Mental Patient’s Death Prompts Investigation of Use of Restraints

A 45-year-old mental patient died at Brotman Memorial Hospital in Culver City after he was heavily medicated and left in physical restraints for more than 11 hours with poor supervision, Los Angeles County health officials have disclosed.

A county mental health official, who also investigated the incident, said her staff found that other patients had been placed in restraints for long periods in Brotman’s 76-bed psychiatric unit. She said she had warned the hospital on prior occasions about the inappropriate use of restraints.

Hospital officials refused to answer any questions about the incident, but they have pledged to the county in writing that they will correct all deficiencies. Nevertheless, county health officials have recommended that federal authorities take disciplinary action against the hospital, which receives millions of dollars a year in federal health care funds.

County health officials, who investigated the death Feb. 14 of Charles Ward, charged in a report that hospital staff members failed to follow detailed regulations governing the use of restraints and failed to report the unusual death to the coroner’s office. Instead of requesting an autopsy, they said, a doctor signed a death certificate stating that Ward had died of heart failure.

The physician, Dr. Christopher Selvage, refused to be interviewed about the case.

State health regulations require that patients be put in restraints for only as long as their behavior is unacceptable and only with a written order from a physician. They must be monitored every 15 minutes and given opportunities to exercise and use the bathroom every two hours.

Ward was put in restraints without a doctor’s written order about 7 p.m. Feb. 13. “He was not assessed and baseline vital signs were not measured,” health officials reported.

Nursing notes report that he was asleep much of the time.

“For at least four continuous hours, there was no ‘unacceptable behavior’ which would warrant the use of . . . any restraints,” the health report said.

The next morning, the patient was found dead--”cold and stiff with advanced changes of death,” according to a complaint that was made to county health authorities.

Robert Karp, a senior health department official, said that the investigation did not uncover problems of overcrowding or understaffing, which have been blamed for many of the well-publicized problems afflicting public institutions that care for the mentally ill.

Brotman is a private, profit-making institution that caters to patients with medical insurance to pay their bills. Ward, a disabled veteran, reportedly had insurance through the military and the government-sponsored Medi-Cal program.

“What this shows is that neither the private nor the public sector has a corner on being perfect,” said Dr. Rod Burgoyne, medical director of the county Department of Mental Health.

On April 9, the hospital issued new guidelines governing the use of restraints and noted “obviously unacceptable” practices that had occurred during the February incident.

Upon learning of the death, mental health advocates said they were shocked.

“This is not a technical, minor violation that occurred,” said Brian Jones of the Mental Health Assn. “It’s a violation of basic medical practice.”

Barbara Lurie of the Patients Rights Advocate Office of the county Department of Mental Health, said that she took immediate action when she received an anonymous complaint about Ward’s death.

“We took this very, very seriously,” Lurie said. “We don’t often get reports of deaths.”

She declined to release her written findings, but she said her staff found “a number of improprieties and deficiencies that led to a more thorough investigation of policies and practices (at Brotman) involving the use of restraints.” She said a review of other patient files found problems with the use of physical restraints.

Marilyn Holle, a senior attorney with Protection and Advocacy Inc., which investigates the abuse and neglect of the mentally ill and disabled, said of the Ward incident, “This case sounds pretty bad.”

She said that it was “absolutely incredible” that no autopsy was performed.

But hospital officials said in a written response to the county’s report that a nurse called the coroner’s office to see if an autopsy was required and was told it would not be necessary if a physician would sign the death certificate.

Ward was taken to Brotman by ambulance on Feb. 13 from the nearby Golden Gate Lodge, a board and care facility where he lived.

Virginia Hawkins, administrator of the home, said that Ward, who had been placed in the facility by the Veteran’s Administration, was acting suicidal. She said that Selvage, who treats many of the residents at the home, recommended that Ward be hospitalized.