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Days after Death at Santa Barbara County Psychiatric Unit, Second Similar Incident Emerges

Federal audit outlines another case involving improper use of restraints, failure to make required documentation and reporting

Just four days after a Santa Maria man died while in restraints at Santa Barbara County’s Psychiatric Health Facility last year, a second patient was also improperly restrained by staff, according to new records obtained by Noozhawk.

Last month, Noozhawk published a series of articles about deficiencies in patient care outlined by a federal audit of the county facility, also known as the PHF unit. After submitting a request to officials with the Department of Alcohol, Drug and Mental Health Services, the county released a version of the federal report — but with 10 pages redacted.

At the time, Noozhawk believed those missing pages detailed the facility’s actions surrounding the April 29, 2010, death of Clifford Detty, 46, of Santa Maria. After filing a Freedom of Information Act request, and receiving the full report from the Centers for Medicare & Medicaid Services, which conducted the audit, that suspicion was confirmed. Scroll down for a copy of the full CMMS report.

The CMMS report outlines the mistakes that PHF unit personnel made in the process of restraining Detty, and concluded that they violated the facility’s own rules. Click here for the original series on Detty’s death.

ADMHS officials would not comment to Noozhawk on the content of the redacted pages, but have said that the facility has issued a plan to address the deficiencies outlined in the federal report.

At the PHF unit, when an order for restraints is issued, a patient is placed in a five-point restraint — meaning a leather strap locks down the patient’s waist and each ankle and wrist — in a seclusion room. A surveillance camera in the room is watched by a staff member on a monitor at the nursing station. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm, according to the CMMS report.

But PHF staff failed to state what justified the use of restraints in Detty’s case at all, according to CMMS findings. They also didn’t document the type of restraints used or document that the use of restraints was time limited, all of which are required by PHF’s own rules.

The report also says that Detty’s death itself was not documented properly, and that the facility did not report his death to CMMS, as is required of all federally certified hospitals supervised by the agency.

The CMMS audit also documents a second offense, which occurred in the PHF unit on May 3, 2010, just four days after Detty died. An order for seclusion and restraints for self-injurious behavior was written to keep another patient safe, but the same mistakes were made as in Detty’s case.

“The order for the use of restraints and seclusion was incomplete,” the CMMS report stated. “The order failed to describe in specific behavioral terms the dangerous behavior the patient was exhibiting that presented a risk of great bodily harm justifying this most restrictive intervention, failed to specify the type of restraint to be used, and failed to specify that the use of the restraints and seclusion was time limited.”

Two days later, the second patient was put in seclusion and restraint again, still without proper documentation, according to the report.

Leslie Morrison, an expert on seclusion and restraint and director of the Disability Rights California investigations unit, knows firsthand how important these regulations are. She helped craft California’s Health and Safety Code 1180, which created more safeguards for individuals in seclusion and restraint.

According to Morrison, it’s community standard for a facility to require that the orders for restraint be specific and to include a statement about the behavior that required the restraint. Placing a patient in restraint is expressly limited to imminently dangerous behavior, she said, and there are limits with how long patients can be kept there.

“These are dangerous interventions and should be time-limited and may not last indefinitely,” she said.

Although it’s not unusual to see restraint and seclusion being used in acute-care facilities like the PHF unit, Morrison said that “these should be remarkable events that occur only in very egregious situations.”

After talking to Morrison, other questions surrounding the audit have also been answered. When Noozhawk published its first story on the federal audit, the facility’s medical director, Dr. Edwin Feliciano, said he wasn’t sure why the audit occurred when it did, since the facility had not been audited before.

In fact, after Noozhawk published an earlier story on the Detty case last year, Morrison began inquiring to CMMS about the Santa Barbara County facility’s status, and whether it was a federally certified hospital, as ADMHS officials asserted, or if had some other legal status.

If PHF were a hospital, staff would have reported the death, according to CMMS regulations. But Morrison discovered that Detty’s death had not been reported. What’s more, CMMS had not been inspecting the PHF unit for years, and the facility had “fallen off the radar,” according to Morrison. Her inquiries eventually prompted the federal agency to conduct the audit, which occurred in January.

Getting a full copy of that report from county officials proved impossible — even for the family members of those involved.

Detty’s father, Rich Detty, a Santa Maria insurance executive, had requested the report but was told by ADMHS director Ann Detrick that he couldn’t get a copy of the full report until he proved he was his son’s next of kin.

“I guess the death certificate that states I am the next of kin is not good enough,” he told Noozhawk in an email.

Rich Detty added that he didn’t get the amended death certificate until February, and the coroner’s report arrived almost one year after his son’s death.

Not only did Noozhawk and Detty have difficulty getting the report, but oversight bodies in charge of the facility were left in the dark about the audit’s results, as well.

Noozhawk this week asked Mental Health Commissioner Ann Eldridge for comment on the second incident at the PHF unit, but Eldridge said she, too, had been given a redacted version of the CMMS report.

The ultimate county oversight body, the Board of Supervisors, was also not provided a full report of the audit, and supervisors contacted by Noozhawk said they were told pages were withheld because of privacy laws.

The PHF’s own bylaws are clear about oversight.

“Subject to the authority of the (Board of Supervisors) ... The facility’s clinical services will be monitored for effectiveness and efficiency and will be provided for in an environment of safety and dignity for patients and staff,” the bylaws read.

The story about why the information was being withheld also has changed as Noozhawk’s investigation has continued. ADMHS officials first cited HIPAA — the Health Insurance Portability and Accountability Act that protects patient privacy — as the reason for the redactions. As a result, Noozhawk checked in with Terry Francke, general counsel and co-founder of CalAware.org, the nonprofit Center for Public Forum Rights, about the county’s claims.

According to the California Public Records Act and the federal Freedom of Information Act, records are accessible unless some specific rule states that they are not, said Francke, who added that HIPAA doesn’t have any provisions to authorize state and local officials to censor federal reports.

“HIPAA, like many laws restricting access to information, is not infrequently misunderstood and mistakenly applied by those who either prefer saying ‘No’ to those who seek such information or who have some misplaced fear of legal liability,” Francke said.

When Noozhawk told Detrick that HIPAA did not apply to the county’s handling of the CMMS report, she cited the California Public Records Act. The law exempts medical records from disclosure under several circumstances, including when the disclosure would constitute an unwarranted invasion of privacy.

This same explanation was also given to Mental Health commissioners as reason for the redactions.

“When ADMHS receives a request for a record that we hold — regardless of whether the record was prepared by ADMHS or by another agency, including the federal government — our department is required to make that record available for inspection, after redacting the confidential medical information that the Public Records Act exempts from disclosure,” Detrick said.

Noozhawk staff writer Lara Cooper can be reached at .(JavaScript must be enabled to view this email address). Follow Noozhawk on Twitter: @noozhawk or @NoozhawkNews. Become a fan of Noozhawk on Facebook.

FOIA Results for PHF’s CMMS Audit

 

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