From the Los Angeles Times
Psychiatric care's peril and profits
at Psychiatric Solutions Inc., a major hospital chain with high
earnings, have put patients at risk, regulators find. Some have even
By Christina Jewett and Robin Fields
ProPublica Staff Writers
November 23, 2008
Psychiatric Solutions Inc. was on its way to becoming the nation's
leading provider of private psychiatric care when it snapped up Sierra
Vista Hospital in Sacramento in mid-2005.
The company put its well-honed business formula into action: Staffing fell. Beds filled up. Profits soared.
It was a winning strategy for investors. But for some patients, federal
records show, checking into Sierra Vista proved dangerous -- at times
In December 2005, Ramona Knapp, 51, was left fatally brain damaged
after hospital workers restrained her improperly, pinning her to the
In March 2007, an unidentified 29-year-old woman was mistakenly given
six times the prescribed dose of a potent antipsychotic drug. Even
after 15 hours, she was too weak to swallow.
When Steven Burton, 55, checked in for treatment of alcohol abuse and
depression in February, he complained of chest pains. The intake nurse
didn't notify a doctor because, as she later told regulators, "he
didn't look sick."
Burton was discovered the next morning, facedown on the floor of his
room, shaking and sweating. Staffers put him back in bed and paged a
psychiatrist, getting no response. Two and a half hours later, a nurse
found him blue and not breathing.
Burton, an El Dorado County agriculture official, came to Sierra Vista only at the insistence of his wife, Vickie.
"The last thing I was thinking," she said, "was that I was taking him to the place where he was going to die."
The lapses at Sierra Vista are among a string of cases involving
abuse and neglect at PSI facilities nationwide, an investigation by
ProPublica has found.
In a challenging field with a troubled history, PSI hospitals often
fare worse than comparable private hospitals in meeting government
standards for patient care, according to an analysis of state and
federal inspection reports.
Since 2005, the 10 hospitals PSI has owned longest have compiled almost
twice as many patient-care deficiencies as 10 similar hospitals owned
by its closest competitor, Universal Health Services Inc.
The PSI hospitals were cited in three patient deaths and for placing
patients in immediate jeopardy four times, the inspection records show.
The UHS hospitals received no equivalent citations.
Among private psychiatric hospitals in California, Sierra Vista had the
single highest rate of state and federal deficiencies -- about eight
times the statewide average.
It has twice been fined $25,000 for endangering patients -- accounting
for the only such penalties levied against psychiatric hospitals under
a 2006 state law establishing the sanctions. PSI executives declined to
be interviewed for this article and, citing privacy law, would not
discuss individual patients.
In written responses, they rejected the analysis showing the company's
hospitals compared poorly to others, saying: "Your assumptions,
calculations and apparent conclusions are invalid."
A spokesman, John Van Mol, said that PSI arguably has improved
psychiatric care in the country overall. He cited the comparatively
poor performance of state psychiatric facilities around the country in
PSI officials apologized for incidents resulting in harm to patients,
saying they acted immediately to correct any problems. "Any incident
involving patient care is one too many in our view, and everyone
involved from the hospital level to the corporate level works very hard
to prevent them," they wrote.
Recent state and federal inspections show the company's efforts have fallen short:
* Poor patient supervision, understaffing and inadequate worker training have led to instances of chaos and brutality.
A 19-year-old alleged he was raped twice within 24 hours by a fellow
patient at an Illinois hospital even after he reported the first
assault, federal records show.
Staffers at a Texas facility had to barricade themselves in an office
and call in a SWAT team to bring unruly residents under control.
In North Carolina, inspectors found, a 12-year-old boy with a history
of sexual aggression was put in a room with a 5-year-old and attempted
to force the younger boy to perform oral sex.
* Medical neglect and errors have resulted in grave harm. A nurse at
another North Carolina facility gave a 7-year-old boy anti-seizure
medication prescribed for an older patient, leaving him so drowsy that
a doctor wrote in his chart that "he refuses to wake up."
Workers in Virginia waited almost an hour to call an ambulance for a
17-year-old girl who had suffered a seizure and was bleeding profusely,
inspection records show. The girl died later that day.
* In several instances, PSI employees have sought to hide their
failings from regulators. A hospital in Texas was cited by state
inspectors for concealing key facts about a patient abduction and a
suicide. Regulators in Virginia uncovered what they called an organized
scheme to cover up violence, suicide attempts and medication errors at
a Charlottesville facility for juveniles.
* Some of the PSI hospitals most under fire from authorities are those
the chain has owned longest. The Justice Department has opened an
investigation into alleged patient-care problems at one of PSI's first
acquisitions, Riveredge Hospital near Chicago, issuing subpoenas for
records earlier this year.
Nationwide since 2006, health officials have pulled children out of one
PSI facility and have moved five times to revoke the state licenses of
others. They have withheld or ordered the company to repay more than $2
million in government funding for providing substandard care.
In addition to thousands of pages of inspection reports by individual
states and the U.S. Centers for Medicare and Medicaid Services,
ProPublica's investigation was based on hospital and court records and
interviews with about two dozen former employees.
