Report: Patient left alone before death
Posted April 3, 2009
Raleigh, N.C. — A patient who died at a state residential treatment center in Goldsboro last month was left alone for more than an hour, despite instructions to staff to check on her every 15 minutes.
A federal report that the Department of Health and Human Services made public Friday revealed that on an employee at O'Berry Neuro-Medical Treatment Center found the patient slumped in her wheelchair with a strap around her neck.
The death occurred March 11 during dinnertime. A worker took the patient, known to slide in her wheelchair, to her bedroom at approximately 5:40 p.m. Another employee found her unresponsive at about 6:45 p.m. She died at a local hospital at 7:43 p.m.
Three of four employees – a health care technician and two supervisors – placed on leave following the death have since been fired, DHHS said Friday.
The investigation, conducted on behalf of the U.S. Centers for Medicare and Medicaid Services, also found checks were not being done in the month prior to the patient's death. On Feb. 12, for example, a worker walked into an activity room and found patients unattended. One required constant supervision, the report said.
The report also said some staff members were not aware how to implement procedures put into place following the March 11 death.
O'Berry, a living facility for people with chronic medical conditions and developmental disabilities, could lose $966,830 in Medicare and Medicaid reimbursements if it doesn't make changes that call for closer supervision of residents.
It has until April 15 to correct all deficiencies outlined in the report.
As one of his first actions in his position, DHHS Secretary Lanier Cansler, instituted a zero-tolerance policy toward employees found to have abused or neglected patients.
Several employees at the state's mental hospitals have been fired since it was put in place in February.