by Joe Mungai

ADDENDUM 4/28/06

by joseph a. mungai, RN

The JCAHO (Joint Commission on Accreditation of Hospitals) has been accrediting Illinois State operated mental health facilities for years, but in March of 2006 the NAMI (National Alliance for the Mentally Ill) FLUNKED the Illinois Mental Healthcare System.

The 2002 University of Michigan Study on JCAHO found their “accreditation is a poor predictor of the quality of patient outcomes”. This is the “system that assures quality in 95 percent of U.S. acute care hospitals, and which is used for Medicare certification and often for state licensure.”

So in March of 2006 the JCAHO increased the number of “requirements for improvement (RFIs) a hospital can receive before receiving conditional or preliminary denial of accreditation”. Yes, you read that correctly--JCAHO is making it even easier for hospitals to become accredited despite the 98,000 patients that already die each year in hospitals due to mistakes.

On March 1, 2006, NAMI (National Alliance on Mental Illness) released a scathing report on the national mental healthcare system. Illinois was one of only eight states that FLUNKED.

There is nothing new about the failed Illinois Department of Mental Health, and what was left out of the NAMI report is even more appalling. In 1992 the ACLU filed a suit, K.L. v. Edgar (Governor), charging the state of Illinois mental health facilities and state-funded outpatient programs with violating the constitutional right to safety and adequate medical and psychiatric treatment, among other things. The State of Illinois selected, in tandem with the ACLU, a group of experts to investigate the allegations “on behalf of the thousands of patients in state mental health facilities”.

In the 12/20/1995 ACLU press release, “Experts Report of Violence, Neglect and Poor Treatment in Illinois Mental Hospitals” it is stated that there is “a pervasive undercurrent of violence between patients”…“Preparation for discharge from Illinois state psychiatric hospitals is a mechanical, underdeveloped process that does not meet minimally acceptable professional standards and leads to ill-conceived and ill-fated discharges”…“Illinois has failed to make a reasonable attempt to provide safe, adequate and humane living conditions for many patients being discharged or deflected (triaged-denied admission) from psychiatric hospitals …We found conditions for many of these patients reminiscent of those in the back wards of state psychiatric hospitals 30 years ago.”

The report goes on to say that state hospitals have “a chaotic unit environment and…low staff morale that we found to be pervasive…” and, “The overwhelming sense from our observations and from those we have consulted is that the Department has done what is needed to do to please outside reviewers while making only marginal and token attempts at systemic reform.”

Setting the stage: After Governor Edgar came Governor Ryan, now awaiting a federal jury’s verdict in his criminal case on corruption charges, and then our current Governor, Rod Blagojevich, his administration is under federal investigation into allegations ranging from pay-to-play politics to potential political kickbacks involving his appointees.

Illinois government officials have misdirected the public for years under democrat and republican administrations and then had the audacity to advertise the evidence on the Illinois Office of Inspector General (OIG) website.

I will list a few examples, there are many, from the OIG website going back to FY 2001 (annual reports prior to 2001 have been taken off the website despite keeping other reports dating back to 1998). I will identify beyond any REASONBLE doubt that “egregious neglect” has been covered up for many years.



“During Fiscal Year (FY) 2005, OIG received 2,191 allegations of abuse or neglect, reversing a recent trend. Compared to FY04, OIG received 43% more at facilities, 38% more at agencies, and 28% more in domestic settings. OIG attributes this to a clearer understanding of what is reportable.” This is our first clue that something is horribly wrong.

“The position of the Inspector General in the Department of Mental Health and Developmental Disabilities (DMHDD) was created by law in 1987. This law required the DMHDD Director to appoint an Inspector General to investigate reports of suspected abuse or neglect of recipients. A later act required that the Inspector General be appointed by the Governor with advice and consent of the Senate.” When it takes almost 20 years to teach staff “what is reportable” then OIG and the Illinois Senate is to blame!


“An individual with developmental disabilities was reportedly physically abused by two employees. The victim had 247 bruises and marks on her body. OIG proved that the injuries were caused by other adults and not by the two employees. However, OIG substantiated neglect by the agency in failing to ensure enough staff were present to prevent the injuries from being inflicted by the other adults. OIG recommended that the agency ensure that staff-to-patient ratios are always adequate. DHS had the victim removed from the residence.”