PSI executives say they are filling a desperate need in a tough business.
"Everyone at Psychiatric Solutions works hard every day to achieve
excellence in patient care, often under extremely difficult
circumstances to serve a patient population that includes extremely
acute and complex diagnoses," Chief Executive Joey Jacobs said in a
Chad Thompson, who worked in the admissions office at Sierra Vista when
PSI took over, has a different view. He felt the chain put intense
pressure on him to keep every bed full, with less emphasis on assuring
that each patient got high-quality care.
"It's a pattern of behavior driven totally by the almighty dollar,"
said Thompson, now the director of a nonprofit that provides therapy to
the uninsured and chairman of Sacramento County's Mental Health Board,
which advises the county Board of Supervisors.
"It's not a client-centered approach. It's a money-centered approach."
PSI got its start in 1997, when Jacobs took the helm after two decades
as an executive at Nashville-based HCA, the nation's largest hospital
States had emptied many public psychiatric hospitals years before. Some
for-profit psychiatric chains that emerged in the 1980s and 1990s were
caught overbilling the government and later collapsed.
PSI stepped into the gap. The company, headquartered in Franklin,
Tenn., has grown from five facilities in early 2003 to 95 today,
running about one in five free-standing psychiatric facilities in the
United States. With more beds than any other chain, PSI treats about
8,800 patients on any given day.
About half of PSI's beds are for adults and children in crisis who stay
an average of 10 days in acute-care settings. They come from all walks
of life, admitted either voluntarily or through commitments. The other
beds are for youths -- many in the foster care system -- who stay in
residential treatment for six months or more.
Roughly two-thirds of the care is paid for by taxpayers. PSI collected
about $900 million through state and federal programs in 2007, the
company's SEC filing suggests.
PSI has thrived in a business in which many thought healthy profits were beyond reach.
The five PSI hospitals in California had a profit margin of more
than 25% in 2007, according to data from the Office of Statewide Health
Planning and Development. The average for the state's other for-profit
psychiatric hospitals was about 6%.
The data also shed some light on how PSI has achieved these results.
PSI's California hospitals proportionally have fewer registered nurses
than other private psychiatric facilities: about one for every four
beds, compared with one for every two beds, according to the state
data. Overall, the PSI hospitals have about one-third fewer staffers
PSI disputed the data, saying its facilities were staffed
appropriately, meeting or exceeding state requirements, and that "we do
not believe that we have fewer nurses per bed."
But in the aftermath of the deaths of Knapp and Burton, regulators
found fault with Sierra Vista's staffing levels and worker training.
When Knapp began yelling and running the hospital's halls one night in
December 2005, a single technician was supervising the 14-patient unit,
according to a federal inspection report.
Knapp, who worked at a social service center for the homeless mentally
ill, had bipolar disorder and had tapered off her medication to prepare
for gastric-bypass surgery.
The technician urged her to stop shouting.
"No, I don't have to. You're going to kill me," Knapp shouted back, according to the report.
A worker in another unit rushed to Knapp's room as she began to crawl
and kick. The worker held down Knapp's upper body, pinning her facedown
on the floor, while the technician held her feet.
About five minutes passed as the worker lay on Knapp's back, waiting for a doctor to order sedatives.
When staffers lifted Knapp onto her bed, they discovered that she had stopped breathing. Knapp died the next day.
Sacramento County's chief pathologist ruled that the death was caused,
in part, by restraint asphyxia, which results from being held in a
position that obstructs breathing.
Inspectors discovered the hospital's staffing levels that night were
not unusual. An audit of dozens of shifts months later showed that
staffing was too low more than 80% of the time.
They also found no evidence that the staffers who restrained Knapp had been trained to handle combative patients safely.
PSI submitted a lengthy plan for improvements after Knapp's death. Yet
Sierra Vista was cited again for understaffing and poor training after
Burton's death just over two years later.
After Burton collapsed in distress at 4:25 a.m., a nurse gave him
anti-anxiety medication and posted a staffer outside his door. But
workers failed to take further action when the doctor on call did not
respond to pages, according to inspection records.
The Sacramento County coroner's office ruled that Burton died as a
result of built-up toxicity from his blood pressure medications, a
finding that led a local newspaper to conclude the hospital had been
"cleared" of responsibility in the death.
But the state upheld a $25,000 fine against Sierra Vista for
failing to ensure Burton's safety and provide him with timely care.
Regulators noted that some Sierra Vista staffers couldn't find the
facility's defibrillator though it was feet from where they stood.
"It doesn't matter what he died from," Vickie Burton said. "It matters that they didn't get him help."
When patients are injured or errors are made at psychiatric facilities, administrators are required to alert authorities.
"PSI has a standard of reporting all incidents fully as required by the
states in which we operate and / or other regulatory authorities," the
company said in its written responses to questions from ProPublica.
Records show that the company has not always met that standard.
In Texas, workers documented making routine 15-minute checks on a
suicidal patient, but surveillance video showed a 26-minute gap. In the
meantime, the patient had asphyxiated himself, wrapping strips of a
pillowcase around his neck.
