VA report details contributing factors that led to patient death last year – Columbia Daily Tribune | Columbia Missouri: Local News.
Contributing factors that led to a 78-year-old man’s beating death at Truman Memorial Veterans’ Hospital last February included ineffective communication among staffers and between law enforcement agencies, “a sense of complacency” among some staff and a failure to provide a safe environment for the victim, according to a report by an administrative board of investigation for the Veterans Affairs Heartland Network.
The board’s report, which was included in materials released by the VA in response to a Freedom of Information Act request, details what happened at the hospital on and around Feb. 1, when Rudy Perez Jr. assaulted and killed Robert Hill of Warsaw, and what the hospital could do to prevent such an incident from happening again. The board made its determinations after interviews with 22 staffers involved and reviewing 45 documents, including competency files for the entire staff of the inpatient mental health unit, where the two men were at the time Hill was killed.
Perez, 34, a former Marine who didn’t serve overseas, first assaulted Hill on the afternoon of Feb. 1. They were separated, and after Hill was treated and brought back to the common area of the inpatient mental health unit, Perez, who also returned after calming down, jumped him again and beat Hill to death.
The board also included in its report a list of eight recommendations for the hospital, including revamping its psychiatric practice model. Nearly all of those have been implemented, hospital spokesman Stephen Gaither said.
Perez’s lawyer, David Tyson Smith, said his client was in the midst of a psychotic episode when the events began that eventually led to his admission to Truman. Sedalia police arrested Perez on Jan. 29 on suspicion of assaulting a neighbor, who suffered minor injuries. Perez was held in the Pettis County Jail for 24 hours.
On Jan. 31, Perez allegedly assaulted his parents on Highway 50 west of Sedalia, their hometown, as they were trying to take him to get treatment in Kansas City. When officers arrived, they saw Perez stripping naked and then dragging his mother into oncoming traffic. He told authorities that he thought his father was a demon and that his mother was a witch.
His parents declined to press charges. Perez’s father was treated at a Sedalia hospital and released.
Perez was charged Feb. 5, 2013, in Pettis County with two counts each of third-degree domestic assault and assault on a law enforcement officer as well as one count each of resisting arrest and second-degree assault for the events leading to his admission to Truman, according to online court records. Those charges were never adjudicated.
After the roadside attack, Perez was taken to Bothwell Regional Medical Center in Sedalia, where a Pettis County sheriff’s deputy petitioned a court for a 96-hour involuntary commitment. The request was approved, and Perez was taken that evening to Missouri Psychiatric Center, which is operated by University of Missouri Health Care.
A psychiatry resident at the center requested Perez be transferred to Truman. That request was approved by the on-call attending psychiatrist at Truman, according to the board’s report. Perez was transported to Truman about 10:40 p.m. by three security officers and one VA police officer took custody of him, according to the report.
The VA police officer “was not advised of any incidents which precipitated the 96-hour hold” on Perez, the report said, and “outside law enforcement agencies did not, as a routine procedure, provide information directly to police concerning police incidents occurring prior to transport of patients to the VA facility.”
Perez was admitted to Ward 2B, a locked 12-bed area at the inpatient mental health unit at 12:11 a.m. Feb. 1. A nurse made a note at 1:56 a.m. that Perez threatened to attack Hill should the elderly man enter his room, the report said. The nurse signed it at 7:25 a.m. and added to it at 8:47 a.m.
The day resident assigned to Perez had examined and interviewed him before a 9 a.m. team meeting at the inpatient mental health unit. The resident did not see outside reports about Perez or the nurse’s note about the threat because they did their record review before the nurse signed it, the report said. The note was inaccessible after the meeting. There was no talk about Perez’s previous aggression during the meeting.
A new attending psychiatrist was assigned to Perez on the day shift and had no experience with him. Perez’s attending physician that day had not seen him before the team meeting, the report said. Attending doctors supervise residents. Nowhere in the report’s findings does it note the transfer of information pertaining to Perez’s history of violence to either of his attending doctors on Feb. 1.
Perez’s mother, the report said, “had numerous conversations with the resident physician and other clinical staff” in which she told them she was concerned that he was off his medications.
Hill wandered into Perez’s room at 3:10 p.m., and Perez assaulted him. The pair was separated. Hill was taken to the emergency department and treated for non-life-threatening injuries to his face. Perez also was briefly isolated but returned to the common area after calming down.
Hill was brought back to the common area at 6:20 p.m., the report said, with a one-to-one sitter, an employee who observes patients from a moderate distance. Before Hill was brought back to the unit, the emergency department did not receive “any information or guidance concerning returning” him. His attending physician assumed he would not be taken back there, the report said, and requested that he be given a one-to-one sitter for safety if he was.
