlington psychiatri­c hospital, where he tied a bedsheet around his neck and hanged himself from a sprinkler head.

She was being treated for depression at a psych hospital in Denton when she was frightened by a naked man in her room. Three hours later, the same man, a patient, attacked a female staffer.

They were at the gym of a DeSoto psych hospital when a 9-year-old boy was choked and thrown against a wall by a homicidal teenager. The Dallas Morning News found these and other similar incidents in inspection reports for local psychiatri­c hospitals. These facilities are supposed to guard against such dangers: The purpose — and the promise — of their business is to help mentally ill patients, especially those who are suicidal and aggressive.

But our review of inspection records and lawsuits found that about half of psych hospitals in

Dallas-Fort Worth have had at least one major safety incident since 2011.

A few have been serial offenders.

We defined a major safety incident as a suicide or significan­t attempt; a report of unwanted sexual contact; or a serious physical attack. We used this threshold because Timberlawn psychiatri­c hospital in Dallas had similar problems before the state threatened to shut it down. Timberlawn closed Friday.

Any hospital, psychiatri­c or not, must offer a basic level of safety, experts say.

“You wouldn’t expect that if your loved one is in the hospital for a heart attack that somebody is going to come in and rape them, right?” said Janie Metzinger, public policy director at Mental Health America of Greater Dallas, a nonprofit advocacy group.

contacted local psych hospitals to ask about their safety records. Those that responded said they are committed to compassion­ate care.

Suicides inside psych hospitals are rare, said Mark Covall, president of the National Associatio­n of Psychiatri­c Health Systems, which lobbies on behalf of 1,000 psychiatri­c and addiction treatment facilities.

“These are difficult patients and they get good care most of the time,” he said.

Psychiatri­c hospitals are meant for the sickest patients. But in practice, nearly anyone in Dallas could end up there in a crisis. If your teenage daughter starts cutting herself. Or your husband confesses he wants to crash his truck head-on. Or your son overdoses and ends up in the emergency room.

In these emergencie­s, there is no easy way to check a hospital’s safety record.

Federal officials make their hospital inspection reports public, but the records are difficult to find online. Texas does not release its inspection reports.

To help fill that void,

examined federal inspection reports dating back to 2011 and combed through lawsuits for the same period for 16 psychiatri­c hospitals in DallasFort Worth. We used state data to identify the hospitals, which exclusivel­y or primarily treat psychiatri­c patients.

We did not include all safety incidents, which ranged from leaving plastic forks around suicidal patients to holding patients against their will. Some of these incidents were neverthele­ss serious; records show hospitals have faced regulatory scrutiny and paid fines for violations that did not meet our criteria.

We also did not include safety incidents at general medical hospitals, which sometimes treat mentally ill patients but account for just a quarter of psych beds in North Texas.

Over the past decade, the number of specialize­d psychiatri­c hospitals in Texas has grown. Some are so new they don’t have long-term safety records. Most are for-profit businesses.

‘Isolated, regrettabl­e’

Timberlawn — the East Dal-

las hospital that had been open for a century before it closed — had been a high-profile example of the danger inside psych hospitals.

In recent years, a suicidal woman killed herself under the hospital’s care and several female patients reported sexual assaults or fondling. A doctor died after a patient tackled her and knocked her unconsciou­s, though inspectors did not fault Timberlawn for her death.

With its license under threat from the state, Timberlawn decided to shut down voluntaril­y.

Timberlawn’s chief executive, James Miller, said the hospital made the decision after considerin­g a number of factors, including its aging campus and “the availabili­ty of beds and mental health services at other facilities within the Dallas area.”

But many of those beds are at hospitals that have had similar kinds of problems, The News found.

Take Millwood Hospital in Arlington, which, like Timberlawn, has been run by a national hospital chain, Universal Health Services. The 128-bed facility has been plagued by a string of safety incidents in recent years, from allegation­s of sexual assault to a 6-year-old boy whose nose was broken after an employee improperly restrained him.

In 2011, inspectors found, a male aide had been visiting the female adolescent unit — in violation of hospital policy — yet no one questioned why he was there. One night, he went into a bedroom where two adolescent girls were staying and forced them to engage in oral sex with him.

A year later, inspectors cited the hospital after a man who had been making “hypersexua­l comments” and had rubbed against a female staffer at a different facility was assigned a bedroom next to two women, far away from the nurses’ station. Records show the man came into the women’s room, exposed himself and asked for “sexual favors.”

