News Room

State of Neglect: Agencies' inspection reports differ widely
January 12, 2009

Inadequate staffing allowed violent teenage patients to assault others, government reports show. State surveyors also cited filth, disrepair and repeated mistakes in delivery of medications.

Written by Doug J. Swanson, The Dallas Morning News


SAN ANTONIO – At the Laurel Ridge Treatment Center, a therapeutic home for troubled adolescents and private psychiatric hospital, state investigators found that a shortage in personnel led to the neglect of children.

Inadequate staffing allowed violent teenage patients to assault others, government reports show. State surveyors also cited filth, disrepair and repeated mistakes in delivery of medications.

Such problems could indicate a troubled facility and send warning signals to patients' families. But don't expect to learn about them in records maintained by the Texas Department of State Health Services, although that agency oversees the Laurel Ridge hospital.

Nearly all of the health department's investigative findings are confidential by law. This allows Texas hospitals to operate in virtual secrecy – and keeps the public from knowing how well the agency polices these hospitals.

"It's a sad statement when you can find out more about a tattoo parlor than you can a hospital," said Rep. Trey Martinez Fischer, D-San Antonio. "I can find out more about my cat's veterinarian."

He and others have tried to repeal the regulatory brownout, which became law in 1999 at the urging of lobbyists, to give the public more information on hospital inspections and complaints.

"It's a public health issue," Martinez Fischer said. "People have a vested interest in knowing how safe they and their loved ones would be when they go to a hospital."

The health department defends its regulatory performance but says it could do better with more money.

"Based on the resources we have, we do an excellent job," said Marc Allen Connelly, deputy general counsel. "But we need a lot more inspectors. We need a lot more people out there to respond to situations immediately."

Second regulator

Laurel Ridge offers a rare exception to the information void.

Because it is a residential treatment center as well as a hospital, the Texas Department of Family and Protective Services also regulates it.

Unlike the health department, Family and Protective Services must make licensing and inspection records public.

The two agencies oversee different programs and use separate regulatory standards. The Family and Protective Services records, nonetheless, shed light on some serious operational shortcomings at Laurel Ridge, while the state health department stays publicly silent.

The center, a low-rise collection of stucco buildings with red barrel-tile roofs, spreads across a woodsy campus on San Antonio's north side. With 196 beds, it is owned by Psychiatric Solutions Inc., a Tennessee company that calls itself the nation's "clear leader in the growing $20 billion inpatient behavioral health industry."

PSI operates 15 facilities in Texas, more than in any other state, including hospitals in DeSoto and Arlington. The company was fined $230,000 for violations by the state health department in 2007. That's nearly as much as the fines of all other hospitals combined.

The health department assessed no fines at Laurel Ridge in 2007. The department's investigative logs show that, after nine on-site visits, it cited Laurel Ridge hospital for nine unspecified violations that year.

At the same time, however, investigators from the Department of Family and Protective Services, in 36 on-site visits, cited 92 deficiencies at the treatment center for children and adolescents.

FPS investigators noted mold, broken plumbing and peeling paint in bathrooms. Also, one inspection report said, a "mound of feces was found in a high-traffic pathway leading to the residents' units."

Some patients received the wrong drugs, while others missed their medications entirely. An unwatched child took medication from the medicine cart. And, inspection records said, employees "did not lock the door to the secured unit, allowing [a] child to run away from the facility." The records say nothing about what happened to the child.

The center has a history of problems. In July 2005, staff complained to FPS inspectors that cutbacks forced them to leave children unsupervised. Five months later, records documented this : "Three staff members acted inappropriately by holding the door closed on a child for approximately 23 minutes while the child screamed and banged his head in his room."

Another collection of records shows even more troubles at Laurel Ridge.

The state health department performs hospital inspections and investigations for the federal Centers for Medicare and Medicaid Services. The records are available through a Freedom of Information Act request with the U.S. Department of Health and Human Services.

Thus the federal government can release records that the state of Texas compiled but is forbidden by law to disclose.

At Laurel Ridge in 2006, these records say, "the facility failed to provide adequate numbers of qualified personnel" when a 13-year-old patient was injured while being restrained by a staff member.

In another incident, a 14-year-old patient sustained "tearing of the anus" and rectal bleeding in sexual activity with another patient. The investigator concluded that "the facility failed to direct, monitor and evaluate the care of patients."

Center management also neglected to monitor patients sufficiently, an investigator found, when a 17-year-old patient with a "long history of violent and disruptive behavior" attacked another teenage patient.

Psychiatric Solutions turned down multiple requests from The Dallas Morning News to interview top executives. Instead, Nashville public relations executive John Van Mol fielded questions.

"PSI has a 'no-excuses' mentality," Van Mol said. "So while it may differ with some regulatory interpretations, company executives realize ... that PSI and the regulators have the same goal of quality patient care."

Two pending lawsuits also make serious accusations against Laurel Ridge.

