Parkland psych ER is again scene of patient abuse

On June 16, 2014 By A.P.In antisocial personality, assault, Crime, Dallas, Dallas Morning News, Dallas Police Department, Human Behavior, Medicine, mental health, mental illness, Neuropsychiatric Disease, Parkland Memorial Hospital, Parkland Memorial Hospital psychiatric emergency room, psychiatrist, Psychiatry1 Comment

Parkland Memorial Hospital said the patient-gagging incident in the psychiatric emergency room was discovered on April 8 during a routine review of security video from March 16. Parkland notified the Texas health department within a day, it said, in compliance with regulations.

By MILES MOFFEIT AND BROOKS EGERTON

The psychiatric patient spat at Parkland Memorial Hospital staff as they strapped her into a chair. Then a nurse shoved a toilet paper roll into her mouth, while a co-worker put a sheet over her head.

“Blood stains can be seen on the toilet tissue” after its removal, says a police report that describes security camera footage. A follow-up report says a third employee warned the caregivers that their actions were “illegal.”

Texas health authorities are investigating the March incident — the first abuse in Parkland’s psychiatric emergency room to become public since the hospital hired a new chief executive. One nurse involved in the gagging was also involved in the 2011 restraint of a psych ER patient whose death triggered a federal investigation and virtual takeover of Parkland.

State health regulations prohibit restraint that obstructs a psychiatric patient’s airway or ability to communicate. A prior state enforcement action against Parkland requires hospital managers to report patient abuse within two days of becoming aware of it.

Parkland reported the gagging incident more than three weeks after it occurred. The hospital said managers didn’t know about it initially but acted promptly once they did.

“Employees on site did not elevate this incident appropriately,” Parkland spokeswoman April Foran said. The hospital fired two of five employees who were present during the restraint, she said. Two others resigned, and a fifth “received corrective action.”

Parkland, which collects hundreds of millions of dollars a year from Dallas County taxpayers, would not name the employees. But The Dallas Morning News confirmed the identities of two: Charles Enyinna-Okeigbo, the nurse who forced the toilet paper roll into the patient’s mouth, and Sherwin De Guzman, a supervising nurse.

Authorities have previously investigated both nurses: Enyinna-Okeigbo for domestic violence, and De Guzman in connection with the 2011 death of psych ER patient George Cornell. State and federal regulators found that Cornell was illegally restrained shortly before dying. They cited De Guzman for failing to supervise the technicians who subdued Cornell.

Parkland’s in-house police department investigated the March incident and asked the Dallas County district attorney’s office whether assault charges should be filed. A prosecutor said that the use of force was “unfortunate” but not criminal.

Both nurses declined to comment to The News. Enyinna-Okeigbo told police that he was merely trying to stop the spitting and was not angry with the patient, according to Parkland records.

UT Southwestern Medical Center, whose physicians supervise care at the public hospital, identified the psychiatrist in charge as Dr. Uros Zrnic. He “was not informed or aware of the incident until the videotape was reviewed” in April, UTSW said.

Terrified patient

Experts criticized Parkland after reading police reports on the latest incident at The News’ request.

“When a patient spits, it’s the last resort of a terrified human being, and being restrained like this is terrifying,” said Dr. Peter Breggin, a New York psychiatrist and former consultant for the National Institute of Mental Health.

“Trained mental health workers in this day and age know that spitting is a cause for staff to back off,” he said, adding that forcing objects into patients’ mouths can escalate violence. “There’s no excuse for this abuse.”

Dennis Borel, executive director of the Coalition of Texans with Disabilities, said some Parkland psych workers “still don’t get it.”

“This is pretty outrageous when it was just a few years ago that these kinds of actions were supposed to trigger training and other safe approaches at Parkland,” Borel said. “Everything in the patient’s behavior indicates she was desperately trying to protect herself, and they were making it worse. They failed the patient miserably.”

The state health department hit Parkland in 2012 with a $1 million fine because of Cornell’s death and several other “egregious deficiencies.” It was by far the largest hospital fine in Texas history.

Under a settlement, the hospital paid $750,000. It can avoid paying the rest if, by later this summer, it demonstrates compliance with safety requirements.

Because of the gagging incident, regulators are investigating whether there have been more “significant, egregious deficiencies and a failure to correct them or an attempt to hide them,” said health department spokeswoman Carrie Williams. “It’s an open investigation, and there have been no findings in this case so far.”

Parkland also remains under a 2013 corporate integrity agreement with the U.S. Department of Health & Human Services. It requires periodic reports on patient safety, among other steps.

Compliance with that agreement is a top stated priority of Dr. Fred Cerise, Parkland’s new chief executive. He started work about a week after the March gagging incident.

Cerise and other hospital officials declined to be interviewed for this report. In written responses to questions, Parkland said “the event was discovered” on April 8 during a routine review of security video from March 16. Parkland notified the Texas health department within a day, they said, in compliance with state regulations.

Parkland also said that in addition to taking personnel actions, it now requires video reviews of restraints within 24 hours. But it would not say whether it previously had a schedule for reviewing the security videos, or why it took more than three weeks to detect the gagging incident.

Quick investigation

The criminal investigation lasted less than 48 hours before the case was closed as “unfounded,” police reports show. A News investigation last year found that Parkland police have a history of quickly closing cases in which hospital employees are accused of abuse.

The hospital released nine pages of reports on the investigation, blacking out the names of employees and the patient. It released no information about why the patient was in the psych ER or whether she was injured in the restraint incident. There is no indication in the records that police tried to interview the woman.

When asked, the hospital spokeswoman told The News that “Parkland made multiple attempts to locate the patient” but failed.

The reports contain conflicting versions of what led to strapping the patient to the chair.

Enyinna-Okeigbo told police the woman became “extremely agitated” while in a common area of the psych ER. He said he gave her medication to calm down, but it didn’t work. When staff then directed her toward seclusion rooms, she began to “spit, swing, and kick at the staff,” police wrote, summarizing Enyinna-Okeigbo’s account.

A fellow caregiver who was interviewed “does not recall seeing the patient strike or attempt to strike any staff members,” a police report says. This caregiver also said he didn’t recall seeing the toilet paper roll put into the patient’s mouth or any bleeding. He denied covering the patient’s face with the sheet. The police report noted that “video of the incident contradicts this.”

The reports quote another staffer as saying he saw the bleeding and thought the patient had been “struck by a nurse.” He described the scene as “very chaotic” and said employees lacked training for such situations.

The police description of video footage begins as the patient resists efforts to strap her into a restraint chair: “She appeared to be acting aggressively toward to the medical staff, including spitting on multiple occasions in the direction of the staff.”

Five staffers approached the woman, including one who “immediately placed the roll of toilet tissue over the patient’s mouth,” a report says. “The patient began to resist,” leading Enyinna-Okeigbo to “shove the end of the roll into the patient’s mouth, at one point even appearing to force the patient’s jaw open to completely insert the roll.”

Then another employee secured the sheet around the patient’s head, and the bloody toilet paper was removed from her mouth. Next, a surgical mask was put on the patient. It, too, later showed blood stains.

