Patient death spurs probes, lawsuit

One report says Elk Grove woman was held down by staff ill-trained to subdue agitated people.
Eighteen months after an Elk Grove woman died after she had been pinned to the floor of a south Sacramento psychiatric hospital, the facility is facing state and federal probes, a lawsuit and potential fines.

One state Department of Health Services report recently found that 51-year-old Ramona Knapp was "restrained inappropriately" and that Sierra Vista Hospital was understaffed with workers who hadn't been trained to correctly subdue agitated patients.

The federal Medicare and Medicaid funding agency is deciding whether to dock the hospital's reimbursements. State health officials are studying whether to fine the hospital $25,000 under a year-old law that penalizes hospitals that place patients in jeopardy. And a civil wrongful death lawsuit is moving forward.

All of this comes as Knapp's daughter, Siina Linville of Elk Grove, maintains that her mother died needlessly.

"I know she had mental problems, but she deserved good care even if she had issues," Linville said. "She just needed help."

A hospital spokesman, Mark Grip, declined to comment Tuesday.

Linville said her mother wrestled with bipolar disorder, a condition that Knapp controlled with medication.

Knapp's symptoms -- ranging from depression to manic behavior -- became apparent only when she altered her medications, her daughter said.

Typically, Knapp spent hours talking on the phone to her family and working night shifts at Turning Point, a nonprofit mental health services agency.

But on Dec. 3, 2005, Knapp had been easing off her medications in preparation for gastric-bypass surgery. That day, she was admitted to Sierra Vista Hospital on Bruceville Road, frantic and agitated.

Linville said family members did not tell her where her mother was because Knapp would not have wanted her daughter to worry.

Details of what happened the evening Knapp was asphyxiated are spelled out in a DHS report completed in February:

At 7 p.m. Dec. 4, Knapp was yelling, punching and pushing staff, according to hospital notes.

By 10:20 p.m., she yelled more loudly. A staff member asked her to stop, and Knapp replied: "No, I don't have to. You're going to kill me."

Knapp began to run around her room, kicking at staff members, the report says.

A mental health technician pinned Knapp's arms across her chest, the report says. In seconds, Knapp was pressed to the floor between two beds, with one technician leaning on Knapp's back. Two other staff members held her limbs.

Knapp grew still. Hospital workers sent her to a hospital, where she died the next evening, a coroner's report says.

The Sacramento County coroner ruled her death a homicide due to asphyxia and a "struggle with medical personnel while being physically restrained."

Sacramento police looked into the death at the time but found no criminal wrongdoing. The hospital submitted information to state regulators saying policies were followed correctly.

Last September, inspectors from DHS visited the 72-bed Sierra Vista Hospital, which is owned by Tennessee-based Psychiatric Solutions Inc.

Inspectors found myriad violations of federal hospital standards, according to the report.

Staffers did not use safe restraining techniques with Knapp, the report says. And staffers violated hospital policy by not calling a "code green" alert and coordinating to gently restrain Knapp.

Further, staff members who held Knapp down had not been trained in crisis prevention, which addresses ways to calm agitated patients.

The report also says the hospital was understaffed the night Knapp was restrained.

And the base line for determining staff levels -- forms that assess how much care a patient needs -- were not all filled out.

"To me that is remarkable and concerning," said Leslie Morrison, an attorney with Protection and Advocacy Inc., a nonprofit disability advocacy group that reviewed the DHS report. "I don't know how they base staffing if they're not evaluating acuity level."

The DHS surveyors also made random checks into staffing and training, finding both areas lax.

In a one-week period, 84 percent of shifts were short-staffed. And reviews of 12 of 13 employee files showed their licenses had not been verified or staffers had no record of training in life support or crisis prevention.

"This shows a history of systemic neglect," said attorney Robert Buccola, who represents Linville in a wrongful death suit against Sierra Vista that is pending in Sacramento Superior Court.

Problems that emerged after Knapp's death had surfaced before. In September 2000, a 16-year-old girl who had said the day before that she was suicidal hanged herself in the hospital.

A 2001 DHS report identified a familiar problem: Staffing levels were not based on patient needs.

Then -- and each time DHS has cited the hospital's shortcomings -- officials signed a detailed plan of correction.

Still, federal officials who determine whether hospitals are eligible for Medicare and Medicaid payments threatened to dock Sierra Vista's reimbursements in 2001. Ultimately, no funds were affected.

Now, officials in the Centers for Medicare and Medicaid Services once again are scrutinizing Sierra Vista. This time they are looking at an in-depth DHS report that was completed in March; it is not yet publicly available, officials said.

Linville hopes attention to the hospital brings about change, she said, reflecting on her mother's death.

"I wish I could make a difference in the way it was handled," she said.

by:www.sacbee.com