This is NOT neglect. This is EGERGIOUS NEGLECT, “Egregious means a substantive failure by an employee to provide adequate medical or personal care or maintenance that results in a death, serious medical condition, or serious deterioration of an individual’s physical or mental condition” as defined by OIG. The law dictates that the OIG determine if a case consists of egregious neglect. Administrators are the ones who address and set staffing ratios per Governor Blagojevich.——-247 bruises and marks on her body, that‘s beyond egregious and well within the realm of torture!

“An employee allegedly hit a resident on the head with an escrima stick (a South American martial arts weapon). The resident had bruises on his shoulders and a head laceration requiring staples to close. The case was referred to the local police for investigation as well. When interviewed, the resident provided a detailed statement but refused to press charges. Since he is his own guardian, the State’s Attorney directed the police to stop investigating. When OIG then investigated, the employee admitted that he had brought the escrima stick to work, intending to hit the resident, and that he had hit the resident on the head with it. OIG substantiated physical abuse and gave the admission to the local police. However, despite efforts of the local police and OIG, the State’s Attorney still refused to prosecute. The employee was fired.”

More torture and the State’s Attorney refused to prosecute. Of course the patient refused to press charges—HE FEARED RETALIATION!

“The suicide in the facility was by an individual with mental illness and a history of talking about suicide. Upon admission, he was put on one-to-one supervision by staff. The next morning, the psychiatrist found him calmer, more rational, and denying he would harm himself. So, he was changed to visual checks every 15 minutes. Two days later, the individual was still calm and giving no signs that he was going to harm himself. Still, he hanged himself with his pajamas. Although visual checks were made only ten minutes apart when he was found, he could not be resuscitated. Neglect was not found.”

“Talking about suicide” means the patient had thoughts of suicide, which includes any plan he had to take his own life (suicidal ideation). He wasn’t teaching the mental health professionals about suicide or discussing treatment options for other patients. What else was in the patients’ history—suicide attempts?

Within less than 24 hours he has a sudden mood change and is taken off 1:1 precautions. A sudden change in behavior should always be questioned, Psych 101, a patient can become calm once they have devised a plan to take their own life, this is a time to closely monitor a patient. If psychotropic meds were given then this patient would also need close supervision as they can cause sedation masking other symptoms, cognitive impairment, confusion, mental depression and an increase in suicide risk, a paradoxical effect, anxiety and agitation to name a few. Of course antidepressants can take 4 to 6 weeks to reach the desired effect if they work at all for the patient.

“A nurse allegedly refused to give a prescribed medication to a resident despite continuing symptoms. OIG substantiated the allegation but also found that the residence manager had removed all postings of the OIG Hotline number and had threatened to fire staff if they continued to call. Based on this and other cases, OIG alerted the DHS Division of Developmental Disabilities, Illinois Department of Public Aid, Guardianship and Advocacy Commission, and Equip for Equality of the agency’s ongoing problems.”

No wonder direct care staff are afraid to advocate for patients. No mention of discipline for administrations’ creation of a hostile environment. How many cases went unreported?

Deaths in Facilities:

“The remaining seven were by suicide, but five of the seven occurred after discharge from the facility. Neglect by the facility was not alleged in any of the five suicides. One of the two remaining suicides occurred in the facility and the other while absent without permission.”

Five suicides after discharge suggests something is wrong. From a thorough investigation we could have learned something about assessments, diagnosing, treatment, placements and teaching family interventions, etc. Proper attention wasn’t given to the patients while they were alive and OIG failed them in death. Furthermore, a suicide at a facility and not one problem could be identified is a lax investigation to say the least.

“The other death occurred while the individual was still “on the books” but was not in the facility. She had been given a pass so her mother could take her to visit a community agency that had agreed to provide services for her LONG-STANDING SUBSTANCE ABUSE AND PSYCHIATRIC PROBLEMS. However, she left her mother and went off with her boyfriend. The mother immediately notified the facility, which asked the police to find and return her. The facility was notified two days later that the individual had collapsed at the friend’s home. The coroner’s inquest determined the death was due to an accidental overdose of illegal drugs. Neglect by the facility was not suspected or found.”