A Parkland officer met with Assistant District Attorney Craig McNeil on April 10 to discuss potential criminal charges against Enyinna-Okeigbo. “McNeil stated that he felt the culpable mental state exhibited was negligence, and the mental state that has to be met for assault is reckless,” a police report says. “Therefore, McNeil stated that he did not feel that [Enyinna-Okeigbo] met the culpable state to be charged with a crime.”

McNeil told The News he did not know why the hospital didn’t consider charges against the staff member who put the sheet around the patient’s head. Foran, the Parkland spokeswoman, said hospital police gave the DA’s office “complete details” of the incident and noted that prosecutors have “full discretion” about how to proceed.

No assault

The News became aware of the incident on May 28 and asked Parkland for all related police reports. That same day, a Parkland detective asked McNeil for a written explanation of his reasoning, which the hospital gave The News.

“The use of force against a patient in an altered mental state is always unfortunate and should be avoided,” McNeil wrote. But it “does not appear to have been done with the intent to harm the patient.”

In an interview with The News, McNeil identified Enyinna-Okeigbo as the nurse who stuffed the toilet paper roll into the patient’s mouth.

The prosecutor said that spitting could be considered assault because of the potential for disease transmission. In using that term, he said, he did not mean to suggest that the patient should be charged with assault but added: “You have the right to defend yourself.”

McNeil said he could not tell from the video why the patient had blood in her mouth. He said he saw no footage of the patient being struck.

McNeil handled a 2011 case in which security video showed Parkland psychiatric technician Johnny Roberts choking a patient into unconsciousness. The hospital fired Roberts, but grand jurors declined to indict him.

“I was not happy about that,” McNeil said. “I still don’t know why they did that.”

Troubled pasts

The News’ reporting of George Cornell’s death ultimately led to a regulatory crackdown and two years of round-the-clock federal monitoring of Parkland.

The hospital installed security cameras — the same ones that captured the recent gagging incident. It also promised to fire problem employees and retrain others, especially on patient restraints.

Parkland would not say whether Enyinna-Okeigbo or De Guzman received this training.

De Guzman left his job at Parkland at some point after Cornell’s death in February 2011. He returned to work later the same year, according to hospital employment data. Parkland would not explain his departure or return.

Cornell’s death also led to a federal civil rights lawsuit that’s still pending against the hospital, UTSW, De Guzman and other caregivers. In court records, Cornell’s family has noted ways that regulators found fault with De Guzman.

Enyinna-Okeigbo, who was hired at Parkland in 2005, was charged with misdemeanor assault of his wife in 2008.

Dallas County prosecutors initially proposed a deal under which he could plead guilty and serve probation, court records show. Instead, for reasons the records don’t explain, they dismissed the charge in exchange for his completion of an anger management class. He never entered a plea and has no conviction record.

Parkland would not say whether it was aware of the allegations against Enyinna-Okeigbo. The hospital said that before 2011 it conducted criminal background checks only on prospective employees. It said it now checks existing employees, too.

In 2013, Parkland hired privately owned Green Oaks Hospital to manage its psychiatric services. Green Oaks, which receives $1.1 million a year under the deal, declined to comment for this report. Parkland would not discuss the company’s performance.

http://www.dallasnews.com/investigations/20140614-parkland-psych-er-is-again-scene-of-patient-abuse.ece

As Dallas hosts Washington on Columbus Day weekend for Sunday Night Football, Washington Redskins state their name is a term of honor and not a racial slur

On October 12, 2013October 12, 2013 By A.P.In civil rights, Columbus, Columbus Day, Dallas, Dallas Cowboys, Dan Snyder, Human Behavior, Human Rights, Jason Begay, National Football League, Native American, Native American Journalism Project, Navajo, NFL, Obama, Oneida Indian Nation, R-word, racism, Ray Halbritter, Redskins Nation, Roger Goodell, Tom Cole, University of Montana, Violence, Wealth and PowerLeave a comment

R-word redskins

It’s one of the NFL’s bigger rivalries, the Cowboys vs. the Redskins. And intentional or not, Sunday’s game occurs during Columbus Day weekend, deepening the meaning of a fresh conflict about whether “Redskins” slurs Indians, their leaders say.

More than 500 years after Christopher Columbus’ encounter with the natives of the Americas, any enduring uneasiness between Indians and mainstream society is exemplified by the controversy over the Washington Redskins name, which took a new turn last week when President Obama spoke of “legitimate concerns” that the mascot is racist, some Indian leaders say.

Team owners strongly dispute any racism behind the mascot and won’t change it, saying the Redskins name honors “where we came from, who we are.”

But many Native Americans contend it’s incredulous that a major sports team in the nation’s capital fails to see the word’s offensiveness, especially in a game Sunday whose rival mascots conjure up the bygone real bloodshed between cowboys and Indians. Some news outlets and sports writers agree and aren’t printing “Redskin” in their stories about the NFL team.

“After 500 years, it’s pretty unbelievable that this issue is at the forefront right now,” said Jason Begay, a Navajo who’s an assistant professor and director of the Native American Journalism Project at the University of Montana. “Even in the last 50 years (of the civil rights movement), we learned so much. It’s just ridiculous that this is an issue.”

The NFL team disagrees. In response, the Oneida Indian Nation of New York began airing this weekend a radio ad protesting the Redskins mascot in the Dallas Cowboys’ hometown. The ad, entitled “Bipartisan,” quotes how Obama, a Democrat, and Rep. Tom Cole, a Republican leader in the House, disapprove of the Redskins name.

Washington team owner Dan Snyder stepped up his defense of the moniker this month. Last spring, he told USA Today he will “never” change the name.

“Our fans sing ‘Hail to the Redskins’ in celebration at every Redskins game. They speak proudly of ‘Redskins Nation’ in honor of a sports team they love,” Snyder wrote in a letter to fans.

“After 81 years, the team name ‘Redskins’ continues to hold the memories and meaning of where we came from, who we are, and who we want to be in the years to come,” he continued.

“I respect the feelings of those who are offended by the team name. But I hope such individuals also try to respect what the name means, not only for all of us in the extended Washington Redskins family, but among Native Americans too,” Snyder said, citing several polls conducted in recent years that show that a majority of people do not want the name changed.

But American Indians like Begay worry about the normalization of an epithet. He’s also vice president of the Native American Journalists Association, which launched last month a media resource page on its website about offensive Native American mascots in U.S. sports.

“We’re on the verge of laying back and letting this name run rampant when we can actually make a difference, which is what we all should be striving for,” Begay said. “I’m glad to see there are so many organizations like NAJA and the (U.S.) President who are standing against it.”

Obama said last week that if he were the team’s owner, he would “think about changing it,” referring to the mascot.

Obama added that “I don’t know whether our attachment to a particular name should override the real, legitimate concerns that people have about these things.” The ad also airs a quote by Cole saying “the name is just simply inappropriate. It is offensive to a lot of people.”

The political leaders’ remarks are repeated in the radio ad advanced by the Oneida Indian Nation and its leader Ray Halbritter, who’s also CEO of Oneida Nation Enterprises, which operates a casino and other businesses.

