State probing two deaths at psychiatric hospital

By Marshall Allen

Wednesday, April 14, 2010 | 2 a.m.

State health officials are investigating the deaths of two patients in two months at Rawson-Neal Psychiatric Hospital to determine whether problems with their care at the facility may have contributed to their demise.

Harold Cook, administrator for the Nevada Division of Mental Health and Developmental Services, which owns and operates the 212-bed facility near Oakey and Jones boulevards in Las Vegas, said seven staff members have been reassigned pending the outcome of the investigation.

The first patient, a man in his 50s, had a medical emergency and died March 2 after being rushed to Valley Hospital Medical Center, Cook said.

The second patient, a woman also in her 50s, went into cardiac arrest April 4. Rawson-Neal staff performed CPR before the woman died at the mental hospital, Cook said.

Officials are awaiting results of toxicology exams to determine the ultimate cause of death in each case, but both appear due to pre-existing medical conditions, Cook said.

“There’s no indication these are treatment-related deaths,” Cook said. “It looks like they were due to medical problems of the individuals.”

Cook said the deaths were not suicides. He would not say why the patients were admitted to Rawson-Neal.

State regulators fined Rawson-Neal $1,000 in January 2009 for failing to protect a female patient who was allegedly raped Nov. 14, 2008, by a male patient prone to violence. The case was never prosecuted, Cook said.

Another sexual assault occurred at the hospital Nov. 20, 2008, but an investigation determined the facility was not at fault.

Rawson-Neal patients are cleared medically at local hospitals before entering the mental facility, where complete medical staffing is available only during normal business hours, Cook said.

The two recent deaths were sudden and would not likely have been prevented had full medical staff been available around the clock, he said. In each case there may have been problems that weren’t detected in the medical exams or initial assessments at the mental hospital, Cook said.

Both incidents were reported to the state’s registry of sentinel events, which tracks unexpected deaths or injuries in medical settings. Cook said part of the sentinel-event process includes a “root cause analysis,” examining events leading to the deaths to determine whether anything could have prevented them from occurring, or prevent similar problems in the future.

The Nevada Bureau of Health Care Quality and Compliance, which licenses hospitals, is investigating the deaths to determine whether Rawson-Neal staff provided adequate care to the patients. If determined to be at fault, the hospital could be required to submit a corrective action plan and pay a fine.

The deaths may also be reviewed by the Centers for Medicare & Medicaid Services, the government’s insurance payer, and the Joint Commission, an oversight agency for hospitals, Cook said.

The Nevada Division of Mental Health and Developmental Services has had about $90 million cut from its budget during the past three fiscal years, as a result of the Great Recession, Cook said.

It now operates on a budget of about $300 million.

Rawson-Neal closed down 22 beds and reduced or relocated staff to adapt to the cutbacks.