Busy mental crisis center fined, but officials see bigger picture

21-month-old facility keeps patients from going to jail and ERs
2013-05-05T00:00:00Z 2013-05-05T18:25:55Z Busy mental crisis center fined, but officials see bigger pictureStephanie Innes Arizona Daily Star Arizona Daily Star
May 05, 2013 12:00 am  • 

The state fined Southern Arizona's only 24-hour mental health crisis center twice in the last year for multiple state violations, but officials with the busy center insist the public should not worry about patient safety.

State investigators found one instance where a diabetic's glucose was inadequately monitored and he went into cardiac arrest.

Two suicide attempts occurred on two separate occasions while patients were in an observation unit, state reports say.

Complaints that prompted the investigations allege overworked staff who unnecessarily medicate patients.

Operators say the facility, on the University of Arizona Medical Center's South Campus, exceeds national patient care standards and is keeping patients with mental health problems out of jail and hospital emergency rooms. They note that the center is less than 2 years old and that getting it going has been a challenge.

In June 2012, the Arizona Department of Health Services found 36 violations of rules and regulations governing behavioral health facilities, and operators agreed to pay a penalty of $16,650 to the Arizona Department of Health Services. Last month, the operators agreed to pay a second fine of $8,200 after investigators found more violations.

The fines are set by the Legislature and amount to a maximum of $500 per violation per day. It is unusual for a facility to be fined more than once within a one-year period, state officials say.

The center submitted a plan of correction to the state last week, which officials will review before declaring it in compliance with Arizona rules and regulations, state licensing team leader Jay McGahee said.

H. Clarke Romans, who directs the National Alliance for the Mentally Ill's Southern Arizona chapter, has heard complaints about the center, primarily that patients keep going back and don't improve. But he noted the center is absorbing the fallout from state budget cuts that have left more people without health insurance and mental-health support that could prevent psychiatric emergencies. As a result, there is a huge local demand for crisis care.

"Things fall through the cracks, obviously," said Neal Cash, president and chief executive officer of the Community Partnership of Southern Arizona, which runs the local, publicly funded behavioral health system. "Opening was not an easy thing, and getting it to the point it is at today would be a difficult task under any set of circumstances."

$57 million center

Center officials maintain there have been relatively few incidents given the enormous population they serve - about 900 adults and 175 children with mental-health crises per month, including 12 to 15 dropoffs per day by law enforcement. The center also has an on-site crisis phone line that takes 10,000 to 12,000 calls per week.

The gleaming, spacious two-story center is part of a mental-health complex built with $57 million in taxpayer-approved Pima County bond money. It opened in August 2011 and is operated by the nonprofit Crisis Response Network of Southern Arizona. The Community Partnership of Southern Arizona, which runs the local publicly funded behavioral- health system, has oversight and provides the $15.7 million in operating costs with a blend of government funding.

The center is for adults and children in any type of mental- health crisis, whether it's a psychotic episode, suicidal feelings or thoughts of hurting other people. Crises are self-defined and walk-ins are accepted at any time of day, regardless of insurance status. Many patients use the center for just a few hours and leave once their crisis has abated.

Crisis Response Network officials directed questions about the violations to public-relations executive Dave Cieslak, who said he could be identified as a spokesman for the center. He answered the Star's questions via email. When asked whether the public should be concerned about patient safety at the center, Cieslak wrote, "absolutely not."

"Nobody has ever suggested that," he wrote. "The safety and well-being of our patients is the CRC's highest priority, and the care they receive exceeds national standards."

Litany of complaints

Some highlights from state reports:

• Staff members failed to get informed consent from patients before administering psychotropic medications. A complaint dated May 4, 2012, says the center was overusing "chemical restraints" rather than following the procedure of the least-restrictive measure first. The complainant, whose identity was not disclosed in the state records, described patients being surrounded by technicians and being "basically overpowered, and any dignity they may have come in with is taken from them."

• Officials were unaware that staff members involved in any level of restraining patients - from monitoring to performing - must successfully complete CPR training once per year.

• Staff members incorrectly gave a patient the same medication twice. One worker was then told to watch the patient for "any signs of respiratory depression."

• On two separate occasions in 2012, patients attempted suicide by hanging themselves with a blanket from hydraulic automatic door hinges in the bathroom. The second incident happened despite a recommendation after the first that patients not be allowed anything they could use to hang themselves in the bathroom.

