Patient appears neglected in hours before his death
Posted November 18, 2008
Updated November 19, 2008
RALEIGH, N.C. — Workers at Cherry Hospital dance, play cards, laugh and watch TV as 50-year-old Steven Howard Sabock sits unattended in the same room for nearly 24 hours before he dies.
Patient advocate Vicki Smith, executive director of Disability Rights North Carolina, called it one of the most troubling images she had ever seen. "Every staff member in a 24-hour time period neglected their responsibility to this man," Smith said Tuesday.
Occasionally, they would check on him, but he was otherwise ignored for hours at a time, according to more than 24 hours of surveillance video released Tuesday by the Department of Health and Human Services.
The video begins with an injury. Sabock is seen falling, hitting his head on the evening of April 28. He needs help to regain his feet and is helped from the room.
Two hours later, he appears in the Goldsboro psychiatric facility’s day room. Until 9 p.m. the next night, no one feeds him, checks his vital signs or helps him from his chair.
An attorney for Sabock's family said that his parents had not yet seen the video. "His family had to deal with his death back in the spring and now they are having to deal with learning how he died," Gene Riddle said Tuesday.
On behalf of the family, Riddle released this statement: We’re heartbroken and we’re truly saddened by the information we received. We don’t want to rush to any judgment. We will investigate thoroughly and at the end of investigation the Sabock family will consider their options.
In the video, Sabock is left in the chair through the night. After workers leave the room, turning out the lights, he sits. Occasionally, staffers check on him.
At 7 a.m. on April 29, a nurse, with the assistance of another patient, changes his shirt.
At 8:13 a.m., a worker approaches Sabock with a breakfast tray, taps him on the shoulder twice to rouse him, then walks off with the tray.
At 12:37 p.m., staffers try to rouse Sabock again. He's apparently sleeping, so again he doesn't eat, drink or leave the chair.
John Tote, executive director of the Mental Health Association inf North Carolina, said the parts of the video he saw were shocking. "When you see people walking back and forth over a period of many hours, when you see that individual slumping forward, when you realize the life is literally draining out of him before your eyes, that's more than a powerful picture. That's a tragic event."
At 8:59 p.m., two employees move Sabock toward the bedroom area of the ward. Less than 10 minutes later, at 9:05 p.m., workers pushing a crash cart head to the bedroom area, followed by numerous others.
Paramedics arrive at 9:21 p.m., and at 9:27 p.m., they leave with Sabock on a stretcher.
An autopsy found Sabock died of a pre-existing heart condition. According to a federal report, he ate nothing the day he died and had little food in the three days preceding his death. Workers were supposed to be monitoring his condition.
The lack of care by workers – at times in the video, they appear more concerned with their cell phones than they do with caring for their patient – prompted DHHS officials to close the ward.
One employee resigned, and 15 other workers involved were disciplined and removed from direct patient care.
Federal regulators in September also pulled the hospital’s certification that allowed it to receive Medicare and Medicaid reimbursements. As a result, the state must pay up to $10 million to cover expenses associated with treating patients under the federal insurance programs.
Compass Group Inc., an independent consultant firm, found Cherry Hospital must undergo a number of organizational and cultural changes before it reapplies for certification. Those changes include improving communication and a new management structure for overseeing patients.
In a two-part plan, Compass Group will bring in a team of experts to work with the hospital's management to design and implement a comprehensive plan to address cultural, operational and developmental needs.
Then, it plans to address the issues necessary to help Cherry Hospital be reinstated. Secretary Dempsey Benton, of DHHS, has said he expects that process to take until next summer.