Staff at hospital criticized in patient killing

Workers slept on the job, lied on forms, investigators find

February 12, 2011|By Yeganeh June Torbati, The Baltimore Sun

Employees at Maryland's maximum-security psychiatric hospital were inattentive, slept on the job and lied about checking on patients, state health investigators say in a report on the strangulation of a patient last September.

Video surveillance showed that as the killing unfolded, one staff member was sitting on a couch on the ward with no view of patients' rooms, another was seated at the nursing station but did not make any movement, and a third was not seen at all, the report said.

In response to the report, officials at Clifton T. Perkins Hospital Center in Jessup, a state-run facility that houses the criminally insane, say they have stepped up staffing of the medium-security ward where 45-year-old Susan Sachs was killed by a fellow patient, and have increased hospital oversight of night-shift nurses and security staff. It was apparently the first killing in the hospital's 50-year history.

"We were disappointed to find out that staff were clearly inattentive on the job that night, and, since learning of the problem, the Department has taken prompt and thorough action," wrote Wendy Kronmiller, the assistant secretary for regulatory affairs at the health department, in an e-mail Friday. "While we believe this was an isolated occurrence, the report is disturbing — our facilities and staff are responsible for meeting needs of patients, during the day and at night."

But advocates for psychiatric patients said that the hospital has for years failed to take enough steps to protect patients — particularly women — from assault. Prompted in part by Sachs' killing, they are pushing for legislation in the General Assembly this year to increase reporting requirements for sexual harassment and require men and women to be housed separately in state facilities.

"Even after the patient was killed last September they've made exactly zero policy and procedure changes at Perkins," said Virginia Knowlton, executive director of the Maryland Disability Law Center.

El-Soudani El-Wahhabi, 50, has been charged with Sachs' murder and is awaiting trial. Video surveillance showed him entering Sachs' room the night of the murder and leaving a few minutes later to go his bedroom, two doors away. He later told police that he strangled Sachs.

Perkins Hospital is run under the auspices of the Department of Health and Mental Hygiene, which launched an investigation of the incident last year under the department's oversight arm, the Office of Health Care Quality. The investigators' report, released Thursday, concluded that:

• The ward's door-locking system, meant to ensure that patients must get permission from staff to enter and exit their bedrooms, was inexplicably turned off and doors to patient rooms were unlocked for much of the night of Sept. 25. As a result, El-Wahhabi was able to slip in and out of Sachs' room unnoticed. Patients on the ward are not allowed in the bedrooms of other patients.

• Just a few hours after Sachs' killing, two of three night-shift workers were spotted in video surveillance watching television and sleeping on couches in the ward instead of monitoring patients. The employees, investigators wrote, "initially appeared to watch television, then appeared to be sleeping or napping, based on nodding heads and a lack of general movement."

• After 9:15 p.m. on the night of the killing, no nursing staff conducted the required half-hour checks on the 24 patients housed there. Instead, workers fraudulently filled out forms indicating they had checked on patients.

Hospital administrators have pledged new controls in response to the killing, including increasing the number of staff on duty in the ward from three to four during the morning and evening shifts, instituting an alarm that sounds when a patient's door has been opened, and directing security staff to monitor surveillance cameras to ensure night staff actually conduct patient rounds.

The health department maintains that the housing arrangement for El-Wahhabi and Sachs was not a contributing factor in Sachs' killing.

"But we are taking a look at this concern," Kronmiller said, "as well as others which may be suggested, in order to create the safest environment possible for patients and staff."

El-Wahhabi has spent more than half his life cycling in and out of Perkins, most recently after he was found not criminally responsible for the 1995 murder of Mona Johnson, 26, in her Druid Heights rowhouse. At the time, he went by the name Saladin Ishmael Taylor.

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