The FY 2000 OIG Annual Report states, “MH (Mental Health) hospital admission data CONTINUE (accentuated) to show that as many as 80% of patients have a diagnosis of substance abuse.”

Addiction to drugs, lobbyists or earmarked money in return for favors, controls many, if not all, aspects of life. The field of psychology knows there are manipulative and anti-social characteristics to addiction, so close scrutiny by trained advocates should accompany these individuals to treatment programs. Can you imagine senators and lobbyists in the Oval Office hovered around a table stacked with earmarked money without an advocate for “we the people”?

“OIG substantiated neglect in clinical issues in seven cases during FY05, two at facilities and five at community agencies. FAILURE TO ADEQUATELY MONITOR was the most common reason for the finding of neglect. In one of the facility cases and two of the agency cases, the staff failed to observe a developing medical problem and, as a result, it worsened and the individual eventually had to be hospitalized.”

EGREGIOUS NEGLECT again. Staffing, training and modeling, supervision, spin, lax and ineffective investigations are the integral parts of the equation that administrators in the OIG, Department of Human Services and Department of Mental Health can’t overcome. Maybe they require the inspiration of being held accountable for the atrocities occurring on their watch.


“An individual, who had been allowed to go to the restroom unescorted, left the building and ran onto a highway where he was struck by a vehicle and died. The agency did not have enough staff on duty supervising the day training program, so there was no one to escort the recipient to the restroom. In addition to substantiating neglect, OIG recommended the agency develop a policy to ensure proper staffing ratios at all times.”

Governor Blagojevich believes staffing ratios are best determined by each hospital and its specific needs. However, no one can train 1 direct patient caregiver to do the job of 3, remedial math. EGREGIOUS NEGLECT.

“The individual died from asphyxiation from choking. The individual was served regular food when he was to have all of his food pureed. The individual was also left unattended during this time while staff conducted personal business.

This case was substantiated due to failure to provide adequate supervision to clients and a failure to implement established treatment plans.”

A patient dies because staff were conducting personal business instead of monitoring the patients is again, EGREGIOUS NEGLECT!

“This case involves the unfortunate death of a woman due to a bowel obstruction which may have been avoided had she received proper nursing assessments and treatment. Communication was also very poor and her symptoms were not communicated to the nurses and physician resulting in a delay in treatment that was too late.”

Some of the signs and symptoms of a bowel obstruction; abdominal swelling and cramps, vomiting, green vomit, fecal vomiting, blood stained mucus, passing jelly-like mucus, constipation–to name a few. This case tells us in the first sentence that the cause of her death was due to EGREGIOUS NEGLECT.


FY JULY 2002 - JUNE 2003:

“An individual who was expressing thoughts of suicide by suffocation was allegedly handed a plastic bag by an employee. It could be substantiated only that the employee had pointed at a bag, and no harm could be shown. However, the investigation found that the individual had been expressing suicidal ideation with a plan since admission and yet the direct care staff did not believe it. OIG recommended that the agency treat threats of suicide seriously.”

30,000 people take their own life each year in this country and OIG can only recommend treating “threats of suicide seriously” to psychiatric professionals hired to manage staff and patient care. This is an obscene failure to train staff appropriately and realistically—EGREGIOUS NEGLECT.


“An anonymous letter to the facility and a telephone call to CrimeStoppers both alleged that an individual’s death was not accidental. The OIG investigation did not substantiate the allegation, but found failures in monitoring: an employee had not visually checked all individuals at 7:00 pm on the evening the death occurred and had later altered the face check sheet; and two other employees did not visually check on every individual at 6:30 pm on the same evening.

As a result of this case, the facility:
–Established a procedure clearly addressing accounting for individuals;
–Re-trained all program staff in this procedure; and
–Implemented the procedure immediately.”

