Head Games
Just after midnight on Saturday, April 28, someone found Charles Johnson sprawled on a bathroom floor at Western Missouri Mental Health Center. Three of his fingers were shoved in his mouth. He wasn’t breathing. Within seconds a panicked “Code blue on 6 Center!” blared over the hospital PA system.
Nurses and doctors from four other acute-care units — wards for patients who pose an immediate danger to themselves or others — as well as from two wards for long-term patients and from the hospital’s emergency room, rushed to the sixth floor. Inside the restroom, a nurse knelt on the tile. She tried to dig out a wad of peanut butter and bread that was stuck in Johnson’s windpipe. She started pumping his chest. He still wasn’t breathing. He had no pulse.
“He was already dead. When I got there, his fingernails were blue. The circulation had already stopped,” recalls one nurse. “He was dead when they found him.”
EMTs from MAST couldn’t revive Johnson. They loaded him onto a gurney and delivered him to Truman Medical Center next door. Johnson was “essentially DOA,” according to an autopsy report by the Jackson County Medical Examiner. That report — based on information the head nurse on duty at Western Missouri gave the medical examiner — said Johnson “was found lying on the ward bathroom floor unconscious by a psychiatric technician.” Staffers had seen him eating “about five minutes before discovery.”
But several sources at Western Missouri told the Pitch that another patient — not the psychiatric technician mentioned in the autopsy investigation — actually found Johnson on the floor. That patient had to tell hospital staffers that Johnson was in the bathroom.
The hospital’s policy when patients die suddenly of unnatural causes is to call the police. But no one notified police the night Johnson died. The only documentation of when and how he died came from the staffers entrusted with his care.
Western Missouri Mental Health Center, which consists of two brick buildings connected by an overhead walkway just east of Crown Center, has the only 24-hour psychiatric emergency room in Kansas City. The state-funded hospital, which receives about $23 million each year from the Missouri treasury, is an affordable option for people who need help for alcohol and substance abuse, depression, anxiety disorders, schizophrenia and other mental illnesses. Western Missouri charges patients according to guidelines that determine how much of the cost the state will pay. The hospital might bill the patient only a small amount or bill insurance, Medicare or Medicaid; in some cases, the state might pick up the tab.
On a recent Friday afternoon, the emergency room was quiet. Two men slept in their street clothes on beds in a dimly lit side room while they waited to be admitted or referred somewhere else. A shivering man with a blanket wrapped around his shoulders sipped water from a paper cup by the admission desk. Outside, two sheriff’s deputies led a handcuffed, orange-jumpsuited jail inmate toward the entrance from the parking lot.
Anyone who goes to Western Missouri’s emergency room is probably in a state of crisis.
But the Pitch has found that the psychiatric hospital is far from a healing sanctuary. Hospital staffers — who spoke on condition of anonymity because many of them fear retaliation and some could face legal action — say they try to keep havoc at bay while the administration ignores their concerns. Sudden deaths remain unexplained, and sources say that nurses and other staffers have sometimes unwillingly falsified medical records to appease federal regulators who have pointed out the hospital’s myriad problems.
Nearly 7,000 people walked into the emergency room at Western Missouri Mental Health Center last year. They went to the state psychiatric hospital to get help. None of them was supposed to die.
For nearly a year before Charles Johnson’s death, the federal Centers for Medicare and Medicaid Services (formerly called the Health Care Financing Administration) had kept a close eye on Western Missouri Mental Health Center. In April 2000, CMS inspectors found enough deficiencies in patient care, safety and staffing to begin decertifying the hospital — jeopardizing Western Missouri’s millions of dollars in reimbursement for Medicare and Medicaid services.
The Missouri Department of Mental Health oversees the hospital, which employs about 700 people. Western Missouri’s superintendent, Gloria Joseph, who has a master’s degree in social work, is in charge of the hospital’s operations. Reporting directly to her is an executive management team — Donna Buchanan, Ph.D., is assistant superintendent of treatment; Rob Hornstra Jr., MD, is medical director; and Glenda Lawson, RN, MSN, CS, is director of nursing.
A few weeks after CMS surveyors finished inspecting the hospital, CMS mailed 150 pages documenting Western Missouri’s inadequacies to the Missouri Department of Mental Health. Western Missouri’s failings were many. Suicidal patients were being admitted for 72-hour holds, then released without community referrals for further treatment. Ceiling vents on the children’s unit hung low enough to offer easy access for suicidal kids to hang themselves. Alcoholics admitted for detox often never met with substance-abuse counselors. In acute-care units, psychotic and schizophrenic patients mingled with drug addicts, people with borderline personality disorders, the clinically depressed and the mentally retarded. Sometimes unit managers expected only one or two nurses to care for thirty patients at a time.
