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State faults Sutter Roseville for violations in psychiatric treatment

Suicidal man received improper care, state says
By: Nathan Donato-Weinstein | nathand@goldcountrymedia.com
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A state investigation faults Sutter Roseville Medical Center in the case of a Roseville man who went missing from the hospital’s emergency room and later killed himself. The 40-page report issued recently by the California Department of Health and Human Services and obtained by The Press-Tribune states the patient did not receive adequate medical screening and ongoing monitoring, nor was he properly treated to stabilize his medical condition. In addition, investigators found problems with how the emergency department handled the cases of nearly two dozen other patients experiencing psychiatric emergencies, and unearthed one other instance of a patient who went missing from the facility after receiving inadequate supervision. The Centers for Medicare & Medicaid Services is now threatening to terminate Sutter Roseville's participation in the Medicare program if the hospital does not improve, according to a letter obtained by The Press-Tribune under a Freedom of Information Act request. That would deprive the hospital of key reimbursement funding. Sutter officials said they are submitting a corrective action plan to the state, as required under federal law. In a statement, Sutter Spokeswoman Robin Montgomery said: “Receiving this report provides us with an opportunity to respond to the issues identified by the survey team. We have already created vital enhancements to our current policies to submit for review to ensure we are providing the best care to our patients.” The investigation appears to have been prompted by the death of Albert T. Cariaga of Roseville. The 39-year-old father of two was admitted to SRMC’s emergency room Dec. 31 of last year for “depression-related issues,” police said at the time, but went missing at about 2:30 p.m. that afternoon. Police discovered Cariaga’s body Jan. 6 in a wooded area 500 yards away from the hospital. Authorities ruled the death a suicide by hanging. The report does not name Cariaga but a detailed timeline of events leaves little doubt he was at the center of the investigation, which took place less than two weeks after his death. The patient believed to be Cariaga was taken by ambulance to Sutter at 6:35 a.m. suffering from an overdose of the sleeping pill Ambien and anti-depression medication Celexa, according to the report. He had also stated he wanted to harm himself, it said. Police placed him on a 5150 hold, an involuntary psychiatric hold because the person is a danger to themselves or others, the report said. But the report found Sutter emergency department personnel did not comply with hospital policy or the 5150 on several fronts. Investigators said they failed to complete a required suicide risk-assessment form; did not document any evidence of the use of restraints, continuous staff attendance or continuous staff observation as required by the 5150 hold; and categorized Cariaga at a lower triage level than warranted. In fact, the report found the physician on duty “medically cleared” Cariaga 10 minutes after arriving in the ER, “and authorized his transfer to a psychiatric facility without assessments to determine medical stability from the drug ingestions,” the report states. Sutter “failed to accurately triage (the patient), failed to assess and provide ongoing monitoring for the toxicity of the drugs ingested, and failed to provide continuous direct observations to prevent self harm,” the report states. The report documented other policy failures involving psychiatric emergencies. For instance, 22 of 29 sampled patients experiencing psychiatric emergencies did not receive either necessary stabilizing treatments or appropriate medical screening exams, and transfer documentation for 10 patients experiencing psychiatric emergencies was not properly filled out. In one case, another patient admitted to the ER on Dec. 27, 2008 and placed on a 5150 hold also went missing. Investigators found no evidence the 47-year-old patient, who was intoxicated and stated he wanted to harm himself, was placed in restraints or observed continuously by staff as required by the hold. The allegations detailed in the document are violations of the federal Emergency Medical Treatment and Active Labor Treatment Act, or EMTALA, and require Sutter to take corrective action or face losing its federal funding, said Jack Cheevers, spokesman for the Centers for Medicare and Medicaid Services, which oversees EMTALA. In a letter sent earlier this month, the Centers for Medicare & Medicaid Services informed Sutter Roseville CEO Patrick Brady it had until mid-April to submit a plan to come into compliance. Federal officials said this week the deadline was extended to April 29 but that they had yet to receive the plan. Sutter Roseville is not an inpatient psychiatric facility but is required to stabilize patients before transferring them to the appropriate agency. In the statement, Montgomery said: “Unfortunately, this case is an example of the significant challenges that hospital emergency departments are facing from the increasing incidences of patients arriving and requiring mental health support for which there are inadequate government, social services and health system resources.” Cheevers said investigators would complete a surprise inspection to verify Sutter had corrected problems. “In the vast majority of cases the hospitals clean up fairly quickly,” he said. “We want to get people’s attention to clean up any problems we find.”