report on critical incidentsreports (cirs) on occurrences in their institutions resulting in...
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Report on Critical Incidents in Virginia’s
State Operated Mental Health Facilities October 1, 2017 - September 30, 2018
Prepared by The disAbility Law Center of Virginia
March 2019
INTRODUCTION
The disAbility Law Center of Virginia (dLCV) is a private non-profit organization, operating under the authority of
federal law and designated by state law to act as the protection and advocacy system for people with disabilities
in Virginia.
The Code of Virginia requires that all facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) must report to dLCV within 48 hours of a “critical incident.” DBHDS is then required to provide all other known information within 15 days. A “critical incident” is any event resulting in death or loss of consciousness or an event requiring medical treatment.
During federal fiscal year 2018 (FY 18), dLCV received a total of 318 Critical Incident Reports from mental health facilities operated by the Department.
EXECUTIVE SUMMARY
In 2018, following review of FY 17 data, dLCV contacted D BHDS about concerns arising from the Critical Incident
Reports. We noted an increase in deaths at DBHDS-Operated mental health facilities and a corresponding
increase in deaths occurring soon after admission. There appeared to be a correlation between the bed of last
resort legislation and the admission of individuals with higher healthcare (as opposed to strictly mental health
care) needs.
In FY18, deaths and the numbers of deaths within three months of admission continue to be major concerns. The number of deaths reported by DBHDS-operated mental health facilities increased for the 2nd consecutive year, from 57 in FY 17 to 59 in FY 18. FY 18 unseated the previous year to become the “deadliest” year at mental health facilities since at least FY 12. All adult hospitals reported at least one death during FY 18. Piedmont Geriatric Hospital, Eastern State Hospital, and Catawba Hospital reported the greatest number of deaths (16, 14, and 13, respectively).
DBHDS psychiatric hospitals are not designed to act as primary medical providers nor, generally, as nursing
facilities. DBHDS should identify any underlying reasons for the increased deaths of individuals recently admitted
– including the inappropriate admissions of individuals who would be more appropriately served in medical
hospitals, or an inability to provide healthcare within the DBHDS system. Once reasons are identified, corrective
action can commence and, hopefully, we will see a decrease in state hospital mortality.
BACKGROUND
The Virginia Department of Behavioral Health and Developmental Services (DBHDS) generates Critical Incident
Reports (CIRs) on occurrences in their institutions resulting in injuries requiring medical treatment, and on
occurrences resulting in loss of consciousness and death. As the populations the state facilities serve are
substantially different, dLCV evaluates data from State Hospitals and Training Centers separately. This report will
detail CIR trends in DBHDS-operated mental health (MH) facilities during the 2018 Federal Fiscal Year (FY 18).
dLCV’s MH CIR data is based on reporting from:
Catawba Hospital (CAT)
2
Central State Hospital (CSH)
Commonwealth Center for Children and Adolescents (CCCA)
Eastern State Hospital (ESH)
Northern Virginia Mental Health Institute (NVMHI)
Piedmont Geriatric Hospital (PGH)
Southern Virginia Mental Health Institute (SVMHI)
Southwestern Virginia Mental Health Institute (SWVMHI)
Western State Hospital (WSH)
dLCV regularly monitors conditions in state facilities and responds to questions and complaints from residents
and their families. dLCV reviews CIRs on a weekly basis and analyzes quantitative data from the reports to
identify trends. Qualitative and quantitative data from the reports inform dLCV’s work in the state facilities and
this report.
DEATHS AT MH FACILITIES
TOTAL DEATHS The number of deaths reported by DBHDS-operated MH facilities increased for the 2nd consecutive year, from 57 in FY 17 to 59 in FY 18. While FY 2017 saw the highest number of deaths in mental health facilities in many years, FY 18 is now the “deadliest” year at MH facilities since at least FY 12. All adult MH facilities reported at least one death during FY 18. PGH, ESH and CAT reported the greatest number of deaths (16, 14, and 13, respectively). The steady rate with which PGH deaths in particular h ave increased over the last 2 years raises significant concerns.
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MH Total Deaths
70 57 59
60 47
50 42
40 32 34 32
30
20
10
0
FY12 FY13 FY14 FY15 FY16 FY17 FY18
20
18
16
14
12
10
8
6
4
2
0
FY12
CAT
FY13
CSH ESH
Hospital Deaths
FY14 FY15
NVMHI PGH
FY16
SVMHI
FY17
SWVMHI
FY18
WSH
40
30
20
10
0
FY 18 MH Deaths: Did Death Involve One or More of the "7 Medical Triggers?"
