Gregory Jones had been at Jackson Park Hospital and Medical Center less than an hour when he turned a sheet into a noose and committed suicide.
His body hung from the door of an observation room for 14 minutes before anyone cut him down.
"I don't want any of this," Jones had protested when he was admitted to the Chicago hospital, records show.
But the bulky 48-year-old with a shaved head was threatening to end his life that night in early January, saying he could no longer handle the death of a brother. His girlfriend and teenage son believed that at Jackson Park Hospital he would be safe.
They didn't know that when Jones was locked in Observation Room 3 with its steel door and cameras, he was entering a system of documented danger.
Illinois regulators had repeatedly cited the hospital for neglecting at-risk patients, records show. No matter how many times hospital administrators promised change, patients were placed in jeopardy, according to state records.
It's an example of failed oversight of Illinois hospitals, critics say.
A previous Tribune investigation found regulators rarely pursue complaints against hospitals, even when there are allegations of serious harm or death.
As the case of Jackson Park Hospital illustrates, when they actually do investigate, the regulators can't ensure dangers are corrected.
With nursing homes, the state issues fines and publicly discloses violations. The nursing home also can be ordered to halt admissions of patients.
With hospitals, regulators are limited to the confines of written plans of correction, filed out of public view. The other enforcement tools are to shut down a hospital or withdraw its federal funding, seen as nuclear options to be avoided at almost all costs.
The organization that lobbies on behalf of hospitals has blocked measures that would impose fines on them.
"The hospitals hold all the cards," said Deborah Kennedy, a vice president of Equip for Equality, a patient advocacy organization in Chicago. "The findings at Jackson Park Hospital show you can have these plans of corrections over and over, but it doesn't mean the problem is fixed."
Merritt J. Hasbrouck, president of Jackson Park Hospital, and W. Dorsey, president of its board of directors, declined interview requests.
The hospital released a statement saying pending litigation and confidentiality requirements prevented it from commenting.
"Jackson Park Hospital is not able to provide any comment other than to verify that it denies any allegations of wrongdoing," the statement said.
The Illinois Department of Public Health declined to comment on its handling of Jackson Park Hospital, citing pending litigation, but it said in an email statement that it would "welcome the opportunity" to impose fines on hospitals.
The federal Centers for Medicare and Medicaid Services, which regulates hospitals along with the state, said its enforcement process was followed at Jackson Park Hospital. At the same time, the agency said it was "reviewing the effectiveness of the enforcement tools" in light of recurring patterns of problems in certain hospitals.
"We are concerned any time we see a pattern of serious deficiencies, especially a repeat of the same type of deficiencies," said Elizabeth Surgener, a spokeswoman for the federal agency.
An acute-care hospital with a psychiatric wing, Jackson Park Hospital draws nearly 25,000 admissions each year, most of them poor patients.
Its policies require that special precautions be taken for patients at risk of suicide, seizures, assaults, falls and flight from the facility. Physicians can order one-on-one observations or visual checks every 15 minutes, for instance.
But in repeated cases over the last two years, orders weren't implemented, policies weren't followed and the safety of patients was threatened, according to investigative findings of the state Department of Public Health.
During an inspection of Jackson Park Hospital in September 2009, a state official discovered that seven psychiatric patients were not receiving one-on-one monitoring as ordered by their physicians. Instead, two sitters in the hallway were responsible for surveying all of the patients while they were in their rooms, some with privacy curtains drawn.
Hospital administrators said in a plan of correction that they would educate nurses about the precaution policy and instruct them to follow physician orders. Supervisors would scrutinize their charts.
But seven months later, other flaws with patient monitoring were revealed.
A 70-year-old man admitted to Jackson Park Hospital for a psychological evaluation was returned to his assisted living facility with "a broken hip, a black eye, a gash on the back of head," among other injuries, according to complaints submitted to the state.
Upon his admission, the hospital had determined the elderly patient was a high risk for falls, which, according to its fall-prevention policy, meant he should have been monitored by a nurse every four hours.
Given his history of seizures, the patient also received an order for seizure precautions, which in practice was supposed to mean safety checks every 15 minutes, state records show.
But during his more than weeklong stay, there were hours, sometimes entire days, when no seizure or fall checks were documented, according to records.
Gaps in monitoring continued, records indicated, after the patient fell one night when no safety checks were documented.
Several days later, he was found on the floor with a bleeding head — the result, a physician's note said, of trying to jump off the bed. It was the morning of his discharge, and no observation checks had been recorded, documents show. So bad were the injuries that he had to be admitted to Mercy Hospital and Medical Center the next day.
When confronted with these investigative findings, hospital administrators revised their precaution policies and promised that patients at risk for falls and seizures would receive the necessary monitoring, according to an April 2010 plan of correction.
But the correction plan wasn't enough to stop other monitoring failures from surfacing two months later. This time, the state said the hospital had placed patients in "immediate jeopardy."