And, in late 2016, a suicidal man whom staffers were supposed to check on every 15 minutes managed to hang himself from a sprinkler head.

Other patients saw him hanging in the hospital; one even tried to save him by lifting up his body. The episode left the other patients shaking with anxiety, inspectors said, and triggered at least one to be “highly suicidal.”

After that 2016 inspection, records show, the state notified Millwood that it planned to suspend the hospital’s license for 90 days and impose a $195,000 fine. The hospital is appealing the penalties.

Dwight Lacy, Millwood’s chief executive, said any safety problems at his hospital have been quickly addressed.

“While these cases represent unacceptab­le deviations from our high standards, they are not reflective of the overall quality of care and positive outcomes provided at Millwood to tens of thousands of patients over many years,” he said.

Universal Health says it fills a critical need in Dallas-Fort Worth. The Pennsylvan­iabased company owns five psychiatri­c hospitals in the area, more than any other corporatio­n.

“Isolated and regrettabl­e incidents unfortunat­ely do occur,” the company said in a statement. “We view any unintended incident as one too many.”

‘Immediate jeopardy’

One other company stood out in inspection records for its repeated safety violations: Sundance, a local company with hospitals in Arlington and Garland.

It’s unclear at which of the two hospitals the incidents occurred. Inspection reports don’t specify, and Sundance wouldn’t say.

In 2015, inspectors came into one of the Sundance facilities and found a torrent of problems.

A 33-year-old woman had nearly died while in the hospital’s care, records show. Depressed over losing a job and splitting up with her husband, the woman had tried to overdose on pills before she arrived at Sundance.

Despite doctor’s orders that staff should keep her within sight, the woman slipped away to attempt suicide. A housekeepe­r stumbled upon feet sticking out from a shower and discovered her slumped to the floor, a plastic bag tied around her neck.

The woman had to be resuscitat­ed, according to the inspection report.

Federal inspectors gave Sundance the most serious safety reprimand for this inspection, saying that patients were in “immediate jeopardy.”

Two days after that inspection ended, a 19-year-old widow almost killed herself at a Sundance hospital.

As she grieved over her husband’s suicide a week earlier, police found her barefoot and standing on a bridge. A few days into her stay at Sundance, inspectors say, staff let her out of their sight and she used a bedsheet to hang herself from a door.

The woman survived and sued the hospital. Sundance has denied wrongdoing; the case is pending.

At least two patients have also reported sexual assaults at Sundance, and inspectors found an incident in which a tech slammed a patient to the floor and hurt his head.

Records show that Sundance took steps to correct the problems, firing some staff members and retraining others. Dawne M. Buckley, an administra­tor at Sundance in Arlington, said she couldn’t comment on specific cases but said safety is a priority.

“We strive for excellence, every day, in all that we do,” she said.

In 2016, state records show, Sundance agreed to pay a fine of nearly $30,000 for safety violations.

Second chances

State and federal officials jointly regulate psychiatri­c hospitals in Texas — and have the power to revoke government funding, impose fines or yank licenses if a facility is unsafe.

“There is absolutely no excuse or reason for patient abuse in any facility,” said Carrie Williams, a spokeswoma­n for the state agency that regulates hospitals.

Williams said the state takes a tough look at all hospitals. But officials regularly allow facilities to negotiate down fines and often give second chances, knowing that no hospital is perfect and that patients need to be able to get care.

Asked why the state was tougher on Timberlawn than other troubled hospitals, Williams said: “It’s about a facility’s willingnes­s and ability to make real progress on fixing the violations we cite.”

Sarah Feuerbache­r, director of Southern Methodist University’s Center for Family Counseling, said there are practical ways for patients and their families to hold hospitals accountabl­e. They can ask for a tour of all areas of a hospital, expect flexible visitation hours and look for hospitals that have someone designated to answer their questions.

She also advocates for posting hospital inspection reports online.

State Rep. Stephanie Klick, R-Fort Worth, proposed a bill last year that would have required the state to make its reports public. The bill did not pass, but Klick said she plans to keep fighting for transparen­cy.

“You can go online and view the inspection reports for a restaurant,” she said. “Why shouldn’t you be able to for a health care facility, too?”

Staff writer Holly K. Hacker contribute­d to this report

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