30
21
9
-Yes No Unknown
THE “7 MEDICAL TRIGGERS” Incidents preceding death at DBHDS-operated facilities have historically been primarily “Medical Condition.” Medical Conditions were the basis for 49 of the 59 deaths (83%) reported by MH facilities in FY 18. Facilities used the essentially meaningless “Loss of Consciousness” to explain 7 of the deaths (11.8%); this is the most that this category has been used since our recordkeeping began. While the number of unexplained incidents resulting in death dropped to just 1 in FY18, facilities generally did not provide much detail on the deaths, in spite of the statutory requirement to provide all known details in the 15 day report. As a result, we could not determine whether or not 30 of the FY 18 deaths (50.8%) involved the “7 Medical Triggers1.”
1 As defined by DBHDS: Aspiration/Aspiration Pneumonia, Bowel Obstruction/Constipation, Decubitus Ulcers, Dehydration, Seizures, Sepsis, and Urinary Tract Infections. (CVTC Community Provider Training)
4
DISCHARGE PRIOR TO D 2 EATH At both PGH and SWVMHI, the majority of reported deaths (62.5% and 50%, respectively) occurred after the
decedent had been discharged from the hospital. As a geriatric facility, PGH discharged many of its residents to
Nursing Homes or hospice providers in anticipation of their decline or death. We do not question the
appropriateness of those discharges, but merely note it. By contrast, facilities like CSH and NVMHI do not house
geriatric residents and reported a low number of deaths (3 and 2, respectively). While some of the CSH and
NVMHI deaths were due to medical conditions, few of the deaths were expected.
The number of deaths occurring during a special hospitalization increased from 9 to 12 in FY 18.
FY 18 MH Deaths: Was the Individual Discharged Prior to Death?
30 28
25
20
15
19
12
10
5
0
Yes No Special Hospitalization
DEATHS BY AGE As expected, geriatric deaths at MH facilities have considerably outnumbered non-geriatric deaths since our
record-keeping began. In FY 18, the number of non-geriatric deaths increased slightly.
2 Facilities are required to submit CIRs for any death that occurred at their facility, or within 21 days of an individual’s discharge, per DI 401.
5
45
40
35
30
25
20
15
10
5
0
22
10
FY12
27
7
FY13
Hospital Deaths By Age 42
31 31
22
16 15
1110
FY14 FY15 FY16 FY17
MH Deaths Non Geri MH Deaths Geri
42
17
FY18
PROXIMITY TO ADMISSION For several years, a number of facility directors have expressed concern with the number of “inappropriate medical admissions” that they have received since revisions to Virginia Code § 37.2-809 went into effect in 2014,
designating the DBHDS hospitals as “facilities of last resort.” We reviewed the number of deaths occurring
within given time intervals after admission. The number of deaths occurring within 90 days of admission has
increased substantially since 2014 and reached an all-time high in FY 18. The proportion of MH deaths occurring
within 90 days of admission has also increased since 2014. Before the 2014 Legislation was in effect, deaths
within 90 days of admission did not exceed 22.7% (in FY 12), and reached their lowest point in FY 14 (15.6%).
From FY 15 through FY 18, the proportion of deaths occurring within 90 days did not dip below 30%, reaching
36.2% in FY 15, 31% in FY 16, 32.1% in FY 17, and 38.9% in FY 18.
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MH Deaths Within 90 Days of Admission
FY18
FY17
FY16
FY15
FY14
FY13
FY12
0 5 10 15 20 25
■ 0 to 7 ■ 8 to 14 ■ 15 to 31 ■ 32 to 61 ■ 62 to 90
100%
Proportion of MH Deaths by Proximity to Admission
80%
60%
40%
20%
0%
FY12 FY13 FY14 FY15 FY16 FY17 FY18
■ MH Total 0 to 90 ■ MH Total 90+
OVERALL INCIDENT REPORTING
dLCV is concerned that specific mental health facilities may be failing to comply fully with reporting
requirements, resulting in underreporting. We are addressing issues with specific facilities as we identify the
issue. Inconsistent compliance necessarily impacts the reliability of our conclusions below. More importantly,
however, inconsistent compliance with reporting requirements may indicate the absence of quality
improvement and risk management oversight by DBHDS and by facility management.
