Our Lady of Peace psychiatric hospital under state investigation
Head-banging incident sparks inquiry at Our Lady of Peace
By Patrick Howington
phowington@courier-journal.com
Locked alone in a room at Our Lady of Peace psychiatric hospital, a 17-year-old girl was allowed to beat her unprotected head on a hard floor more than 120 times last spring while as many as three employees watched.
Those employees — including a behavioral analyst — were trying to determine the cause of the teen’s self-injuring behavior. But now, the Kentucky attorney general’s office is investigating the May 13 session as a possible crime.
The investigation follows an August report from state Cabinet for Health and Family Services inspectors that concluded that the hospital “failed to … assure the safety of the patient.”
Though the girl — whose diagnoses include autism, cerebral palsy and mental retardation — “appeared dazed” afterward, a doctor wasn’t told about the incident until almost 21 hours later. The call was made after hospital staff helping the teen shower noticed a bald spot that was “pretty swollen with popped blood vessels,” one worker told inspectors.
The inspectors’ report, based partly on a video of the procedure, didn’t detail the girl’s eventual medical care or the extent of her injury. She was discharged in August.
Hospital officials declined to give her name or discuss her treatment, citing confidentiality rules. The Courier-Journal obtained the state inspector’s report through a state open-records request.
The state conducted the inspection on behalf of the federal Centers for Medicare and Medicaid Services — which requires hospitals to meet safety conditions and other requirements to receive federal funding.
The findings prompted the agency to threaten to cut off reimbursements to the Louisville psychiatric hospital and its parent company, Jewish Hospital & St. Mary’s HealthCare.
But the cutoff was averted after Our Lady of Peace changed its procedures, including adding a requirement that doctors be involved in such assessments.
Based on those changes, the Medicare program told hospital officials Sept. 12 that the facility was back in compliance with federal regulations.
“We’re trying to put in every single protection and process and policy in place to prevent any injury to any patient,” said Thomas Gessel, the hospital’s interim chief executive. “We want to make sure that we have a safe environment.”
Allison Martin, spokeswoman for Attorney General Jack Conway, confirmed Friday that the office’s Medicaid Fraud and Abuse unit is investigating the incident.
The case was referred to the office by the health services cabinet’s Child Protective Services section in July, she said.
Martin said that she could not release details of the investigation. No charges have been filed.
When asked why the six-month-old investigation has not been concluded, she said: “It’s a complex issue (and) we are looking at many different factors … and it is our goal to be thorough.”
She said Conway wasn’t available for an interview Friday because he was traveling out of state.
JoAnne Maamry, chief executive officer of Our Lady of Peace at the time of the incident, resigned in August. She is not working now.
Reached by e-mail, Maamry declined to comment on the case or her resignation.
Gessel, the interim chief, would not say if Maamry’s resignation was related to the incident, saying personnel matters are confidential.
He also said the hospital provided the attorney general’s office with some documents it asked for, but he said he doesn’t know more about the criminal investigation.
‘Assessments’ are rare
Our Lady of Peace, on Newburg Road, is one of the nation’s largest nonprofit psychiatric hospitals.
About 70 percent of its patients are younger than 18, many of them wards of the state.
Gessel said “functional analysis assessments” of disturbed and uncommunicative patients — which can include watching them hurt themselves — are fairly rare at the hospital, used on 20 or fewer patients last year.
They are made by behavioral analysts — certified clinicians who typically have advanced degrees but are not doctors or nurses.
But such assessments were suspended in August and won’t resume until safety policies are honed, Gessel said.
In a plan of corrections submitted to state and federal authorities in September, Jewish Hospital & St. Mary’s pledged that procedures for functional analysis assessments would be revised to require doctors’ involvement and having nurses present.
The company also said hospital staff would be trained to determine how long an assessment exercise should last, grounds for stopping it, and the use of protective equipment.
Despite agreeing to those and other changes, however, the company disputed that it had been out of compliance with health-care regulations.
The May 13 session involving the 17-year-old girl consisted of five 10-minute segments, including one in which she was alone, inspectors reported.
Staff members conducting the session disregarded an order from the patient’s doctor to put a helmet on her if she began banging her head, the state report said.
The behavioral analyst in charge of the session — whom the hospital refused to identify — later told inspectors that despite the doctor’s order, it was his decision when to apply the helmet, and that nurses were not present because “they would stop the session.”
After the patient hit her head on the tile-over-concrete floor 129 times, intermittently biting her arms, employees put a helmet on her. She then stopped the banging, the report said.
“The patient appeared dazed, as she swayed back and forth while knocking on the door to get staff’s attention to let her out of the room,” the report said.
Michelle Spurlock, chief nursing officer and vice president of Our Lady of Peace, would not say whether the analyst was disciplined over the incident. She said he is still employed there.
National experts on autism said that while an observation session is a valid diagnostic method, the May 13 session lacked the proper controls.
If patients regularly bang their heads, watching the behavior can help “understand what sets it off, what keeps it going,” said Dr. Fred Volkmar, director of the Child Study Center at the Yale University School of Medicine. But, “you want to be sure, first and foremost, of the person’s safety.”
“It sounds like the behavior analyst did not display good clinical judgment,” said Robert LaRue, assistant director of research and training at Rutgers University’s Douglas Developmental Disabilities Center and a certified behavioral analyst. “If you’re letting a kid hit a hard linoleum or concrete floor 130 times, you’re probably not doing it right.”
LaRue said that with a head-banging patient, he might change the assessment procedure to measure how fast a stimulus such as noise triggered head banging, rather than how long the banging lasted.
“They’re lucky that she didn’t split her forehead open,” said Sandra Harris, executive director of the Rutgers center, who has studied autism since 1972.
State inspectors’ report
In their report, the state inspectors concluded that Our Lady of Peace lacked procedures to make sure such patients received prompt medical attention.
They also wrote that hospital officials failed to thoroughly investigate the incident, reprimanded a nurse who reported it to the patient’s doctor, wrongly secluded the patient in a locked room without a doctor’s approval and failed to report the incident to state authorities.
Spurlock said the locks have been removed from the treatment room since the report was written.
Gessel said that he does not know why the incident was not reported, because it is the hospital’s normal practice to do that.
State inspectors also said the hospital failed to ask the patient’s legally appointed state guardian for permission to conduct the assessment. The guardian told inspectors that she would not have consented to an assessment that allowed the girl to continuously bang her head.
The guardian also wasn’t told that an X-ray of the patient’s head was performed and wasn’t given the results, the report said.
Reporter Patrick Howington can be reached at (502) 582-4229.
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This update from Bob Kafka, National Organizer of ADAPT (3:58 PM, ET): 