Halbritter acknowledged his tribe’s “Change the Mascot” campaign faces an uphill struggle. He refers to the mascot as “the R-word,” without explicitly stating it.

“Well, history is littered with people who have vowed never to change something — slavery, immigration, women’s rights — so we think one thing that’s really great about this country is when many people speak out, change can happen,” Halbritter said.

When asked about other team mascots such as the Atlanta Braves, Cleveland Indians, Kansas City Chiefs and Chicago Blackhawks, Halbritter cited how “redskin” is defined in the Merriam-Webster Unabridged online dictionary as “usually offensive.”

“Let’s be clear. The name, the R word, is defined in the dictionary as an offensive term. It’s a racial epithet. It’s a racial slur. I think there is a broader discussion to be had about using mascots generally and the damage it does to people and their self-identity. But certainly there’s no gray area on this issue,” he said.

Halbritter asserted the word was born out of hatred — and referred to the long, ugly history between the native people of the Americas and the colonizers from Europe who followed Columbus.

“Its origin is hated, use is hated, it was the name our people — that was used against our people when we were forced off our lands at gunpoint. It was a name that was used when our children were forced out of our homes and into boarding schools,” he said. “So, it has a sordid history. And it’s time for a change, and we hope that — and what’s great is when enough people do recognize that, change will come.”

Fans are sharply divided about the issue.

A non-scientific online poll by the Washington Post shows 43% saying the team should change its name. But 57% say no, keep it. One respondent said the term is “a racist holdover from another day, a time when Indians were depicted as violent, ignorant, savages (by) whites (who largely were equally violent, ignorant and savage).”

But another respondent referred to political correctness and said: “The liberal PC society has gotten out of control, if you don’t like the teams name THEN DON’T WATCH THEM…!”

Redskins attorney Lanny Davis said the mascot is “not about race, not about disrespect.”

At games, he joins fans in singing “Hail to the Redskins” because “it’s a song of honor, it’s a song of tribute.”

http://www.cnn.com/2013/10/12/us/redskins-controversy/index.html?hpt=hp_c2

Dallas Parkland Memorial Hospital built wealth as patient care conditions worsened

On February 18, 2013 By A.P.In Alan Walne, Allan Shulkin, Alvarez & Marsal Healthcare Industry Group, assault, CMS, Crime, Dallas, Dallas Morning News, Dana Forgione, Harry Hines Boulevard, Human Behavior, James A. Smith, John Dragovits, Joint Commission, Kevin Holloran, Lauren McDonald, Louis Beecherl III, Medical City Dallas, Medical City Dallas Hospital, Mike Herrera, Parkland Health & Hospital System, Parkland Memorial Hospital, Parkland Memorial Hospital psychiatric emergency room, Parkland Women’s and Infants’ Specialty Hospital, Reese Dunklin, Ron Anderson, sexual abuse, Ted Shaw, Texas, Texas attorney general, Texas Department of State Health Services, Texas Medical Board, Texas Public Information Act, Texas Society of CPAs, Texas State Department of Health Services, U.S. Centers for Medicare & Medicaid Services, UT-San Antonio, Violence, Wealth and Power, WISH1 Comment

Pkld_MAIN_1_oldnew
Cash reserves of more than $1 billion were built up, in part, by skimping on staff and building upkeep.

By REESE DUNKLIN
Staff Writer
Dallas Morning News
rdunklin@dallasnews.com

Parkland Memorial Hospital quietly amassed more than $1 billion in cash reserves even as deteriorating patient-care conditions brought it to the brink of closure, an analysis of financial records shows.

The Dallas County taxpayer-supported hospital built the reserve over the last several years, in part by reducing staff and available beds, neglecting its aging building and moving hundreds of millions from the operating budget to help finance construction of a new hospital.

Federal regulators have since forced Parkland to plow at least $75 million back into operations to remedy lapses that they said threatened patients’ lives. That has prompted questions about whether focus on the new $1.2 billion hospital complex exacerbated Parkland’s patient-safety breakdowns.

Dr. Allan Shulkin, a member of Parkland’s governing board from 2004 to 2009, said a reason he left was because he was “a little troubled by what I thought to be an over-emphasis” on construction. He recalled hospital management assuring the board that patient care was under control and sufficiently funded.
It is clear now neither was the case, he said.

“Did we — the board, my board, the current board — get so focused on the new building that we forgot about operations?” said Shulkin, a pulmonary specialist who trained at Parkland in the mid-1970s. “I worry that that began to happen.”

Parkland officials declined Dallas Morning News interview requests. They referred to annual year-end statements of the Parkland Health & Hospital System for information about hospital finances. The News analyzed 10 years of such statements, obtained under the Texas Public Information Act. The statements don’t clearly explain how much money Parkland has at its disposal, but the hospital eventually said its “reserves” encompass cash, investments and assets limited to use, which is akin to savings.

By the Sept. 30 close of fiscal year 2012, those sources totaled just over $1 billion. Of that, about $315 million was restricted to new construction or bond debt repayment.

“We have plenty of cash on hand,” Ted Shaw, Parkland’s interim chief financial officer, told the Board of Managers during a December public meeting.

Parkland benefits from one of the nation’s biggest local-government hospital subsidies — a property tax that generates more than $400 million annually, about a quarter of Parkland’s total revenue. The tax rate is the second-highest for a Texas public hospital, at 27.1 cents per $100 in assessed property value.

Dr. Dana Forgione, an expert on health-care finance and accounting at UT-San Antonio, said public hospitals often don’t make clear how much they have in reserves so as to avoid questions from taxpayers.

“How can they have $1 billion and they couldn’t improve quality a little bit? Those are the questions they don’t want,” Forgione said after reviewing Parkland’s two most recent annual statements. “I understand there’s got to be a trade-off between current expenditures and long-term investment in new and improved facilities. But $1 billion is a lot of money, right?”

Starting in fiscal 2005, Parkland took surplus revenue from daily operations and saved the funds for construction of a new state-of-the-art hospital. Officials have touted what became a 17-story facility on Harry Hines Boulevard as “the largest hospital construction project in the United States,” likening it in size to Cowboys Stadium.

By 2011, Parkland had set aside more than $400 million, records show. The surpluses came from cutting spending on staff and charging higher prices for treating its mostly poor, uninsured patients, among other things.

The amount saved was higher than the $350 million in “cash reserves” that hospital officials had promised to contribute as part of a bond deal approved by voters in 2008. That election gave Parkland permission to sell more than $700 million in construction bonds — the biggest chunk of the new hospital’s financing.

Parkland’s total cash supply peaked at nearly $1.5 billion in early 2011 and began to decline as construction got under way.

Kevin Holloran, a health-care analyst from the Standard & Poor’s credit-rating agency, said Parkland’s balance sheet looked a “little rich.” But the cash levels were a “blip right now on the radar screen” because of construction.

“Cash becomes a very contentious topic at a public hospital. ‘Shouldn’t you spend it all down?’” Holloran said. “But if you’re about to build a new hospital, our opinion would be they financially, soundly did a good thing to put away some money.”