In FY 18, DBHDS-Operated MH facilities reported 318 Critical Incidents—a very slight decrease from the 333
reported in FY 17. ESH reported the greatest number of incidents (66), followed by PGH (55). ESH is the largest
DBHDS-Operated MH facility in Virginia, so their status as highest reporter is expected. PGH, however, is a
relatively small facility with 123 beds and an entirely geriatric population. One might expect a geriatric MH
facility to have a higher rate of certain incidents, such as falls and deaths, compared to facilities serving a
younger population; still, it is concerning that PGH residents were subject to a greater number of serious injuries
than facilities with substantially more psychiatrically acute admissions.
For comparison, CSH, the second largest hospital, houses Virginia’s maximum security forensic unit. CSH was the
third-largest CIR reporter, with 44 serious injuries in FY 18—eleven fewer than PGH. FY 18 CIR data supports
staffs’ assertions that the populations of CSH and ESH have become far more acute and prone to self-injury and
peer assault, as evidenced by the fact that they reported the highest numbers of self-injurious behaviors (SIB)
(CSH reported 14 and ESH reported 12). These rates of injury may also be related to the transfer of individuals
from jails for restoration of competence. While numbers remain high, the number of SIB incidents at CSH and
ESH h ave decreased substantially in the last year; in FY 17, they reported 24 and 17 incidents of SIB, respectively.
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CIR Incident Types at DBHDS-Operated MH Facilities FY18
70
4
60
12
6 50
2
2
1
9 15 40
7 2
14 4
1 8
30 13
11 4
8 3
1 2 20 3 1 1
1 28 2 1 4
12 1 2 17 3 13 1 7
1
10
0
1 12 2 1 1 1
3 1 10
2 3 8 6 1 2 2 1 4 1 1 4 3 3 1 2 2 1 1 1
2
6
2
CAT CSH CCCA ESH NVMHI PGH SVMHI SWVMHI WSH
■ Accident ■ Aggressive Behavior ■ Alleged Assault-Peer Alleged Assault-Staff □
■ Alleged Sexual Assault-Peer ■ Allergic Reaction ■ Aspiration/Choking ■ Fall
■ Loss of Conciousness ■ Medical Condition ■ Other ■ Recreational Activities
■ Self-Injurious Behavior ■ Unexplained
INCIDENT CATEGORIES
In previous years, falls and SIB made up the vast majority of MH CIRs. Falls are still the most prevalent incident
type, accounting for 28.93% of incidents. Meanwhile, SIB decreased substantially in the last year, dropping from
20.72% of incidents in FY17 to just 13.21% of incidents in FY18. Peer assaults and medical conditions continue to
make up a sizeable proportion of incidents.
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Proportion of CIR Incident Types at All DBHDS-Operated MH Facilities FY18
Aggressive Behavior 3.77%
Accident Unexplained 5.35%
6.92%
Self-Injurious Behavior
Recreational Activities 13.21% Alleged Assault-Peer Alleged 2.20% Other 15.41% Assault-Staff
1.26% 0.63%
Alleged Sexual Assault-Peer
Medical Condition 2.20%
17.30% Allergic Reaction
0.31%
Aspiration/Choking 0.31%
Fall 28.93%
Loss of Conciousness 2.20%
We compared the 4 most prevalent incident types—peer assaults, falls, medical conditions, and SIB—across the
facilities within the context of population. Below are the per capita statistics for FY 17 and FY 18. Due to CCCA’s
uniquely small population and high bed turnover, including them in the per capita analysis can lead to
misinterpretation of the data. While the rate of CCCA incidents is correct within the context of dLCV’s analysis,
we do not believe it is a comparable statistic; it has been excluded from our per capita analysis of incidents.
The rate of incidents secondary to falls increased during FY 18, particularly at PGH, where the rate increased
from 0.175 per capita, or about 17% to 0.228 per capita, or about 23%. At SVMHI, the rate of falls remains
unusually high at 0.154 per capita, or about 15%. This rate of falls is more consistent with PGH and CAT, which
house geriatric residents, than it is with other, non-geriatric hospitals. The rate of SIB decreased at every facility.