This is EGREGIOUS NEGLECT and PATIENT ENDAGERMENT, if employees are not doing their most basic job duties or if they are understaffed then it is not accidental. ALTERING MEDICAL RECORDS (FACE CHECK SHEETS ARE LEGAL DOCUMENTS) IS A CRIME!!! If there wasn’t neglect involved then employees wouldn’t have re-written the medical records. Administrators are supposed to be monitoring, educating and evaluating staff routinely.

“An employee left an individual who has developmental disabilities and is non-verbal in a whirlpool bath, unattended. The individual nearly drowned before other staff found her. The OIG investigation substantiated neglect against the employee for failing to supervise the bath. It was also noted that the habilitation plan did not specify what level of supervision the individual required.

As a result of this case, the facility:

–Revised its rules on using the whirlpool and other equipment, including a requirement for supervising individuals who use it;

–Held a special meeting to make the individual’s habilitation plan more specific about supervision; and
–Re-trained staff in these rules and the plan’s expectations.”

If this patient was your child and you had no policies to follow, common sense would guide your actions and there wouldn’t be any case of EGREGIOUS NEGLECT.

“An employee allowed an individual with mental illness to leave the facility on an approved pass. However, the employee did not document that the individual was gone, and a second employee documented that the individual was present on the unit even after he was gone. The individual was missing for six days before he returned. The OIG investigation did not substantiate neglect. It was also noted that the facility failed to get initial written statements from the staff as required by Department policy.

As a result of this case, the facility:

–Suspended the first employee for one day;
–Suspended the second employee for three days;
–Re-trained both employees on proper documentation and monitoring procedures; and
–Instituted a tracking system to prevent tardy witness statements.”

Thus far the OIG is telling the world that monitoring patients is NOT a priority. Tardy witness statements suggests we are not getting the whole truth. Retraining staff on their most basic of duties leaves too much to be desired.

“An individual with developmental disabilities took a unit key from an employee’s key ring that he found laying on a table. He later unlocked a door and left the unit. Once off facility grounds, he stole a truck with keys left in the ignition. He was found unhurt 50 miles away at a highway rest stop when he was recognized by facility staff who were there on an outing with other individuals. The OIG investigation substantiated neglect against the facility.

As a result of this case, the facility:

–Took administrative action against the employee for leaving her keys on a table and failing to count them when she retrieved them;

–Revised a policy to require employees to account for all keys at each shift change;
–Put new locks and alarms on the unit and requires that problems with the alarm system are immediately addressed; and
–Assigned staff to provide better supervision to the individual.”

This makes a bold statement. The OIG doesn’t believe patients are smart enough to take the entire key ring but feels they have to teach staff to count keys and monitor patients.

In the OIG FY 2000 Report an increase in “violence and injuries to both staff and patients” was identified. Without a doubt, this terrorized patients receiving “treatment” in an environment expected to be a safe haven for psychiatric care!!

And in 1997 the OIG found 435 serious patient injuries and in 2001 found 1,096, but didn’t even suspect neglect, inadequate staffing, training or supervision. From 1997 to 2001 there was a 152% increase in serious patient injuries—that is enormously more than a suspicion! So far we can see that government officials (tax dollars) are having a difficult time learning the readily apparent.


Mr. George Jenkins “began acting abnormally three to four months prior to his suicide.” Mr Jinkins had told his wife, “to get out of the house, go live with her mother, because he didn’t want her to be there with him or there would be-INSTEAD OF ONE BODY BAG, THERE’D BE TWO BODIES.”

George began drinking heavily, giving away his money and possessions and dressed in dirty and disheveled manner. He started running in front of cars and a neighbor reported that George started saying, “THINGS GOING TO CHANGE.” He was taken to Christ Hospital (private) where family and friends explained he had been suicidal for the last 3 weeks. He was diagnosed with “ACUTE PSYCHOSIS WITH SUICIDAL BEHAVIOR” and medicated, he later tried to escape.

He was then sent to the Madden Mental Health Center (part of the state operated mental health system)) where the psychiatrist on duty gave him the diagnosis, “ALCOHOL RELATED DISORDER, NOS [NOT OTHERWISE SPECIFIED] AND ALCOHOL ABUSE” and refused to admit him despite George being a danger to self and others. Within hours he killed himself.

