Workers fired after suicide attempt at state mental health facility

MOUNT PLEASANT - At least three employees were fired from a state mental health facility marked for closure after a botched response to a patient suicide attempt last fall, records show.

Iowa Department of Inspections and Appeals conducted a three-day investigation Nov. 24-26 at the Mental Health Institute in Mount Pleasant after the facility reported suicide attempts on Oct. 19 and again on Nov. 18, according to the department. The investigation found violations of federal rules protecting patient rights for a safe environment and care.

Gov. Terry Branstad has proposed closing the mental health facilities in Mount Pleasant and Clarinda, citing the challenge of attracting key clinical professionals, particularly psychiatrists, and a desire for community-based care. The state facilities in Independence and Cherokee would stay open.

A Branstad spokesman referred questions to the Department of Human Services, which oversees the facilities. Amy McCoy, a DHS spokeswoman, said the investigation is not connected to any plans for reorganizing.

The Mount Pleasant corrective action plan, which the inspections department accepted, included revising suicide precaution procedures, removing glass windows and mirrors from the adult psychiatric unit, installing breakaway door handles and retraining about 50 nurses.

'On rare occasions, we find that our services do not meet the high quality standards we strive to achieve,” McCoy said in an email. 'When we become aware of those rare occasions, immediate and decisive steps are taken to correct the situation.”

The incident that led to the employees' dismissals occurred Oct. 19.

The investigation found that staff didn't respond quickly enough to an 'immediate jeopardy” situation in which a patient had tied a sheet from his neck to a bathroom door handle. Then they failed to report the matter to higher-ups.

The patient had been on suicide watch at least nine times since February and had a history of violence and drug abuse, the report showed. Over a three-minute period after the patient was seen with the sheet around his neck, staff walked past, stood watching with 'arms crossed,” 'walked at a normal pace” toward the patient and finally used a cutter to remove the sheet, records show.

The staff should have intervened immediately and notified the nursing administrator, according to the investigation. Because the incident wasn't immediately reported, the facility failed to quickly address problems including installing breakaway door handles as a suicide precaution, the investigation found.

The report doesn't name the mental health workers, but four employees were disciplined in the incident and at least three lost their jobs.

In appeals for unemployment benefits, records show, residential treatment workers James Yasenchok of Fort Madison and Elaine Lehman of Burlington said the patient wasn't in imminent danger - and that while he could become violent toward staff, they weren't properly trained to deal with suicide attempts.

In Yasenchok's case, Administrative Law Judge Beth Scheetz wrote that the facility didn't train staff how to deal with situations like that of Oct. 19.

All three employees, including Diana Powers of Mediapolis, were suspended Nov. 19 and fired Dec. 19. The administrative judges sided with the employees in granting unemployment benefits.

In the second incident, on Nov. 18, a patient broke a glass bathroom mirror and cut his neck. Staff responded appropriately in this case, immediately entering the bathroom and transferring the patient to the hospital. But several features of the building were found to be out of compliance with federal rules, records show.

The corrective plan called for replacing glass in the unit with Lexan.

Ron Honberg, national director of policy and legal affairs at the National Alliance on Mental Illness in Arlington, Va., said every suicide attempt should be taken seriously, but it appears the facility took necessary steps to correct the problems when found.

'When a sheet is tied on the neck and to a door, it is a lot more serious then just talking about it,” Honberg said. 'It sounds like staff did not respond with enough urgency.”