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0.250
0.200
0.150
0.100
0.050
0.000
Per Capita Rate of CIR-Reported Incidents at DBHDS-Operated MH Facilities FY 17
0.0
29
0.1
44
0.1
73
0.0
10
0.0
55
0.0
29
0.0
34
0.1
01
0.0
27
0.0
20
0.0
30
0
.05
7
I .. 1 •• 1 ••• , It I I I.. I ■ .111 ••• 0.0
34
CAT CSH ESH NVMHI PGH SVMHI SWVMHI WSH 0
.02
60
.00
0
■ Alleged Assault-Peer Per Capita ■ Fall Per Capita 0
.06
0
■ Medical Condition Per Capita ■ Self-Injurious Behavior Per Capita 0
.03
3
0.1
75
0
.10
0
0.0
08
0.0
63
0
.14
3
0.0
00
0
.01
6
0.0
24
0.0
66
0.0
54
0.0
66
0.0
00
0
.04
7
0.0
26
0.0
21
0.250
0.200
0.150
0.100
0.050
0.000
0.0
19
0
.16
2
0.1
24
0.0
00
0.0
50
0
.01
30
.01
3
0.0
59
0.0
44
0.0
37
0.0
31
0.0
41 0.0
66
0
.01
70
.01
70
.03
3
0.0
08
0.2
28
0
.12
2
0
.00
0 Per Capita Rate of CIR-Reported Incidents at DBHDS-Operated MH
Facilities FY18 0
.01
5
0.1
54
0
.00
00
.00
0 0.0
36 0
.07
10
.04
80
.04
8
0.0
26
0
.03
0
0.0
09
0
.00
4
• 1 •• 1 1111 l •• 1 _ • 1111 ••--CAT CSH ESH NVMHI PGH SVMHI SWVMHI WSH
■ Alleged Assault-Peer Per Capita ■ Fall Per Capita
■ Medical Condition Per Capita ■ Self-Injurious Behavior Per Capita
INJURY YPES TMost of the injuries reported by MH facilities in FY 18 were lacerations or skin tears (108 total, or 32.39%),
followed by deaths (59 total, or 18.55%) and fractures (56 total, or 17.61%). Overall, the proportion of primary
injuries reported in FY 18 was very similar to that from FY 17.
10
70
60
50
40
30
20
10
0
CIR Primary Injury Types at DBHDS-Operated MH Facilities FY18
1 2 -1
2
2
28
14 1 2
2
6 12 19 3 13
11
5 8 16
8 1 1 1 10 1
2 2 11 14 2
4 8 9 2 13 1
1 1 4 8 3 3 2 1 3 5 2 2 2 2 1 2 1 1 1 2 2 2 2 1 1 1 1
CAT CSH CCCA ESH NVMHI PGH SVMHI SWVMHI
■ Abrasion/Scratch Alleged Sexual Assault ■ Allergic/Adverse Reaction □
■ Bite (Human) ■ Bruise/Contusion/Hematoma Concussion/TBI □
■ Death ■ Eye Injury ■ Fracture
■ Ingestion of Foreign Object Insertion of Foreign Object ■ Laceration/Tear □
Loss of Consciousness Other ■ Pain □
■ Swelling/Redness ■ Tooth Injury ■ Unknown
3
1 1 1
3
5
1
4
2
2
WSH
11
.11 111 .I II 111 111 .11 ■ ■ ■
I .II II •• I I ■■I 111 -·· ■ ■ ■
For the reasons stated previously, we have not included CCCA in our per capita analysis of injuries. Fractures
decreased at all facilities except NVMHI during FY18.
The rate of deaths decreased slightly at CAT (from .173 per capita or about 17% to .124 per capita or about
12%). Deaths increased substantially at PGH, however, from .092 per capita or about 9% in FY 17 to .13 per
capita or about 13%. The increase at PGH is more dramatic when you consider that the FY 17 rate was already a
huge increase from FY 16, when the rate was only .041 per capita or about 4%. The high rate of deaths at CAT
and PGH is due, at least in part, to the large proportion of geriatric residents at both facilities. Still, as we
previously stated, DBHDS must endeavor to identify causal factors to this increase in deaths if they hope to
reduce mortality in the state hospitals.