As Parkland’s cash supply grew, the hospital’s medical care in 2008 was coming under “near constant surveillance and investigation” because of “scores of patient complaints, injuries and death,” a federal report later showed.

The scrutiny intensified in 2011, when the U.S. Centers for Medicare & Medicaid Services found that Parkland’s patients were in “immediate jeopardy” of injury and death because of poor staffing and hospital conditions. Federal regulators took the unusual step of placing Parkland under independent safety monitoring in lieu of closure, making it the nation’s largest hospital to face such oversight.

In their February 2012 overview report on Parkland, the monitors said some hospital units lacked enough staff to accommodate emergency patients, worsening overcrowding and treatment delays in the ER. Cuts in the women and infants’ specialty hospital led to bed shortages and “unsafe” nurse-to-patient ratios. The building had soiled floors and holes in walls — duct tape covered one in an operating room — that jeopardized infection control.

The monitors quoted Parkland employees as saying that some safety problems were “the result of a budget reduction in a previous fiscal year” and “budgeted staffing constraints imposed last year.” Some concerns, such as the ER backlogs, were flagged by hospital consultants as far back as 2004, The News found.

The state also faulted Parkland for a “failure to adequately staff nurses in certain areas of the facility” — including the psychiatric ER, where a 2011 patient death triggered the CMS crackdown. In August 2012, the Texas Department of State Health Services fined Parkland a record-setting $1 million.

James A. Smith, former chair of the Texas Society of CPAs and managing director of a Dallas accounting firm, said Parkland’s leaders couldn’t blame patient-care problems on a lack of money, based on his analysis of the two most recent annual financial statements.

“Knowing what we know now,” Smith said, “it seems to me like the construction project, which was a grandiose plan, sucked an awful lot of air out of the room financially.”

For at least a decade, Parkland administrators and board members have argued that a new hospital was the cure to old Parkland’s problems.

“Indeed, Parkland’s future is largely being pinned to the public hopes arising from a new billion-dollar hospital that is making its way up from the ground across the street,” federal safety monitors noted last year. “But hospitals are not simply buildings, bricks and mortar.”

The existing hospital, which opened in 1954, had long been overcrowded. Even $140 million in improvements wouldn’t bring the structure into code compliance, consultants said at one point. And if Parkland hoped to compete for new patients, it needed modern facilities like those of other Dallas hospitals, officials said.

But expansion planning stalled in 2003. Parkland suffered a $76 million budget shortfall that year and started cutting about 500 jobs. County commissioners, who approve Parkland’s budget and appoint its board, were angered they weren’t consulted about new construction and hired outside consultants to study Parkland’s operations.

In February 2004, the board chairwoman sought a succession plan for Dr. Ron Anderson, putting his two-decades-long tenure as hospital CEO in doubt. She didn’t succeed and quit two months later, along with three other members who clashed with Anderson. A newly constituted board led by Dr. Lauren McDonald and other Anderson supporters extended his contract, and Anderson announced that his priority was to “get into a new hospital.” He did not respond to requests for an interview.

With political tensions easing, commissioners in 2005 appointed a blue-ribbon panel to explore construction options. In 2007, it proposed replacing Parkland with an 862-bed hospital. The replacement was about one-fourth larger, along with clinics and offices. Construction would be completed in phases, each likely needing voter approval. The first — featuring a medical, surgical and trauma facility — would tentatively open in 2013 at a cost $840 million.

As final plans were drawn up, Parkland administrators recommended a different approach: Building all at once.

The final bill could drop by $100 million to about $1.2 billion by avoiding the price inflation and redundancies of a gradual move-in, according to a 2008 planning briefing The News obtained. Accelerating construction, though, would require another $400 million sooner in the process.

To make that work, $747 million in bonds and a property tax-rate hike as high as 2.5 cents would be necessary. Parkland promised “to reduce the burden on taxpayers” by raising $150 million in private donations and using $350 million in “cash reserves.”

Parkland’s cash supply was nearly $600 million by mid-2008, after doubling in the previous three-year span. One-time windfalls and record-setting budget surpluses had stabilized Parkland’s finances. Commissioners also let Parkland keep its tax rate at 25.4 cents per $100 in valuation to generate extra money from higher property values.

That meant Parkland could immediately put $250 million of the $350 million into the project, according to the 2008 planning briefing. Enough cash would remain that Parkland could operate for at least four months without collecting another dime — above the median “days cash on hand” for hospitals with strong credit ratings, the briefing said.

The cash commitment helped reduce the amount of bonds needing voter approval but was about $130 million more than originally planned. Parkland forecast that its cash and investments would grow once construction began, according to the briefing.

Aiding that growth, hospital officials said, would be “revenue enhancements” and “productivity and expense improvements.” Parkland’s briefing described those as price increases above inflation and “strategic pricing” of patient services, as well as improvements in billing coding, “employee productivity” and “salary and benefit costs.”

Parkland did not define specific terms for achieving those savings but said doing so could gain $150 million between 2009 and 2014 — perhaps even eliminating need for an additional 1-cent tax hike once the new campus opened.

When Parkland’s board voted for the build-at-once plan in summer 2008, it prompted applause. “When the project got derailed almost five years ago,” Anderson said, “I wasn’t sure that this day would ever come.”

Two months later, safety inspectors showed up unannounced.

The inspectors, working on behalf of CMS, found that Parkland patients were undergoing surgery without informed consent, as federal rules require. The American Medical Association’s code of ethics says patients have the right to approve or reject their surgeon in advance.

Yet Parkland’s consent forms and other records reviewed by inspectors in September 2008 were unclear over who was performing the surgery — faculty physicians from UT Southwestern Medical Center, which staffs Parkland, or resident trainees. Consultants as far back as 2004 had found that many UTSW physicians weren’t supervising residents and urged Parkland to make changes, including hiring its own doctors.

In late October, two weeks before the November bond election on the new hospital, Parkland officials presented CMS a new consent form and insisted they saw no evidence of residents operating unsupervised. Six days later, CMS told Parkland it had revised the original inspection report to remove references to “deficiencies.” The incident remained out of public view until The News reported on it in March 2010.

Another complaint in September 2008 did get noticed. A 58-year-old man named Mike Herrera died after languishing 17 hours untreated in the main emergency room — the type of problem consultants foreshadowed in 2004. A national hospital accrediting agency, the Joint Commission, cited Parkland for about a dozen safety failures.

Parkland enacted new ER procedures and made 10 nursing hires early in the next year, as it promised CMS. Anderson, however, later said Herrera, who had a history of heart disease, was probably going to die even “had our system been working.”

Shortly after Dallas County voters overwhelmingly approved construction of the new hospital, Parkland’s board agreed to reserve the $250 million, as planned, plus another $16 million in cash for the project.

The new building, by that point, was taking more and more of the board’s time, said Shulkin, the former member. Meetings were lasting longer, and new ones were added to the schedule.

“There was a sort of new charge and direction for the board,” he said. “I got the sense that there was a lot of enthusiasm, ‘Oh, man, let’s do the new building.’”

Shulkin said he understood the project’s enormity. But that should not “distract from what we do today” — patient care, he said.

“I thought, hire the people and build it. We’ve still got a hospital to run. We still have patients to take care of,” said Shulkin, who practices at Medical City Dallas Hospital and serves on the Texas Medical Board. “We don’t need to be picking out the drapes.”

Herrera’s ER death had been appalling, he said, and frustrated some board members who had “demanded that the ER’s long waits had to stop.”

In March 2009, Shulkin decided to depart the board months earlier than planned.

“I knew, for me, I didn’t fit in there anymore,” he said. “If so much of the demands on the board are the development and construction of the new building, then let the people who are going to be there at the end be at the beginning as well.”

A month later, Parkland awarded $100 million in contracts to construction managers and designers. At a news conference to announce the firms, administrators talked excitedly about having a first-class, environmentally friendly building that was “patient-centered.” Anderson added that Parkland would no longer be a place of last resort, but rather “a hospital of choice.”

Construction bonds for the new Parkland were sold in August 2009, doubling its cash supply from about $600 million to more than $1.3 billion.

Then in January 2010, Parkland met its election pledge to put $350 million toward the new hospital. The board unanimously approved hospital administrators’ recommendations to transfer a lump sum of $53 million and monthly $2.5 million allotments during the next year from operations.

Before the vote, then-board member Louis Beecherl III cautioned that taking the money from operations at that time left Parkland “with a pretty fine line here of comfort.”

“If we don’t earn a positive bottom line, we’re going to be in real trouble,” Beecherl said, noting Parkland might not be able to build new community clinics if money became tight. “We need to be careful about what we’re doing here.”

Another board member, Alan Walne, said the money could be used for operations if necessary later. But there needed “to be pressure to bear that … we can put these other dollars away and can, in fact, perform in a manner that we told the voters we would,” according to a tape-recording of the meeting.

Parkland’s chief financial officer at the time, John Dragovits, told the board that the hospital would enforce fiscal “discipline so that we’re not in that situation.” Anderson added, “This is first things first.”

In a recent interview, Beecherl said his comment had “nothing to do with patient care.” He simply wanted Parkland to ensure a strong bottom line to maintain investor confidence, he said. Two credit-rating agencies, Fitch and Standard & Poor’s, had given Parkland’s bonds their highest scores, which reduced borrowing costs.

Asked whether Parkland’s large construction project had created financial pressures, Beecherl said the only pressure was finishing it.

“We were functioning in a 60-year-old building, and patient care was not up to current-day standards because of the age of the facility,” said Beecherl, an energy businessman. “The quicker we could build a new facility, the quicker we could get in and improve patient care to modern-day standards.”

Walne added, in an interview, that there was no talk that “we can skimp on patient care so that we can spend on a new hospital.”

“At the end of the day,” he recalled, “when we’d gotten everything taken care of, any dollars that we had … [in surplus,] we would try to set those dollars aside for the new hospital.”

As the hospital broke ground across Harry Hines Boulevard in October 2010, Parkland was also delivering on the “operational improvements” promised before the bond election.

Parkland earned nearly $150 million more in revenue between fiscal years 2009 and 2011 despite the sluggish economy. The hospital did that through price hikes in commercial insurance contracts, rate increases in Parkland’s managed-care plan for Medicaid recipients and “record-breaking reimbursements” through improved medical billing.

Parkland also cut salaries, wages and benefits. From fiscal 2007 to 2009, those expenses had increased by nearly $130 million. But in 2010, they were up only $33 million and, in 2011, they declined $3 million. That was the first reduction since 2003, when state budget cuts prompted layoffs.

A similar trend was apparent in the number of full-time employees, according to a News analysis of data Parkland produced in a public information request.

From fiscal 2007 to 2009, nurses and other classifications of caregivers increased by 9 percent, and Parkland’s total workforce was up by 8 percent. Both exceeded a nearly 7 percent growth in patient volumes.

In 2009 through 2011, however, nurses and caregivers increased by 1 percent, and the total workforce decreased by about 1 percent. Both lagged behind an 8 percent growth in patient volumes.

The cutbacks included about 200 jobs that Parkland eliminated to save $14 million in the fiscal 2010 budget. Officials had cited fears that property values would decline. Parkland said at the time most of the jobs were clerical, and an unspecified number would have been phased out because of a shift to electronic medical records. About half were already vacant, officials said.

For their 2009 and 2010 efforts, top hospital executives and administrators were awarded year-end “incentive” payments. Those bonuses totaled about $6 million for achieving goals such as reducing ER wait times and improving Parkland’s net income.

In recent interviews, former board members Walne and Shulkin said they may have asked administrators to justify staffing expenses, in general. But they recalled no edict to slow hiring or salary spending starting in fiscal year 2009.

“The question of staff was always,” Walne said, “do you have the resources you need to meet the goals you’re trying to achieve in the increase in quality?”

Walne said periodic safety inspections and News coverage of Parkland’s patient care failures had not suggested a “chronic problem” by the time his term ended in early 2011. The Joint Commission, he noted, had also extended Parkland’s accreditation after doing its own inspection in 2010 and was “very complimentary, quite frankly, of the care that was going on.”

“We would have reacted to whatever the recommendations would have been to accommodate patient care,” said Walne, who runs his family’s auto paint and body business. “We would not have known as a board where we needed to be spending money, because no one was giving us an indication that we had deficiencies where stuff needed to be addressed.”

Parkland finished its 2011 fiscal year with a surplus of $105 million — the seventh straight year with a margin of 5 percent or more. It even committed nearly $50 million more to construction. All of that despite having lowered the property-tax rate from 27.4 cents to 27.1 cents per $100 in assessed value.

Some county commissioners had questioned that cut, because of looming state and federal health-care overhauls that might change funding and patient volumes. But Dragovits had assured them during public discussions over the 2011 budget: “We’re not in a position of needing any kind of relief.”

Ongoing patient-safety breakdowns, meanwhile, prompted CMS to launch a massive, top-to-bottom inspection of Parkland.

Regulators found patients were in “immediate jeopardy” of harm or death and faulted the board’s oversight of the hospital. In September 2011, just weeks before the fiscal year ended, the government threatened to cancel more than $400 million in annual Medicare-Medicaid funding.

Continued federal funding was made contingent on Parkland hiring outside safety monitors to overhaul hospital operations, under CMS supervision. The board hired the Alvarez & Marsal Healthcare Industry Group, at a cost now exceeding $9 million, and accepted an April 2013 deadline to reform.

Alvarez & Marsal monitors found that Parkland was failing to meet about half of the government’s 100 or so safety standards and continuing to have an “extremely troubling” number of adverse patient events. Senior hospital managers also hadn’t kept board members “as informed as they should have been” and did not initially share “critical information and documents” during the government crackdown, the monitors wrote.

“Parkland faces regulatory, safety and patient care deficiencies in nearly every aspect of its organization and delivery system,” the monitors said in their February 2012 overview analysis. “If the deficiencies catalogued in this report are not addressed and fixed, Parkland could not pass a CMS hospital survey [inspection] and would not continue as a Medicare and Medicaid participating hospital.”

Some problems were attributed to past budget constraints that led to staff reductions and beds taken out of service. Others were the result of a lack of investment in operations and the existing building.

Parkland, for instance, hadn’t implemented rigorous methods to track the quality of care and performance of UTSW physicians and residents. Hospitals were required in 2008 by the Joint Commission and other accrediting groups to collect such data, monitors noted.

Other problems were in plain sight. In medical and surgical units, there wasn’t an “appropriate level of care-staffed inpatient beds” at key times. That translated into about 30 available but unstaffed beds a day.

“We were told that this was due to budgeted staffing constraints imposed last year,” monitors wrote.

In the ER, patients were forced to wait “longer than acceptable” to transfer. The backlog increased workloads for an already understaffed nursing team. It also “creates safety risks and creates delays for other persons presenting to the hospital for evaluation and stabilizing treatment,” monitors said.

Patients chose to leave without treatment at rates twice the national average in 2011, monitors found. The ER was so full Parkland diverted ambulances to other trauma centers during one-third of its hours each month.

In Parkland’s women’s and infants’ specialty hospital, known as WISH, two units were closed in 2011 and staff decreased by about 20 in anticipation of a decline in deliveries. But the number of patients increased in a few months’ time, monitors wrote.

That made beds scarce at peak times and forced women to recover in hallways or classrooms. Nursing-to-patient ratios in some areas became “unsafe.”

“While Parkland’s new hospital facility should be designed to resolve the inadequate size, proximity and model of care,” the monitors wrote, “Parkland must still make investments in the current hospital facility, specifically in WISH, to ensure a safe environment.”

The hospital itself was in such disrepair that some areas required immediate attention. Floors were soiled, paint chipped and furniture torn in WISH. An operating room had a hole covered by duct tape and a door that wouldn’t close completely. In another unit’s break room, large wet stains on ceiling tiles contributed to infection control risks.

“While Parkland’s current facility may show wear and tear due to its age, it does not have to be unclean,” monitors wrote. “Even the oldest facility can maintain an appearance and standard of cleanliness appropriate for patient care.”

Monitors warned that fixing the deficiencies by the April 2013 deadline was a “heroic challenge” that would require the focus of front-line staff, executives, the board and the community.

“The hospital is in the midst of a major construction project with the ongoing construction of a new hospital facility,” they wrote. “However, construction updates and discussions should not overwhelm or overtake the critical time necessary to oversee quality and safety functions and successful performance.”

The challenge also required money. Parkland estimated that it spent about $32 million in CMS-related expenses by fiscal 2012’s end in September. Just over half of that was on staff salaries, retention payments and benefits. Parkland projected adding roughly 250 full-time employees, including nurses, patient-care assistants and social workers.

The additions contributed to an 11 percent increase in nursing and other caregivers from 2011 to 2012, while patient volumes fell by about 1 percent. The growth rate was also the biggest since at least 2005, the earliest year-to-year comparison possible using the employment data Parkland provided The News. Despite the hires, another 400 nursing positions remained unfilled just before fiscal 2012’s end.

Another $45 million in CMS-related spending was estimated for fiscal 2013 year.

Among the specific investments made since the government’s intervention:

•New hires in the hospital’s medical and surgical units to accommodate more patients from the ER. Parkland also will create a 13-bed medical unit by converting space UTSW researchers were using and add 22 beds by remodeling offices that were once patient rooms.

•Renovations totaling up to $4.3 million in the main emergency department and psychiatric ER, and a redesign of the replacement hospital’s ER to meet safety standards. More than 100 caregiver positions were added in those short-staffed areas at nearly $6 million in fiscal 2012 alone. In early February, privately owned Green Oaks Hospital in Dallas was hired for about $1 million annually to manage the psych ER.

•An additional 28 beds in the women’s and infants’ hospital by reopening one of the closed units and filling 26 positions. Monitors also recommended studying how to use the second closed unit.

•At least $3 million on software systems to better manage patient cases, collect data, and measure clinical outcomes and physician performance. The monitors had urged Parkland’s board to “commit to the provision of financial support for the quality program.” They also recommended a patient rights and safety executive post, which is unfilled.

The expenses had Parkland executives worried publicly over their bottom line. Blaming the CMS-related improvements in part, they predicted fiscal 2012 would end in a loss for the first time in a decade.

“This is something we haven’t had to worry about since I got here,” Dragovits, the CFO who arrived in 2006, said during a March 2012 board meeting.

Dragovits retired last summer. He did not respond to requests from The News for an interview.

By the fiscal year’s end in September, Parkland reported making about $30 million more than it spent, according to its financial statement.

“We’re very financially healthy,” Shaw, Parkland’s interim CFO, said during December’s board meeting. “We continue to be well positioned.”

Nonetheless, there was some financial uncertainty.

Parkland forecast that it would close the fiscal year in September 2013 with a $6 million deficit because of the CMS-related spending, increased drug costs, more uninsured patients and Medicaid funding changes. Officials said balancing its budget would require using some of the $1 billion in “reserves.”

Parkland staff also told the board the replacement hospital would either need more funding to finish it as originally designed under the build-at-once plan or would need to be scaled back. And the 1-cent tax-rate increase it thought “operational improvements” could eliminate would be assessed starting in fiscal 2014, at a slightly higher rate of 1.4 cents.

If Parkland requires more money for construction and patient safety, the hospital could have its finances tested unlike in previous years, financial experts said. Dipping excessively into reserves would potentially make investors nervous, and asking for additional tax support is politically risky.

Already Standard & Poor’s has placed a “negative” outlook on Parkland’s bond rating. It did so after monitors released their critical analysis of Parkland’s problems. That meant a 1-in-3 chance Parkland’s rating could be downgraded, increasing future borrowing costs.

“We felt the risk is significant enough,” said Holloran, the S&P analyst, “that we owed it to the public to say they have a potential problem here.”

For former board member Shulkin, Parkland’s failures have left him “stunned and heartbroken.” He said he’s read the inspection reports and analyses and agreed with CMS’ mandates that the hospital spend millions on improvements.

Given the financial resources Parkland had at its disposal, Shulkin said, “It never should have come to this.”

“The problem with Parkland is, they forgot to take care of what they have to deal with every day,” he said. “They were so seemingly focused on what’s going on across the street that they’re forgetting about what’s going on inside these hallways.”

Staff writers Miles Moffeit and Sherry Jacobson contributed to this report.

http://res.dallasnews.com/graphics/2013_02/parkland/#day5main

Parkland Memorial Hospital blaming affiliated UT Southwestern Medical Center doctors for problems with patient care

On February 10, 2013 By A.P.In Allan Shulkin, Alvarez & Marsal Healthcare Industry Group, assault, Chartis Management Consultants, Chris Luna, Crime, Dallas, Dallas County Commissioners Court, Dallas Morning News, Health Management Associates, Human Behavior, Jessie Mae Ned, John Dragovits, Kern Wildenthal, Medical City Dallas Hospital, Mile Moffeit, Parkland Memorial Hospital, Parkland Memorial Hospital psychiatric emergency room, PricewaterhouseCoopers, Ron Anderson, sexual abuse, St. Paul Medical Center, Texas Medical Board, U.S. Centers for Medicare & Medicaid Services, U.S. Centers for Medicare and Medicaid Services, Zale-Lipshy HospitalLeave a comment

A major factor behind Parkland Memorial’s patient care crisis is the hidden power struggle between the hospital and its medical school partner, UT Southwestern Medical Center.

