Falling Through the Cracks

In honor of Suicide Prevention Month, and in recognition of the essential ongoing efforts in this field nationwide and throughout the world, UHS Behind Closed Doors joins our allies in mental health advocacy to raise awareness that the tragedy of suicide is so often preventable.

Too often, the role of healthcare providers is left out the conversation about suicide prevention; yet the Surgeon General’s National Strategy for Suicide Prevention prioritizes the importance of enhancing clinical services and approaches towards suicide prevention as an essential tool in the fight to reduce the number of suicide deaths.[1] UHS Behind Closed Doors firmly believes that inpatient behavioral health providers must be applauded for their efforts, and be held accountable for their failures, in suicide prevention and we therefore want to shed light on UHS’s track record in the area of suicide prevention at their behavioral health facilities.

Universal Health Services’ (“UHS”) Behavioral Health Division states that the company takes its “leadership position very seriously and act[s] as advocate for mental health issues at the national, state and local levels, including suicide prevention.”[2] However, research conducted by UHS Behind Closed Doors has uncovered numerous documented instances in which UHS failed to address the needs of patients identified as being at risk for suicide, resulting in serious harm to those patients and, in multiple instances, patient deaths by suicide. The distressing cases summarized below are just a few examples from numerous patient care failures that have taken place in recent years at UHS facilities across the country.

Timberlawn Mental Health System failed to address unsafe conditions identified by CMS

In February 2015, officials from the Centers for Medicare & Medicaid Services (“CMS”) cited Timberlawn for practices and facility fixtures that “posed an immediate jeopardy to the health and safety of patients, and resulted in actual harm to Patient #1.” This surprise inspection came after the tragic death by hanging of a Timberlawn patient, aka ‘Patient #1’, who was known by the facility to be at risk for suicide and yet was not placed on suicide precautions and was not monitored as she should have been. Still more grievous is the fact that the facility could have prevented this death by following its own advice.

During the February inspection, CMS officials uncovered an internal facility document from May 2014 entitled “Hospital Plant Anomalies” in which the hospital itself identified that “patient door handles and closet door handles could be a ligature risk.” Despite this, when CMS conducted an inspection 9 months after this document was produced and 2 months after Patient #1’s tragic and preventable death by suicide, officials found that Timberlawn had taken no action to remove these ligature risks until after Patient #1’s death. During that inspection, CMS officials also found that other patients known to be at risk of suicide were not monitored every 15 minutes as they should have been in addition to finding “the continued presence of unsafe items accessible to psychiatric patients for potential harm which included, plastic liners in trash cans, electrical cords and phone cords.”

As a result of these failures to provide a safe environment for its patients CMS terminated funding to Timberlawn Behavioral Health System in August 2015. UHS, rather than invest in improving the conditions and commitment to Suicide Prevention at the facility, announced plans to close the hospital.

Riveredge Hospital cited by CMS for placing 40 or more patients in “immediate jeopardy”

In June of 2013, CMS officials found Riveredge guilty of condition level violations, the highest severity of CMS violation, related to the Medicare patient rights condition of participation. The facility was found to have placed at least 40 patients in “immediate jeopardy” by failing to ensure that all suicide hazards were removed from patient rooms. One of these patients, who was known to be at risk of suicide, was placed in a room with ceiling vents that had previously been identified as potentially dangerous to patients.

These ceiling vents were accessible in such a way that presented a serious ligature risk, and had been identified as dangerous by the state as many as five years before this patient’s death. Riveredge had been ordered to take steps to remove these ligature risks from patient rooms no later than 2008 and yet, in 2013, the facility had failed to remove or cover these vents, leaving the danger in plain view of its struggling patients. Sadly, this patient also identified the potential for danger in these vents and was found in her room having died by hanging. The patient’s husband filed a wrongful death suit against Riveredge Hospital in November 2013 alleging that his wife had exhibited several risk factors for suicide, including a non-fatal attempt while being transported to the facility, and should have been monitored more closely.

UHS, as the market leader, should be setting standards—not lowering them

Despite its claim to be a leader in the field of behavioral health, including the area of suicide prevention, UHS has repeatedly failed to provide a safe environment for its patients. At the same time, UHS has failed to fully implement crucial elements of the Surgeon General’s 2012 update to the National Strategy for Suicide Prevention, such as suicide risk assessment protocols and safety planning[3] and protocols to ensure immediate and continuous follow-up after discharge from an inpatient unit.[4]

These failures are evidenced by the Systems Improvement Agreement CMS recently required Texoma Medical Center to sign, following the apparent death by suicide of a patient who had been discharged from TMC’s Behavioral Health Center just days prior. This patient had clearly informed Texoma staff of his desire to harm himself, and his plan to attempt suicide by jumping off a bridge. Nonetheless, TMC discharged him 10 days after he made this revelation to staff and instructed him to travel almost 200 miles home, on his own. Tragically, the former Texoma patient was found 2 days later under a bridge, deceased.

These heartbreaking incidents—and others at UHS facilities such as SummitRidge, Cumberland Hall, Two Rivers Psychiatric Hospital and South Texas BHC— paint a comprehensive picture of UHS’s lack of commitment to preventing suicide deaths and attempts within the vulnerable patient population it serves. As the largest provider of inpatient behavioral health care in the nation, UHS is the market leader and, as such, must strive to set high standards for the field of behavioral health. Instead UHS routinely lowers the standard, as evidenced by its being one of the only major for-profit healthcare providers that does not have a dedicated and independent committee on its governing board charged with ensuring UHS’s compliance to national quality standards.[5] UHS Behind Closed Doors continues to strongly urge UHS to take immediate steps to reaffirm its commitment to suicide prevention, and to providing quality treatment, by creating a Quality of Care and Compliance Committee on its Board.

These tragic examples of UHS facilities failing to protect their patients are, sadly, three among many. A longer list of reported incidents where patients suffered serious, and sometimes fatal, self-inflicted harm while in the care of UHS facilities can be found using the “Word Cloud” tool on this website, which is in the sidebar at right on this page. Click on “self-harm” or “suicide” to find more documented cases.

Suicide is NEVER the answer, getting help is the answer.

If you or someone you know is in immediate danger because of thoughts of suicide please call 911 immediately. If you or someone you know is struggling with suicidal thoughts please do not hesitate to call one of the National Suicide Prevention Lines at 1-800-273-TALK [8255] or 1-800-784-2433. When calling 1-800-273-TALK you can press ‘1’ to reach the Military Veterans Suicide Hotline or press ‘2’ to reach the Suicide Hotline in Spanish. An additional resource is the LGBT Youth Suicide Hotline at 1-866-4-U-TREVOR [1-866-4-8-873867]. You can also refer to this list from suicide.org for a hotline number local to your state.