Nurse Loretta Ramos claims she was fired from Laurel Ridge "because she reported violations of law regarding unsafe staffing, failure to provide a safe environment of care and was a witness to the cover-up of the facts surrounding [a] patient's suicide."

The family of that patient also has sued Laurel Ridge. Patricia Connolly, 32, was admitted to Laurel Ridge in 2007 with suicidal ideation. She hanged herself there with a telephone cord.

Ramos said staffers had been told one day before to remove phone cords from the rooms of suicidal patients, but did not do so.

In court filings, PSI has denied the allegations.


PSI has enjoyed significant financial success in recent years, with ever-expanding revenue and profits. In 2007, it had $76 million in net income. Most of its revenue comes from public sources such as Medicare and Medicaid.

Joey Jacobs, chief executive officer of PSI, told analysts last year that publicity about regulatory reports can be misleading. "There is a disconnect between the sensationalism of an incident that might get put in the paper vs. the actual reality," he said.

PSI has established itself in Austin, hiring a well-connected lobbyist – Marc Samuel of HillCo Partners – and contributing to key legislators.

Last year, PSI's political action committee and Jacobs each donated $2,500 to state Rep. John Davis. HillCo contributed $3,000 to the Houston Republican.

Davis sponsored an amendment to a 2003 bill – legislation that privatized many state health services – that would have permitted the privatization of state mental hospitals and state schools. His amendment was not included in the version of the bill that passed.

An aide to Davis, Meghan Weller, said the legislator has no plans to reintroduce the legislation, and he has never heard of PSI "to the best of his recollection."

Jacobs did not address that issue in his remarks to analysts, but he did say the company constantly seeks to "expand [its] market share."

He also defended its regulatory performance. "Our facilities are surveyed multiple times each year on average, and less than 1 percent of these surveys result in serious deficiencies," he said. "We are pleased with this track record."

Repeated citations

In addition to Laurel Ridge, other PSI treatment centers for children and adolescents in Texas have been repeatedly cited by the Department of Family and Protective Services. (Because they are not hospitals, the state health department does not oversee them.)

At The Oaks in Austin:

•In 2005, an inspection report said, "it is alleged that there are rats in the [facility] and children have to put towels under the doors to keep rats from going into their room."

•Unwatched children escaped from the center. One robbed a liquor store.

•In 2006, "staff failed to supervise two children which resulted in a subsequent sexual assault to one child."

•Mattresses had holes that allowed the springs to "stick out and poke the children." Bedrooms and bathrooms were moldy and dirty.

Perhaps the most serious incident occurred in March 2007. A disturbance and possible hostage situation became so dangerous that the Austin police SWAT team was called. "Six children were arrested," the FPS investigator said.

The same investigator noted that several staff members at The Oaks had "made numerous requests of administration to increase staffing levels." The requests had received no response, they said.

At the San Marcos Treatment Center, cited deficiencies included the following:

•In 2005, a child care investigator wrote that residents beat a 15-year-old boy for 90 minutes. He was hurt so badly that he spent 29 days in a hospital.

•In another instance, a teenage girl hit her head on the floor when restrained by a male employee. Apparently as a result of this injury, "her behavior that evening was described as delusional by one staff and psychotic by another," an investigator found. "She also complained of dizziness, was crying and was seen vomiting in a trashcan."

The report said she did not see a doctor.

•That same year, a 13-year-old boy with Asperger's syndrome was ill for three days with acute respiratory problems and pancreatitis but did not see a doctor.

He vomited seven times. Staff notes showed that they believed he was faking his illness.

"For the four hours prior to his being taken to the emergency room, he was, according to medical records, in critical condition," the investigator wrote.

But no one called an ambulance. Instead, center employees took him to a hospital in a facility van.

"The child ... almost died," the investigator wrote. "The behavior of facility staff places children in their care at significant risk of harm."

•On numerous occasions, investigators found, center administrators were aware of serious problems but did not act properly. In one case, a state finding said, "facility administration" knew of a sexual relationship between a staff member and a 16-year-old resident, but did not report it to licensing authorities.

•In 2007, two suicide attempts by children were not reported to the state.

•During just one inspection, in July 2007, an investigator cited the center for 52 violations. A state administrative review later upheld 25 of the cited deficiencies.

Van Mol, the PSI spokesman, declined to address the specifics of the findings at the treatment centers.

"In every instance in which a regulator identifies an area of concern and that condition or circumstance needs to be changed or improved, PSI makes the change or improvement," he said.

Since 2005, he said, PSI has spent more than $26 million on capital improvements at its Texas facilities.

Critics of the company sometimes forget that it takes some of the most seriously troubled patients, he added. "Good people working hard in a difficult field are not perfect but are trying to continuously improve operations to benefit the patients," Van Mol said.

Putting an undue emphasis on regulatory problems, he said, serves to "simply tear down good people doing a hard job."

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