One RN told a surveyor that she chose to work the night shift, when most patients were asleep, because, working days, she often left “feeling guilty for not being able to complete what she felt was professionally responsible patient care,” a CMS report says.
But not everybody on staff got a chance to talk to CMS representatives about the hospital’s problems.
“Certain people were being switched to nights so they wouldn’t be able to talk to [inspectors],” recalls one RN who worked at Western Missouri at the time. “And once the administration found out that staff talked to them, management people were assigned to stay with staff the whole time so no one could talk.”
One CMS inspector sat in on a community meeting group for which the director of nursing and the unit nurse manager had dutifully rounded up twelve patients from their rooms, the dining area and the hallway. At community meetings, patients sit on sofas in the day-room area and talk with staffers about problems they have with their hospital stay: The unit might be too noisy, the food might be bad, psychiatric aides might not take them outside for enough smoke breaks.
A therapist led the group, while social workers, nurses and three other staffers looked on. But the well-attended session was merely a show put on for the federal agency. The director of nursing and unit manager didn’t usually gather patients or attend the meetings themselves, an employee later told the surveyor. RNs and social workers rarely attended. Instead, psychiatric technicians nearly always led the groups.
Another former employee says that staff members scrambled in a desperate attempt to correct years of incomplete records.
“Before [CMS] even showed up, we were saying, ‘Man, we’re in serious trouble,'” he says. “We would tell management some records were gone, paperwork for fire drills, fire codes and scheduled training that we needed to have. And they’d say, ‘Why are they gone?’ We’d tell them, ‘Well, they were never filled out.’ And they’d say, ‘Make them. Fill them out.'”
The administration at Western Missouri turned in its “Plan of Correction: Blueprint for Change” in October 2000. The blueprint, along with a follow-up survey by CMS that same month — which found that the hospital had corrected many of the problems — convinced the federal agency to halt the decertification process.
But as recently as just a few months ago, the hospital was still under the watchful eye of CMS, according to an April 10 memo written by Superintendent Joseph.
“We recently had a monitoring survey by the [Missouri] State Department of Health on behalf of [CMS],” wrote Joseph. “It did not go well. In some areas, there was some improvement, but not sufficient improvement to justify compliance. In essence it is not being done.”
Joseph agreed to talk with the Pitch for this story, but, through a secretary, she cancelled her interview the day before the appointment. Joseph referred all questions to a Missouri Department of Mental Health spokesperson.
“We were surveyed with a number of deficiencies noted and given an opportunity to correct those deficiencies,” says Dick Gregory, Ph.D., Western Missouri’s regional administrator. “We take all certification and licensure reviews seriously.”
Another CMS survey this June listed only three pages of deficiencies — down from 150. But this time, investigators noted, the hospital’s therapists, nurses and psychiatric aides seemed confused about procedures and fearful of management retaliation if they asked questions or complained.
Hospital workers who cared directly for patients worried that “complaint or concern about policies, procedures or working conditions might result in punitive actions against the employee by management,” the surveyor wrote. Some employees remained silent, hoping for a combination of divine and federal intervention.
“I wanted to talk to those [CMS] people, but I knew [administration] would retaliate,” says one psychiatric technician. “I was praying to God that [CMS] would move everyone in administration out and bring its own people in so that everyone that worked there and all the patients could have a brand new start.”
In the span of a year, Western Missouri Mental Health Center had managed to save its certification — and its Medicare and Medicaid funding. But some sources at Western Missouri say that many of the improvements are empty words on paper.
“After the [CMS] survey, we were told to make changes in medical records,” says a former RN at Western Missouri, who says that hospital administrators were determined to meet CMS standards. But those standards hadn’t been followed for so long that records were often incomplete.
“If medical records needed a doctor’s signature, it was added,” says the nurse. “If a person had been restrained or secluded, the record was changed to show that a treatment planning meeting was held, even when it hadn’t been.”
“Nurses were told to change things in the charts and backdate records,” says another RN. “Sometimes we put down that something was done when it actually wasn’t. If a treatment plan wasn’t done, they’d tell the nurses to put one in the file. Someone would sign it without ever seeing the patient.”
A falsified treatment plan is no small matter. A team of social workers, nurses, psychologists and doctors is supposed to compose a personalized plan for every patient. The plan might include medication, therapy and other services that move the patient toward mental health and release from the hospital.