The sitter also was not told that Hill had been assaulted, the report said. Two minutes after Hill was returned to the mental health unit, escorted by the sitter and a VA police officer, Perez attacked him, hitting him with his fists as he knelt over him in the hallway. Hill was taken to University Hospital, where he died around 10:30 p.m.
All of this could have been avoided, Tyson Smith said.
“Mr. Perez should have been isolated,” he said. “He was put right back in the day room again, when Mr. Perez was in the middle of a psychotic episode. Clearly someone dropped the ball.”
The investigative board identified eight “contributing causes” of the incident: Ineffective hand-off communication related to a history of violence; lack of consistent, reliable communication between law enforcement agencies; reluctance to use restraint, seclusion and pharmacology; failure to provide a safe, alternate environment; model of physician coverage; mixed population of patients; complacency; and different philosophies on violent and disruptive behavior within the inpatient mental health staff.
To address those issues, Gaither said, Truman has taken measures to increase communication with other law enforcement entities, crafted new policies, sought to hire a new full-time attending psychiatrist, and started training staff on the prevention and management of disruptive behavior.
In regard to law enforcement, Gaither said there is now an emphasis on sharing information on patients. Truman Chief of Staff Lana Zerrer said her staff is working to be more involved with police on mental health training and sorting out jurisdictional issues.
Finding an attending psychiatrist has proven difficult, Gaither said. The report said Truman’s primary care model — which included attending psychiatry coverage instead of a dedicated psychiatrist — might have contributed to delays in evaluation of Perez and hampered a safe approach for Hill’s return to the unit after the assault.
Hiring an attending psychiatrist will be done as part of changing the practice model for how psychiatrists cover inpatient duties, as recommended in the report. So far, interim measures include notifying everyone at Truman when there is an assault or incident that would raise concern, he said. Roles of nurses and other inpatient staff have also been defined more clearly, Gaither said. Zerrer said so far, the changes have been effective.
“I’m very pleased with the way we’ve changed our inpatient practice model at this point, but we need another psychiatrist for sure,” Zerrer said.
Zerrer wrote the new policies with other staff members and oversaw the changes. She researched medical journals on assault risk in psychiatric settings to aid in the changes.
“When a patient comes in to a psychiatric unit, we look at things like if they’ve assaulted anyone recently, if they have active psychosis and if they’re on withdrawal from a substance” and give them a risk assessment score, Zerrer said.
A board was installed in the unit that lists all patients with their risk levels, Gaither said.
Part of the problem was that some of the medical staff members at Truman were unaware that restraining a patient was within protocol, Gaither said. The hospital has taken pride in reducing the number of incidents in which restraints are used, Gaither said, something done after a national outcry a few years ago on the topic. The new assault policy addresses the issue and makes it clear that restraints can be used when there is a clinical decision that deems them necessary, he said.
Lack of communication among staff was the main breakdown that led to Hill’s death, according to the report.
Now, doctors are required to notify and document communication between departments when a patient is moved to the inpatient unit. Nursing personnel also are required to have a safety plan in place for patients who have been assaulted when they return to the unit, Gaither said. If necessary, they will now transfer them to a different unit at Truman or another area hospital, Gaither said, or a different VA hospital in the Heartland Network, which includes Missouri, Kansas and parts of Arkansas, Illinois, Indiana and Kentucky.
If an assault takes place, all personnel who are responsible for the patients are now required to meet and discuss the safest option for the victim. The report said everyone involved “agreed there was no place to have” Hill “go after the first assault other than back to the ward.”
“It didn’t quite happen the way it should have happened, and we didn’t have this huddle in place at the time,” Zerrer said of what happened after Hill was beaten the first time.
Zerrer, however, defended her staff.
“When you know what the staff knew at the time of the incident, it’s debatable,” she said. “It’s hard to say they should have done anything differently.”
Training for all employees in assault prevention — something in which the report cited a “large gap in staff awareness” — is expected to be completed within the next couple of months, Gaither said.
All of the new policies and procedures have amounted to a “culture change,” Gaither said.
“The important thing here when we talk about a culture change, a culture change is an evolutionary process. … There are continuing activities that are being reinforced,” he said.
One of Hill’s sons, Chris, declined comment and referred questions to the family’s attorney, Sedalia-based Spencer Eisenmenger. Hill’s other son, Tim, and Eisenmenger did not return calls requesting comment.
Perez was charged with first-degree murder in Hill’s beating death. He was acquitted Sept. 23 when Boone County Circuit Judge Gary Oxenhandler accepted his plea of not guilty by reason of insanity after two psychiatric evaluations determined that Perez was “driven by psychosis.”
Perez was remanded to the custody of the state Department of Mental Health and remains at Biggs Forensic Unit, a 186-bed maximum security unit of Fulton State Hospital. Perez’s family is doing well, said Tyson Smith. So far, Perez’s response to treatment has been positive, he said.
“Mr. Perez more likely than not is going to return to society if he responds to treatment well,” Tyson Smith said.