0.200
0.180
0.160
0.140
0.120
0.100
0.080
0.060
0.040
0.020
0.000
0.1
73
0.0
96
0.1
44
0.0
17
0.0
55
0.0
88
0.0
37
0.0
40
Per Capita Rate of CIR-Reported Injuries at DBHDS-Operated MH 0
.04
7Facilities FY17
0.0
00
0.0
09
0.0
78
0.0
92
0.0
75
0.1
33
0.0
32
0.0
32
CAT CSH ESH NVMHI PGH SVMHI SWVMHI 0
.04
8
Death Per Captia Fracture Per Capita Laceration/Tear Per Capita 0
.04
8 0.0
72
0.0
78
WSH
0.0
13 0
.03
9
0.0
34
0.200
0.180
0.160
0.140
0.120
0.100
0.080
0.060
0.040
0.020
0.000
0.1
24
0.0
76
0.1
81
0.0
13
0.0
46
0.0
50
0.0
47
0.0
37
0.0
95
0.0
17
0.0
25
0.0
74
0.1
30
0.0
49
0.1
14
0.0
15
0.0
15 0.0
31 0.0
48
0.0
60 0.0
77
Per Capita Rate of CIR-Reported Injuries at DBHDS-Operated MH
Facilities FY18
CAT CSH ESH NVMHI PGH SVMHI SWVMHI
Death Per Captia Fracture Per Capita Laceration/Tear Per Capita
0.0
09
0.0
17
0.0
21
WSH
12
60
50
40
30
20
10
0
Total CIR-Reported Incidents Occurring on a Given Day of the Week at DBHDS-Operated MH Facilities FY18
50 47
44 41 41
38 40
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
18
16
14
12
10
8
6
4
2
0
CIR-Reported Incidents Occurring on a Given Day of the Week at DBHDS-Operated MH Facilities FY18
Monday Tuesday Wednesday Thursday Friday Saturday
CAT CSH CCCA ESH NVMHI PGH SVMHI SWVMHI • •
Sunday
WSH
TIMING OF INCIDENTS Facilities reported a slight “bump” in incidents occurring on Saturdays (50 total incidents). Reporting seems to
be fairly consistent across other days of the week. The only real outlier among the “day of week” data is PGH,
which reported a disproportionate 16 incidents on Tuesdays. It is unclear what caused these “bumps” in the data, but dLCV advocates will use this information to guide monitoring in FY19.
As expected, most of the incidents were reported during periods of higher social activity, such as lunch and leisure times. That said, there are much higher number of incidents reported during the lunch hour (12pm-1:59pm) during FY 18 (46) than in FY 17 (24).
13
Total CIR Incidents Per Month at DBHDS-Operated MH Facilities FY18
40
30
20
3533
26 26 25 25
31
22 24 24 23 24
10
0
Oct. Nov. Dec. Jan. Feb. Mar. April May June July Aug. Sep.
Reported Time of CIR Incidents at DBHDS-Operated MH Facilities (Total) FY18
50 46
45 41 40
40 35 30
28 28
25 20
20 20 17 17 16 18
15 10
5 3
0
FY 18 CIR reporting at MH facilities peaked in July (35), with the fewest reports coming in October (22). Monthly
reporting during FY 18 was more consistent than in FY 17 (high o f 42, low of 18).
CONCLUSION
dLCV continues to have serious concerns about the ability of DBHDS mental health facilities to manage the
increasingly acute and medically fragile individuals admitted to their care. This is not necessarily an indictment
of the care provided, but may be a result of the inability to provide that care in a facility designed for psychiatric
purposes. In Federal Fiscal Year 2018 (FY 18), dLCV notified DBHDS of these concerns, particularly the increase
in deaths and the corresponding increase of deaths occurring soon after admission. We shared with the
Department our speculation that there is a correlation between the bed of last resort legislation and the
admission of individuals with higher healthcare (as opposed to strictly mental health care) needs.
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RECOMMENDATIONS
The Department of Behavioral Health, together with other relevant state resources, should take immediate
steps to identify the causes of the increased death rates at state mental health facilities. Specifically, the
Department should
- Determine the source of admission for every death that occurred within 90 days of admission, in
every mental health facility operated by the state, to determine whether there are any obvious
problematic sources of admission,
- Conduct a complete analysis of each death, regardless of admission date, to determine whether any
death was related to one of the “7 Triggers.” In our experience, many deaths related to one of these
triggers (aspiration, bowel obstruction, decubitus ulcers, dehydration, seizure, sepsis, and urinary
tract infection) can be avoided with improved staff training and appropriate resources,
- Evaluate staffing levels at each facility, especially for medical staff,
- Increase staff training to be able to identify and respond to medical conditions, and
- Review the falls protocol in each of the state’s mental health facilities
As always, the disAbility Law Center of Virginia welcomes any opportunity to discuss these findings with the
Department of Behavioral Health and Developmental Services, with relevant policy makers or with other
concerned parties.
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