Within the same week period Robert James Williams was arrested for disorderly conduct and while in police custody, “attempted to injure himself by ramming his head into the cell bars and trying to hang himself.” He was then sent to Christ hospital on a certificate and petition for involuntary admission where, “Robert’s behavior required the use of physical restraints.”

“The physician at Christ Hospital contacted Mr. Pazhampally, a social worker at the Madden Mental Health Center, and requested that Robert be transferred to Madden. Mr. Pazhampally, acting on behalf of Madden, accepted the transfer. Robert was transported to Madden by ambulance, along with copies of his records from Christ Hospital and the petition and certificates for involuntary admission.” [NOTE: According to the Illinois Department of Financial and Professional Regulation, MR. PAZHAMPALLY IS NOT LICENSED TO PRACTICE AS A “SOCIAL WORKER”]

“Mr. Pazhampally reviewed Robert’s history, which included information that he had managed to free himself from one restraint.
Robert also admitted to defendants Davet and Hayes that he had recently started using crack cocaine.”

“However, Robert was released to the plaintiff’s (Bernadette Williams, special administrator of the estate of Robert James Williams) custody without treatment. The plaintiff was unaware that Robert had attempted to hang himself and was not warned of the risk of suicide. After returning home, Robert hanged himself, resulting in his death on June 21, 1996”.

In both cases the individuals attempted to kill themselves, the best, most logical and compassionate reason for admission—to observe and further assess and then refer to an appropriate residential or out-patient treatment center. Mr. Jinkins wasn’t admitted because he abused alcohol, he also used drugs (more predictors of suicidality) and Mr. Williams also had a problem with substance use.

On the Illinois “Department of Financial and Professional Regulation” website you will find numerous nursing licenses dating back to 1997 that were reprimanded, placed on probation or given a suspension for “diverting” (stealing meds from patients/hospitals) and “conversion of a prescription pad” (forgery) to obtain controlled substances like opiates, methamphetamine, Ritalin (prototype is amphetamine) and benzodiazepines. There is also use of alcohol, marijuana and cocaine. These nurses WERE NOT denied help, nor should they be, but neither should our vulnerable patients. These nurses were given a second chance, Mr. Jinkins and Mr. Williams were not given any chance.

Take into consideration that the Coalition for Consumer Rights came out with a report in 2000, “Condition Critical: DPR (Dept. of Prof. Reg.) Conceals Names of Risky Practitioners”. Speaking about Illinois and in the first paragraph it reads, “At the dawn of the 1990’s, (IL.) DPR ranked 16th in a national consumer group survey. Today, after a decade of mismanagement and neglect, DPR ranks 41st, one of the worst in the country“…

‘“The agency claims that it strives to balance two duties: “to serve, safeguard, and promote the public welfare” and to be “sensitive to the professionals they regulate.” In practice, however, it appears more sensitive to the needs of doctors than to the public welfare.”’

To make matters worse, [Private] “Hospitals all over the country charge their highest prices, by far, to those who can afford it least, the 46 million Americans who don’t have health insurance. Hospitals charge uninsured patients 2, 3, 4 or more times what an insurance company would pay for the same treatment”, per Dan Rather of “60 Minutes”, aired 3/5/06. These patients that can’t afford health insurance “often find themselves the target of collection agencies or in bankruptcy court”.


Training should always be conducted by professionals with an education in psychiatric care and experience working on a mental health ward. There is an extreme lack of effective training and supervision of direct patient caregivers by elected and appointed officials. The problems originate with our leadership that bears no responsibility or accountability for their ineptitudes.

“The universe will expand, then it will collapse back on itself. Then it will expand again. It will repeat this process forever. What you don’t know is that when the universe expands again everything will be as it is now. What ever mistakes you make this time around you will live through on your next pass. Every mistake you make you will live through again and again—–forever. So, my advice to you is to get it right this time around, because this time is all you have.”

~Prot, 2001, K-PAX


1) NAMI: Grading the States: A Report on America's Health Care System for Serious Mental Illnesses:

2) DHS Office of Inspector General:



5) Department of Financial and Professional Regulation: