Washington State Long-Term Care Ombudsman Program

FOR IMMEDIATE RELEASE

November 1, 2007

CONTACT: Louise Ryan, Washington State Long-Term Care Ombudsman,

(office/message) (253) 838-6810 or (800) 422-1384;

Email: louiser@multi-servicecenter.com.

Neglect by Mental Health Agency Inexcusable; Severe Action Needed, Says State Ombudsman for Long-Term Care Residents

NOTE: Press Conference to be held in front of Spring Manor Boarding Home at 1103 16^th Ave., Seattle, today, Thursday, Nov. 1, 2007, at 2:30 p.m.

The Washington State Long-Term Care Ombudsman Program, established under federal and state laws to protect the rights of disabled and elderly residents in residential care facilities, calls for immediate strong action to correct the harmful conditions and practices at Spring Manor boarding home in Seattle, Washington.  This latest call for action is prompted by the tragic suicide on Oct. 7, 2007, of a resident who committed suicide after repeated warning statements to the staff.  Spring Manor, a 57-bed facility for the chronically mentally ill, is operated by Community House Mental Health Agency and is a subcontractor of King County Mental Health Division to provide housing and services to persons with mental illness.

The Ombudsman Program has a mandate to act as a public watchdog in long-term care facilities that care for some of our most vulnerable citizens.  In most cases issues can be resolved at the lowest levels with a good outcome for all involved.  Unfortunately our efforts have failed in this case. We fear that without aggressive action by those charged with the oversight and enforcement of the standards of care, more harm to residents can be predicted. 

Despite having over 50 residents, Spring Manor is staffed with just one caregiver during its evening, night and morning shifts.  Spring Manor Administrator, Constance Jones, admitted to DSHS investigators that the facility has been short-staffed and without a lead caregiver for over a month.  Ms. Jones acknowledged that much of the needed resident supervision, monitoring, medication management, and care planning have not been done. 

In the most recent case, a middle-aged resident slashed his wrists and leapt to his death from his upper story bedroom, after making suicidal statements to the staff for the prior week and apparently going without his psychotropic medications for the previous two weeks. The day before his death the resident broke his bedroom window, and the facility left the glass shards on the floor and sticking out of the window frame.  On the day of his death, the facility’s caregiver left the resident alone in his 3^rd floor room with the glass shards.

DSHS cited Spring Manor for a number of violations involving this resident and other residents.  The state regulatory agency found that Spring Manor: (1) had no protocol to handle possible suicide cases or to evaluate and correct dangerous conditions in the building; (2) had no adequate system to dispense and monitor critical medications needed by the residents; (3) failed to monitor residents’ medical well-being, including failing to check the blood sugar levels of residents with diabetes; (4) failed to adequately train its staff, some of whom had not even completed CPR training; and (5) was understaffed, having only one caregiver for 57 residents on most shifts.

Spring Manor, and its operator the Community House Mental Health Agency (CHMHA), have been cited repeatedly in the past by DSHS for poor care of its mentally ill residents.  In the past two years, two other residents attempted suicide at Spring Manor by jumping off the second floor balcony and a third resident lay dead in her bed for over 36 hours before being noticed.  Other facilities operated by CHMHA have been cited repeatedly by DSHS for deprivation of basic needs including unsanitary conditions such as cockroaches throughout the facility, soiled clothing in the resident lounge, broken furniture, and garbage piled up outside their buildings creating fire hazards, and a lack of emergency food and water.  Ombudsman substantiated findings include illegal evictions of residents onto the street, inadequate meals and food choices, and a lack of meaningful activities.

In response to the current failings at Spring Manor, DSHS has imposed a stop placement—no new admissions—and ordered the facility to re-train its staff and hire a medications consultant.  While we applaud these steps, they do not go far enough.

The Washington State LTC Ombudsman Program is calling for the following steps:

1. Temporary management of Spring Manor by an outside company.  The Community House Mental Health Agency has repeatedly failed to provide appropriate care to its residents and made no meaningful effort, despite being on notice of the problems, to improve their services or facilities. 

2. Require increased staffing at Spring Manor and similar facilities operated by CHMHA.  DSHS identified inadequate staffing at Spring Manor—the administrator explicitly admitted it—yet DSHS did not require the facility to increase its caregiver staffing.  It is impossible for one caregiver to provide care to 57 chronically mentally ill residents.  The staffing increase needs to be permanent, not just a temporary consultant.

3. Require King County Mental Health, which subcontracts to CHMHA, to operate Spring Manor and to increase its funding for the facility.  King County currently pays only $36 a day for CHMHA to provide room, board, medication management, housekeeping, activities, supervision, and other basic boarding home services.  This is a completely unacceptable funding rate and a recipe for ongoing neglect.

The care for the mentally ill members of our society should not be a begrudging afterthought.  Instead, their care should be provided with adequate dignity and resources to meet their needs and basic civil rights.  The Ombudsman calls upon King County, the service agency CHMHA, and DSHS to each fulfill their responsibilities in this regard.