Two staff members told the state there was not a consistent patient observation practice until after the second incident. Officials with the Crisis Network of Southern Arizona said last week that the center has eliminated automatic door hinges, enhanced policies and clarified for staff members what is required of them for monitoring high-risk individuals.

Patients must now be within the line of sight of a staff member at all times except when they're in the bathroom, when a behavioral health technician is to stand outside the door and regularly check to make sure the patient is OK.

Open observation

In the center's open observation area, patients sit in reclining chairs that can be divided by curtains, though on a recent visit none of the curtains was in use.

When staff members are doing crisis observation, they must have maximum visibility. Eliminating visual barriers was a key component in the unit's development, officials say.

About 20 people per day remain up to 24 hours in the observation area, and another 15 adults stay in a separate sub-acute unit for an additional three days for stabilization. Patients in court-ordered treatment or who need longer-term in-patient care may be referred to the behavioral-health pavilion next door, which is operated by the UA Medical Center.

Jeff Perto, 57, who says he has been to the center six or seven times, described the observation area as "rather crude."

"It's like sitting in a dental chair for 23 hours, but they try to treat you nice," said Perto, who first visited the center 18 months ago when he was suicidal. "If you were sensitive and alert, I don't think it would be a nice place to be. People yell, scream, want drugs. But I always felt safe."

Overworked staff

Perto said the staff seemed overworked, which was cited in one of the state reports, as well as in one of the complaints. A complaint from March 2012 says one nurse was caring for 15 to 23 patients at one time. Another complaint dated April 27, 2012, says low employee morale was affecting the way patients were treated. Cieslak noted that more nurses have been hired to address staffing concerns.

In the most recent action against the center, the state found it was not ensuring diabetic patients were provided "safe and appropriate care."

In one case, a patient's glucose wasn't closely monitored during his two-day stay. The patient became weak and drowsy and was sent to the emergency room, a state report says.

"In the trauma room patient coded and warranted emergent care ASAP," the report says.

Tucson resident Josh Taylor, 25, describes his recent visits in the center observation area as chaotic.

"I got antsy, I got more anxiety," he said. "I don't like sitting in one spot for 23 hours. There's nothing to occupy you."

Still, Taylor said spending the night in the center's sub-acute unit was much more pleasant - more interactive, calm and private.

Perto says the crisis center is better than going to a hospital emergency room for mental-health needs.

"Thank God they are there. I had nowhere else to go," said Perto, who didn't have health insurance on his first few visits to the center.

Perto said, in his experience, a hospital emergency room is not a good place for someone in a mental-health crisis.

"In an emergency room, people know the psychiatric beds. You feel like you are on display," agreed Tucson mental-health advocate Christina Jasberg, 37, who estimates she has been to hospital emergency rooms more than 80 times for mental-health crises. "They have sitters to make sure you don't do anything and then you wait and wait to talk to a psychiatrist or a social worker. The emergency room is definitely not the place for someone who is symptomatic."

Jasberg is far along in her recovery and has not needed the Crisis Response Center. But she said having a separate psychiatric crisis facility is an asset to Southern Arizona, particularly since access to local mental-health support has dwindled with budget cuts that included freezing low-income, childless adults out of Medicaid.

High demand

Demand for services is so high that other local providers remain busy even with the Crisis Response Center to ease the burden.

The Southern Arizona Mental Health Corporation in central Tucson has seen its patient load decline by a mere 5 percent since the Crisis Response Center opened, chief executive officer Chuck Burbank said.

Burbank's organization has walk-in crisis care from 8 a.m. to 8 p.m. daily, and demand remains high.

"With fewer people on Medicaid, people have less access to behavioral-health services," Burbank said. "Everyone has access to crisis services."

Crisis Response Center officials stress that, among other things, they provide crisis transportation, help with petitions for court-ordered treatment, connect patients with appropriate community resources and arrange follow-ups. They also work closely with the nearby Desert Hope Detoxification Center.

The staff is striving to address problems and complaints so they aren't repeated, said Cash, who oversees the public behavioral- health system.

"Any time there is an incident it's not a good thing. You hope any kind of deficiencies are not there. But it is hard to expect it's going to be perfect," he said.

"I think we have the right folks with the right resources. This center is something we built as part of our infrastructure and we're pretty lucky to have such a strong safety net."

Contact reporter Stephanie Innes at sinnes@azstarnet.com or 573-4134.

Copyright 2014 Arizona Daily Star. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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