Publicly, Parkland Memorial Hospital and its affiliated medical school, UT Southwestern Medical Center, present a united front. “We have a great relationship,” the hospital’s longtime leader told a group of aspiring UTSW doctors just last fall.

Behind the scenes, however, the reality has been far different. Dr. Ron Anderson, the former CEO, lamented the “vitriol” from UTSW faculty doctors, who supervise patient care at Parkland.

“They honestly don’t know how to work collaboratively with another (non-UTSW) physician who is demanding higher levels of performance and accountability,” he wrote in late 2011.

The tension between the two institutions reflects their tangled relationship. Parkland actually has little control over the doctors working under its own roof. Most are employed by, or answer to, UTSW. Parkland’s priority is supposed to be patient care. Yet UTSW lists its missions as medical education, research and patient care — in that order.

The organizations’ divergent missions, business interests and turf battles contributed to a dysfunctional culture at Parkland over the last decade, jeopardizing patient care, The Dallas Morning News has found.

Federal safety monitors have flagged the culture as a major factor in plunging Dallas County’s hospital for the poor and uninsured into its safety crisis.

Many times over the last decade, UTSW faculty physicians have failed to show up to care for Parkland’s patients. Instead, they see privately insured patients at the medical school’s separate system of hospitals, or focus on research. Resident doctors-in-training at Parkland often have been left with little or no faculty supervision. And front-line caregivers who report to the doctors, especially nurses, have felt powerless to resolve patient-care breakdowns.

Trust and transparency issues abound.

Welcome to the annual UTSW-Parkland cage match,” UTSW’s chief of internal medicine wrote in a September 2010 email to colleagues, describing contract talks with Parkland over the cost and scope of physician services.

“We can’t let them control faculty,” another UTSW chief said in an email to co-workers last March.

The problems between the two institutions run deep. Parkland’s ability to change depends in large part on UTSW. But few, if any, governmental or industry standards exist nationally to help responsibly manage such complex partnerships.

Since 2004, at least three separate consultant firms have urged Parkland, for the sake of better and more efficient patient care, to change its management model to take more control of clinical operations from UTSW. The Dallas County Commissioners Court, which approves Parkland’s budget and appoints its board of managers, also was put on notice. But the contractual relationship between Parkland and UTSW has remained fundamentally unchanged.

“That [relationship] has to be dealt with,” said former Parkland board member Chris Luna, who left in early 2011. “It’s daunting. The culture at Parkland can’t be fixed unless UTSW’s power is addressed.”

The institutions’ problems could worsen after Parkland and UTSW both open new, larger hospitals in the next few years.

Federal regulators and onsite safety monitors have prescribed 499 reforms to turn around Parkland by the end of April. By then the hospital must prove that the changes have taken root or lose massive government subsidies vital to staying open.

Doing that means transforming the culture, according to the monitoring team of Alvarez & Marsal Healthcare Industry Group. The monitors have warned of widespread divisiveness. They have said Parkland workers are lacking in personal accountability and could be desensitized to patients. They have cautioned that UTSW may put the “training and teaching of new doctors above a safe patient experience.”

Recently, the monitors said progress had been made toward a safer culture but warned that a “check-the-box” mentality, instead of sincere efforts at reform, persists. They also wrote of doctors’ lack of engagement in changing their practices, as well as their limited grasp of the government’s action plan for reform issued a year ago this month.

UTSW declined to discuss its relationship with Parkland or furnish details about the work its doctors provide at the hospital. In a statement to The News, it called the model “successful” and stressed the school’s commitment to improving health care through doctor training, biomedical research and patient care.

“UT Southwestern’s partnership with Parkland Hospital is structured to ensure outstanding patient care while fulfilling our responsibility as a state institution to educate and train future generations of physicians to care for the people of this community,” the statement said. “Based on the many hundreds of thousands of patients cared for under this arrangement, we believe the current model has been — and will continue to be — effective in achieving both of these mission-related goals.”

Current Parkland officials also have declined to answer most questions from The News about the alliance, including whether they would pursue a new staffing model.

Since 1943, the public has entrusted the two tax-funded institutions with balancing their different missions.

Parkland furnishes the grounds for UTSW’s doctor training and research pursuits. The medical school serves as the exclusive provider of care for Parkland’s mostly indigent patient population. For those services, UTSW is now paid about $160 million a year.

Their 10-year affiliation agreement, last renewed in 2006, touts the relationship as a national model and a “covenant of mutual responsibility.”

But UTSW’s influence inside Parkland is vast: Its physician force accounts for virtually all of the doctors at the hospital — about 1,000 residents and an estimated 700 faculty members who are supposed to supervise them. Doctors, with a few exceptions, don’t directly report to the hospital’s leadership.

The school has essentially acted as a shadow government over clinical care. Its department chairmen oversee Parkland’s clinical departments. Its faculty physicians serve as the direct chiefs over departments. Its faculty members serve as medical directors over units inside departments.

Parkland directly employs only a handful of attending physicians in its administration or on the main campus. It mainly provides the supporting cast for the UTSW physicians: about 2,500 nurses, hundreds of aides and techs, and directors who supervise them.

The patient safety spotlight has been on Parkland as the entity certified by the U.S. Centers for Medicare & Medicaid Services to receive government funding. But most of the serious patient care breakdowns that forced Parkland into a rare form of federal oversight last year were a shared responsibility with UTSW, which doesn’t answer to CMS.

Dr. Kern Wildenthal, president of UTSW from 1986 to 2008, said the “standard of physician care and supervision by UT Southwestern faculty in Parkland was judged to be high in each and every review by every accreditating agency during my tenure.”

Yet, Alvarez & Marsal outlined more than 50 violations — better than half of all regulations — in the comprehensive analysis of Parkland it completed a year ago. Parkland’s failures in infection control, emergency care, surgical services, resident supervision, physical medicine and rehabilitation, and psychiatric care, among other areas, also fell under UTSW oversight.

“We believe the current operation of Parkland’s resident training program is contributing to the hospital’s deficiencies in meeting all standards,” the monitors said, referring to the program jointly administered with UTSW.

In reality, there are two separate chains of command inside Parkland.

Parkland’s chief medical officer, for example, is supposed to provide leadership over clinical affairs and quality of care at the hospital. Yet the UTSW president “is actively involved in the selection, regular evaluation and decision to continue or terminate the employment of the CMO,” according to the affiliation pact. The current interim chief medical officer is a UTSW faculty member paid by the university, not Parkland.

Employees say the system — what some call the “two-headed beast” — fosters confusion and chaos.