“The patient needs to know as soon as he or she gets in the hospital, ‘What’s going to be provided to me? What’s going to keep me from having to come back?'” says the former nurse. “Patients weren’t getting to sit down with the people making decisions about their treatment. People on the treatment teams were just writing their own goals for the patient and putting it on paper to make it look good. But that treatment plan is going to affect the rest of that person’s life.”
Psychologists at the hospital — who average caseloads of about 25 patients at a time in acute-care units — claim they were told by an administrator to get a psychological assessment into every new patient’s chart, even if they’d never interviewed the patient. The psychologists say they were told to assess patients by simply reviewing their records.
Several Western Missouri staffers now have cases pending before the State Personnel Advisory Board, a seven-member panel appointed by the governor to set policies and regulations for state employees. The board also appoints an officer to preside over hearings for employees who feel they have been unfairly disciplined or fired.
David Neuhaus, an attorney handling cases for several current and former Western Missouri employees scheduled to go before the personnel board, says the hospital’s administrators retaliated against two psychologists who disagreed with what they considered to be unethical assessment procedures.
One psychologist alleges he was fired when he objected to completing psychological assessments based solely on reviewing the patients’ records. Another psychologist refused to write assessments on patients she hadn’t actually seen and then informed the Missouri Department of Mental Health about the questionable practice. That psychologist — who had an exemplary work record at the hospital until she reported the assessment procedures — alleges in court records that she was punished for challenging those procedures.
“These psychologists were instructed to complete documents in a way that they felt was fraudulent,” says Neuhaus. “Their feeling is that the hospital is under a lot of pressure to conform with [CMS], and some of that compliance is on paper but is not the reality.”
The reality is that life inside Western Missouri puts employees as well as patients at risk for their lives.
“Diane,” an RN who rushed to 6 Center the night Charles Johnson died, worked one evening in January as the only licensed nurse on an acute-care unit, along with two psychiatric technicians. Many psych techs have received certified nursing assistant training at community colleges, and all are part of the nursing staff. They get further training at the hospital for crisis management, CPR and how to handle potentially aggressive patients. Psych techs provide the patients’ hands-on care, helping them with hygiene, talking to them and taking them outside to smoke. They may be assigned to watch suicidal or dangerous patients.
Diane and her staff were responsible for the well-being of seventeen patients, two of whom were supposed to be under constant observation. But as the clock neared 10 p.m., the staff shortage was under observation as well. As Diane walked toward the room where the unit kept medications, a patient eyed the jangling keys in her hand.
“Motherfucker! Give me the keys or I’ll kill you!” he screamed. The burly man threw the nurse against the wall, snatched the keys from her and bounded toward the exit door. She called security, and guards restrained the man before he could escape. But several staffers at the hospital say chaotic outbreaks are the norm.
“When you have mentally ill people, the mentally retarded and people who are there for alcohol and substance abuse, and you’ve got all those people together, you’ve got a bad mix,” says “Michelle,” who has worked as a psych tech at Western Missouri for several years. “We might have a crack smoker who is in for detox. But she could have a roommate who is psychotic, going through her personal things, talking crazy all the time.
“One time we had a male patient beat up another patient. He blackened both her eyes and punched her in the nose,” adds Michelle, who insists that the assault was not reported to state authorities, but only to the staff.
One former staffer says that when a male patient kicked a female patient in the stomach and hit her in the face several times, the dangerous man was placed in seclusion — for a few minutes. Then the nurse let him back out on the floor. “I can only imagine how the female patient must have felt with her attacker still roaming the unit,” he says.
But the patients aren’t the only ones who suffer injury. Last year at Western Missouri, the hospital reported 121 staff injuries, according to the Missouri Department of Mental Health. (The department failed to provide the number of patient injuries reported.)
Working in chaotic, understaffed units has taken a toll on most of the staff, say several sources at the hospital. And many say the administration doesn’t show much appreciation for its employees’ hard work. Last Christmas, for example, hospital administrators gave employees decorative paper bags donated by Hallmark — which had been intended for the patients.
“We got a Cat in the Hat little bag, a candy cane, an apple, an orange and some Cinderella stickers,” says one staffer. “People said, ‘I don’t want this shit.’ This is what they think of the staff here. Kids enjoy that stuff, but we’re adults. They could have given me a $5 gift certificate to go to Family Dollar, and it still would have been better than that.”