At Whisper Ridge Behavioral Health, a PSI facility for juveniles in
Charlottesville, Va., licensing officials received only a brief report
in January 2006: A teen provoked a fight, his peers hit him and
staffers brought him to the nursing station.
The facility did not mention that by the time staff intervened, the
teen had been so brutally beaten that he briefly stopped breathing and
suffered a seizure and concussion, according to Virginia's mental
health department. When police responded, Whisper Ridge employees
initially tried to keep officers out of the facility, a police report
Nurses had sought to call an ambulance, but facility managers resisted
at first, for fear "that the state might find out," a state mental
health department report said.
The department's 2006 investigation found that the assault was just one
of many incidents that Whisper Ridge managers had mishandled or not
Workers took two teens who had overdosed to a hospital in their own
cars or a facility vehicle instead of calling an ambulance, endangering
the patients' health, the regulators found.
"Staff was telling us they organized interviews about what to say to
us, and gave residents treats so they wouldn't talk about what was
happening," said Leslie Anderson, director of licensing for Virginia's
mental health department. "It was probably the worst case of that kind
of deceit that we had seen."
In one instance, a doctor ordered workers to send a patient who had a
13-minute seizure to the emergency room, but the facility's chief
operating officer told the director of nursing to "sit on it and
reevaluate later," mental health department documents show.
Dr. James Jarrell, the doctor involved, said he did not realize his orders had been overridden until regulators uncovered it.
"That's disturbing," said Jarrell, who left the facility in 2007.
Authorities fined Whisper Ridge $30,000 as a condition of keeping its
license. Medicaid ordered the facility to return more than $750,000 in
payments for rendering inadequate care.
PSI is appealing that order.
In its responses to ProPublica, the company "categorically denied"
there was systemic deceit at Whisper Ridge, adding that, since June
2006, the facility had been in compliance with state and federal
Steven Nickel woke up just after 2 a.m. lying on the floor of his
shower. The water was running, flooding into his room at Cypress Creek,
a PSI hospital in Houston.
He had tried to kill himself, cutting his left wrist with a razor,
federal inspection records show. Workers were supposed to check on him
every 15 minutes that night in May 2007, yet he had been slumped over
the drain, unconscious, for about five hours.
Once awake, Nickel recalled in an interview, he left his room and
showed the gaping wound to a nurse who yelled at him and accused him of
forcing her to fill out more paperwork. Nickel said he felt numb,
"If I would have died, how long would I have laid there before anyone would have known?" he said.
Cypress Creek's former risk manager, Janet Geiger, submitted her resignation days after the suicide attempt.
"I felt it was basically an unsafe environment for patients and staff,"
Geiger said in an interview, explaining that she reviewed at least five
reports of injuries, medication errors or suicide attempts every day.
Looking into the case, federal regulators found that hospital managers
had failed to address or to learn from a series of patient-care
Officials moved to impose the harshest sanction at their disposal:
termination from the Medicare program. Cypress Creek became only the
sixth psychiatric hospital in the nation since 2000 to face the
"We said, 'These people really are not getting it,' " Molly
Crawshaw, a regional administrator with the Centers for Medicare and
Medicaid Services, testified at a federal court hearing.
Cypress Creek was denied Medicare money for more than four months,
costing the facility at least $1.5 million, based on an affidavit filed
in the court proceeding.
The termination prompted PSI to make significant changes at the hospital.
The company brought in a turnaround specialist with a nursing background, Brian Brooker, as the new chief executive.
Brooker renovated the facility with patient safety and dignity in mind,
installing special door hinges and shower heads to thwart patients bent
on harming themselves. He added leather couches, art and plants. Signs
went up throughout the facility saying, "Wow, it's a new day."
"You had to create a different attitude and environment," Brooker said in a recent interview.
Cypress Creek reapplied successfully to the Medicare program.
In the first inspection after the hospital's reinstatement, however, regulators cited it for inadequate staffing.
To some mental health advocates, PSI's problems reflect the inherent
pressures for-profit companies face in trying to deliver both quality
care and robust profits.
Since the billing scandals of a decade ago,
insurers have sharply limited the types of inpatient psychiatric
treatment they cover. Now, the primary way to achieve big margins is by
cutting costs, experts say.
"The incentive is to give less and less service, and [business
leaders] are applauded for that in our upside-down world," said New
Jersey psychiatrist Gary Glass, an industry expert who has been hired
to testify in a lawsuit against a PSI hospital.
On the contrary, PSI executives say, they want to provide more care to more patients.
The company is adding about 150 beds to its California hospitals,
including Sierra Vista, a complex of brick buildings alongside a
freeway about 10 miles south of the Capitol.
Last week, scaffolding surrounded the cinder-block walls that will
house 48 beds set to be in use by 2009. A sign posted at the work site
says: "Sierra Vista Hospital / Expanding Our Service to the Community /
Changing Lives, Saving Lives."
Christina Jewett and Robin Fields are writers for ProPublica.
ProPublica fellow Benjamin Protess and Times staff writer Jordan Rau contributed to this report.