Because they were not receiving safety checks every 15 minutes as ordered, psychiatric patients were at risk for escape, injury and death, an inspector found. Some patients had not been checked for more than an hour. In other cases, observation records had obviously been falsified, the state said.
Meanwhile, a storage room was left unlocked, giving suicidal patients access to plastic bags, a television set with detached glass, and cords from a video recorder and CD player, according to records.
And in another misstep, locks were installed in the rooms of suicidal patients that allowed them to lock out medical staff.
The locks had remained on the doors even though a 32-year-old patient suffering from hallucinations commanding her to end her life had attempted suicide behind a locked door nearly a month earlier.
It was her second suicide attempt in the hospital. In the first case, she was found in bed "nonverbal" with a sheet wrapped around her neck.
Several days later, she walked into her room, closed the door against her one-on-one sitter and locked herself in.
"They tried to open the door, but no one on the unit has the key to her room," according to state records.
Staff eventually was able to open the door, but not before the woman had again knotted a sheet around her neck.
The inspector also saw a hospital employee responsible for observing 17 cardiac patients leave their monitors unattended, placing the patients at "risk for an adverse outcome," according to state records.
Jackson Park's response to these discoveries?
In addition to removing the locks on the psychiatric rooms, administrators offered up a written plan of correction that echoed earlier promises.
Once again, staff would be educated on safety checks. There would be more supervision.
And the hospital would work harder to ensure that suicidal patients did not have access to contraband, among other steps.
Once again, the state Department of Public Health and federal Centers for Medicare and Medicaid Services accepted the correction plan.
Regulators accepted other corrective plans from Jackson Park Hospital in recent years for repeated violations involving bugs, fire hazards and failed infection control, among other problems.
They can revisit hospitals and review records to make sure such plans are implemented, but they want more enforcement tools.
The hospital lobby, however, has successfully opposed legislation backed by the state Department of Public Health that would allow it to impose fines on hospitals for repeatedly committing severe violations. That's what state officials in California do.
"The best way to make sure that hospitals provide the best and safest care is make sure they have the resources needed to correct problems," said Danny Chun, spokesman for the Illinois Hospital Association. "Taking resources out of the hospital through fines won't do that."
Chun said the system will be sufficiently stronger when Illinois implements a law that requires public disclosure of certain "adverse events" in hospitals, such as botched operations. Passed in 2005, the law still has not been implemented.
The case of Gregory Jones began at 8:39 p.m Jan. 2 when he entered the emergency department at Jackson Park Hospital agitated and with an elevated heart rate, records show.
After drinking and fighting earlier with his girlfriend, he had "emerged from the bedroom upset over the death of this brother … and stated he wanted to kill himself," according to a police report. When he tried to leave the house, his girlfriend tried to restrain him and called police.
When they were done signing the petition for involuntary admission, his girlfriend and teenage son took a seat in the emergency room, while Jones was escorted by a nurse, police and hospital security down the hall to Observation Room 3, records show.
It was one of four observation rooms in the emergency department that were monitored by video. A medical assistant at least 5 feet away watched 3-by-4 inch screens relaying videos from each room.
An inspector visiting the emergency department later that month would note that this setup made it impossible to observe pertinent health signs of psychiatric patients such as changes in breathing, moans or threats.
Jones, in his light blue hospital gown, found a sheet in his room.
At 9:07 p.m, he stood on his bed and affixed the sheet to the top of the bathroom door and around his neck. One minute later, he was hanging. His body dangled from the door until 9:22 p.m., according to video recordings.
Based on a video of the monitoring station, the state noted: "During the 14 minutes (Jones) was hanging, (the medical assistant) was in front of the monitor for 9 minutes and away from the monitor for 3 minutes. The (nurse) was in front of the video monitor the remaining 2 minutes. … The video recording indicated that (the medical assistant) and (nurse) were not paying attention to the monitor and the monitor was left unattended for a period of time."
Jones' son was close enough to the observation room that he heard the body fall to the floor. He saw hospital employees drag it into the hallway, according to a wrongful death lawsuit filed by the family.
At 11:20 p.m, Jones was pronounced dead.
When the state investigated later that month, it discovered that the night Jones died, another suicidal patient had escaped out a window under the nose of his one-on-one sitter. At the time of the inspector's visit, psychiatric patients in the observation rooms were still being monitored by video, state records show.
Regulators concluded that the hospital had placed patients in "immediate jeopardy" again, by failing to ensure a safe setting for monitored patients, among other problems.
But the immediate jeopardy citation was withdrawn within days when hospital administrators assured regulators they had replaced video monitoring with one-on-one monitoring for suicidal patients entering the emergency department and had taken other responsive steps.
The administrators said emergency staff had undergone observation training and would more closely monitor suicidal patients. The medical assistant and nurse who failed to monitor Jones had been suspended for a period of time.
Within a couple of months, regulators had closed out the case after determining the hospital had implemented its corrective plan.
Chicago police, meanwhile, closed their investigation of Jones' death, records show, after hospital staff refused to provide complete video of what transpired that night and the names and contact information of everyone involved.