Western Missouri frequently staffs its units with temporary-agency nurses and psych techs who may have no mental health training. And in its survey two months ago, the CMS found that when the hospital did hire temp nurses and psych techs, it was not verifying that they were trained in CPR. Even some of the full-time personnel, working double shifts on understaffed units, have little patience for the troubled people in their care.
“A lot of the staff talk to the patients like, ‘You better go sit your crazy ass down,'” says Michelle. “They think just because these people are mentally ill, they’re real crazy or psychotic. But some of these people are brilliant. I’ve met people who can draw, people who can sing, real talented people.
“It’s not against the law to be mentally ill,” she says. “Even though people are mentally ill, they still need to be respected.”
Hospital staffers were familiar with
Charles Johnson when they admitted him to Western Missouri for the last time in April. Johnson was physically healthy and forty years old, but the Jackson County public administrator had been his guardian since 1982. That’s when his mother decided she could no longer control her son, who suffered from schizophrenia, hallucinations and violent outbursts.
By the time Johnson was 22, his mother had admitted him to Western Missouri eleven times. Each time Western Missouri released Johnson, he soon returned to the streets, gave away his medication and resumed using drugs.
High and delusional, he roamed the city, sometimes tormented by voices that told him to kill. When police brought Johnson to the hospital in 1982 — out of touch with reality and reeking of urine — he had threatened to kill his mother and broken a window screen with an iron rod.
Johnson spent the next eighteen years at group homes for the mentally ill. At one point, the public administrator placed him at Paseo Nursing Home, where he sat idle among the elderly and infirm for nearly a year as his condition worsened. The county placed him in boarding and group homes at least six times, but he rarely stayed anywhere for more than two or three years.
At one of the homes, a two-story house on Campbell Street, three women recently smoked outside on the stone porch. Orera Causey, who once lived at another group home with Johnson, remembered him well. She recalled one Thanksgiving when her family didn’t invite her to dinner and she sat alone in her room for most of the day. But that night, Johnson tapped on the door with three plates of ham, chitlins and sweet potato pie.
“He told me, ‘Come on, you have to eat this ’cause I had to sneak out with it.’ He came on in and we ate that dinner,” said Causey. “He was a beautiful person.”
Like Johnson and Causey, many of the people under guardianship of the public administrator know one another. They might have been friends at a group home or met during a long-term stay at Western Missouri. Many of those former patients and others who suffer from schizophrenia and psychosis have symptoms that resist treatment. Even with medication, they can still hear voices telling them to hurt themselves or others. Even in a boarding home, the troubled people have a hard time coping with life. They’re not always safe around others. These are typically the mentally ill patients who frequent the extended-stay unit at Western Missouri.
At least nine times at the public administrator’s request, judges issued court orders committing Johnson to Western Missouri, where he often remained for six months at a time. He meandered up and down the hall, brushing past other patients between the day room and the nurses’ station. He was psychotic and delusional, responding to internal voices and laughing loudly to himself. Sometimes he was hostile and aggressive and refused to cooperate with his treatment.
“But once he was on his meds for a couple of days, he was the most pleasant person you would ever want to meet,” says Michelle. “He was kind of a comical person. He would make you laugh, even though he was sick.”
Although Johnson’s mother had asked the public administrator to assume guardianship of her son years ago, she remained involved in his life. “Even when Charles was in the hospital, his family used to bring him nice clothes to wear,” Michelle remembers. “Charles Johnson was a well-dressed man when he was a patient here.” Johnson’s mother, a stylish older woman with salt-and-pepper hair, sometimes brought homemade cakes and holiday cookies to the hospital workers who cared for her son.
“You don’t find too many people who do that. We hardly ever get a card or thank you from anybody,” says Michelle. “But it was her way of saying thanks. She was saying, ‘I appreciate what you did for my son.'”
“You couldn’t help but like him. At his core, he was quite good-hearted,” recalls one man who worked at a sprawling three-story group home on a block of historic Kansas City mansions. “He’d talk about how he was trying to get along with people.” Johnson stayed distracted most of the time, rarely slept and paced late at night. “He would posture all the time with threats and big talk. You had to really watch him because it was different when he was on his meds and when he wasn’t.”
But no one was watching the night Johnson choked to death at Western Missouri Mental Health Center.
On a recent Wednesday evening, the long-term care unit at Western Missouri was full. A middle-aged man wearing a short-sleeved shirt, gray boxer shorts and socks strolled in and out of his room, roaming the hallway end to end. A white-haired man in a red T-shirt paced back and forth repeating the same phrase again and again: “I got it, I got it, I got it.”
In a room shared by three women, one patient lay curled in a fetal position beneath a blue blanket pulled over her head. In another darkened room, a young man lay on his stomach wailing into his pillow, pulling at the sheets. In the “quiet area,” a groaning man dressed in a T-shirt and surgical scrubs lurched in jerking steps toward the door with a psychiatric aide by his side. In the day area at the end of the hall, four men halfheartedly watched an episode of Spin City.
At a workstation beside the door to the unit, a clipboard held a yellow “flow sheet” listing every patient. At least every fifteen minutes, a nurse or psychiatric aide walked down the hall to check the day area, the dining room, the bathrooms and all the patient rooms. The person doing rounds wrote a letter code beside each name, indicating each patient’s exact location.
On the acute-care unit where Johnson died, the bathrooms are midway down the one long hall. Three toilet stalls with curtains offer limited privacy, and patients walk past the toilets and three sinks to shower in the small, tiled room in back. The semiprivate bathrooms are ideal spaces for sex, drug use and suicide attempts. Nurses and psych techs are supposed to check them frequently. Staffers are supposed to know where every patient is at all times. But on the night Johnson died, the one RN and four psych techs on duty didn’t know.
No staff members heard Johnson coughing and choking when he collapsed in the middle of the night. And discrepancies remain about who found Johnson and how long he lay unconscious or dead on the bathroom floor.
“We were told that he and another patient came to the desk hungry, and nurses gave them bread and peanut butter to make their own sandwiches,” says one former staff member. “Soon after, someone came up to them and said, ‘Charles is in the bathroom.'” One nurse wondered why no staffers watched Johnson, who had a seizure disorder, while he ate his sandwich.
“Nurses are supposed to do an initial choking assessment,” says one staffer. “Everybody that is eating is supposed to be observed because psychotropic medicines cause dryness of the mouth.”
“People with seizures are normally a choke precaution. And why would you give a person with a choke precaution peanut butter?” asks Michelle. “If [the workers on the acute-care unit] were doing what they were supposed to do, he would not have been up there that time of night fixing a peanut butter sandwich.
“When he died, that was the talk of the hospital,” she adds. “They took all the peanut butter out. We can’t even get peanut butter and crackers in the gift shop any more.”
Administrator Dick Gregory will not discuss Johnson’s death, citing confidentiality concerns. The Missouri Department of Mental Health reports that three patients have died at the hospital since last July, but it will not disclose details.
The department also declines to discuss Johnson’s death. “It is the practice of the Department to conduct investigations into any sudden or unexpected deaths or any deaths that are the result of suicides or in which there is any suspicion of abuse or neglect,” a department spokesperson tells the Pitch. “Those investigations include interviews, review of documents and observation by departmental investigators.”
Johnson’s death certificate says he died at 1:03 a.m. as an outpatient in the emergency room of Truman Medical Center. The place of injury is listed simply as “mental health center.” According to the certificate, Johnson “choked on bread and peanut butter.” The time of injury noted on the death certificate: “unknown.”
Several sources at Western Missouri have told the Pitch about another death a few months ago, a woman they say died shortly after another patient hit her on the head. But the details of that death also remain “unknown.” Protected by laws of patient confidentiality, the hospital doesn’t have to explain its patient deaths to the public.
On Friday, June 15, Superintendent Gloria Joseph welcomed about one hundred people to a groundbreaking ceremony for a new Western Missouri Health Center. The crowd gathered in the afternoon beside a vacant lot on Hospital Hill just a few blocks from the hospital’s current location. As the ceremony commenced, The Majestic Three, a saxophone, drum and piano trio, provided entertainment.
The list of 22 honorary groundbreakers included U.S. Representative Karen McCarthy, Jackson County Executive Katheryn Shields, City Councilman Alvin Brooks, Senator Mary Groves Bland and Dianne Cleaver. Gloria Joseph and Dick Gregory were groundbreakers as well and received commemorative plaques.
Western Missouri opened nearly forty years ago in the old General Hospital No. 2, the facility where black people in Kansas City had to seek medical care before desegregation. The new hospital has been a long time coming, and construction is supposed to begin in September.
“Hopefully we’ll be open in two years,” says Gregory, who adds that the new environment will be much better for patients. “Patients will have private and semiprivate rooms. They’ll have access to the outdoors. There will be a substantial increase in therapy rooms and recreational facilities.” All these factors, he says, will improve patient flow and allow patients a greater degree of freedom.
But it seems unlikely that a new building will solve the behavioral problems of the people in charge.