UTSW medical directors, for example, are expected to collaborate with Parkland department directors on decisions. But the structure stymies cooperation.

“Ideally, they’re supposed to meet and discuss the best approach to provide the best of care for patients,” said a former Parkland nurse who has filed a legal claim against the hospital and requested anonymity for fear of retaliation. “What occurs is: they collide. Both have power and both want control.”

UTSW research projects — about 700 studies are currently under way at various stages at Parkland — also can derail patient care priorities.

“If the resident or attending is seeing a patient for medicine management, yet there is also a study on medicine management for which they need participants, during their appointment the resident may cover both,” the nurse said. “This will back up the patient load for the day. The residents get brownie points from their attending [faculty] doctor for signing up participants.”

Parkland’s longtime management structure failed to give the chief nursing officer direct oversight of nurses, despite the title. Many nurses have felt powerless because of the blurred lines of authority. Yet they are expected to backstop and monitor the very doctors who give them orders.

Safety monitors flagged that as a serious problem in their February 2012 report. Nurses, they said, are the “constant eyes and ears of hospital care,” adding that it was crucial to have a vigilant nursing service to monitor the residents.

As part of its reforms, Parkland has now given the chief nursing officer direct authority over the nursing staff.

Concerns about physician oversight kept surfacing over the years as UTSW embarked on an ambitious growth and profit-making strategy, opening its own hospitals.

In late 2000, the school purchased St. Paul Medical Center as a private-referral hospital for its faculty physicians. Five years later, it took formal ownership of Zale-Lipshy Hospital, a private facility adjacent to Parkland that UTSW had managed since 1989.

Some Parkland officials were alarmed.

“Up pops St. Paul, and we’re thinking, it’s a difficult situation for faculty doctors to be covering three different spots,” said a former Parkland board member.

Nurses were regularly noticing that faculty physicians weren’t showing up for work, leaving residents alone to deal with patients. A frequent comment was, “Where’s the doctor?” several caregivers told The News. Parkland employees weren’t always sure whether to take problems up their own chain of command because some of the hospital’s top executives were paid UTSW faculty members.

Anderson, for example, was a tenured professor at UTSW, his alma mater, for most of the 30 years he served as Parkland’s chief executive. He earned $100,000 total in supplemental salary from UTSW until payments stopped in 2007, records show. Parkland officials told The News that board members became concerned that state law prohibited such dual payments, and the practice was halted by UTSW. Parkland’s policy now is that “no one double dips,” according to a hospital statement.

Anderson was forced to resign as Parkland’s CEO more than a year ago after federal inspectors confirmed the hospital’s patient-safety breakdowns, though he was retained as a paid consultant through the end of 2012.

For years, there were concerns that Anderson had conflicting loyalties between the hospital and medical school. After Anderson resigned, a coalition of area churches and schools asked Parkland board members to find a new permanent CEO “free of any conflict of interest.” The group’s leaders, who had worked with Parkland for years on community health care issues, told The News that Anderson’s potential conflicts were behind the request.

Anderson told The News that his role with the school did not compromise his Parkland oversight. As for the payments from UTSW, they were “small” and were reported to the board, he said.

By late 2003, Parkland’s emergency room waits were averaging 13 hours. Women were going through labor in hospital hallways. Packed operating rooms were forcing delays.

Anderson believed a new larger hospital complex was the solution to those problems. So he and the Parkland board moved forward with a $1 billion strategy to build one.

But county commissioners, concerned about the hospital’s ability to manage costs amid government funding cuts, forced Parkland to put the plans on hold. Instead, they hired an outside firm, Health Management Associates, to do a comprehensive study of Parkland.

In 2004, the firm began pointing to the medical school as a major source of problems.

UTSW president Wildenthal was demanding that Parkland increase by $24 million what it paid for annual medical services, saying the school was being underpaid. In Texas, because of a lack of state funding, medical schools generally recover the costs for providing indigent care from the hospitals that contract for their services.

At Parkland, faculty doctors, Wildenthal contended, were working longer hours because of new national accreditation standards that capped residents’ work hours. At the time, Parkland paid UTSW $70 million for its doctors’ services, including supervision of residents and administrative overhead. (Parkland ultimately paid UTSW an additional $7 million for the next fiscal year, which began that fall.)

But the HMA consultants questioned the payments. UTSW had been unable to document much of what it was delivering to Parkland. Administrative costs were “extremely high.” UTSW was charging for “performance enhancements” to encourage more faculty members to supervise care at the hospital — behaviors that consultants said “shouldn’t need additional payments to assure.” And payments to more than 100 medical directors who “had no identified real authority” needed explanation, they said.

They also noted the contract had more than tripled since 1993, when it was $22 million, “despite the lack of any significant service volume increase over the past decade.” They called for more transparency in the partnership and suggested a third party verify costs.

Dr. Allan Shulkin, who served as a Parkland board member between 2004 and 2009, recalls that steps were taken to try to confirm UTSW’s physician costs. But he wasn’t sure how effective they were.

UTSW’s new focus on profits saddened Shulkin, now a pulmonary specialist at Medical City Dallas Hospital and a member of the Texas Medical Board. “You could see that there was another agenda evolving,” he said.

He remembered a different culture during his residency at Parkland in the 1970s.

“We viewed our mission as almost sacred to take care of the poor.”

The consultants also spent months evaluating Parkland’s clinical operations. They found a chaotic and fragmented structure.

UTSW’s academic mission was sidetracking care, they said. Parkland was a “resident-run” hospital.

“The foundation of the clinical care delivered at Parkland is built on the teaching model wherein the training needs of residents essentially guide policy and practice,” the HMA report said.

Trainee-doctors bottlenecked emergency care through unnecessary patient evaluations. Those “who need to experience certain kinds of surgeries in their training, will often look for the most interesting cases, leaving general surgeries behind.” In Parkland clinics, residents ran patient care while a faculty physician “personally never lays eyes or hands on the patient.”

“Most [UTSW] physicians work substantially in other venues and admit [patients] to other hospitals,” consultants said, referring to UTSW facilities.

A common complaint among doctors was that they didn’t know “who is in charge.’’

HMA urged Parkland to work with UTSW toward achieving a dedicated staff, where UTSW physicians — or doctors hired by Parkland — would spend most or all of their time at Parkland. It also urged the hospital to negotiate with UTSW to give the chief medical officer clear authority over the school’s doctors.

But Anderson hesitated.

“Our partnership with the medical school has been a wonderful asset,” he said, adding that he would explore the dedicated staff proposal.

At the time, Parkland’s board was operating without a patient quality committee — a common vehicle used by hospitals across the country to address problems. Such a panel wasn’t activated until after John Dragovits took over as chief financial officer in 2006.

Over the next few years, Anderson’s administration moved aggressively on the new construction front. Parkland hired PricewaterhouseCoopers to work on a strategic plan and master facility plan.

Parkland developed a campaign to replace its old hospital. “We will define the standards of excellence for public academic health systems,” the vision statement said. “The construction of this facility is an opportunity to maintain that vision.”

In 2007, PricewaterhouseCoopers supported plans for a new $1.2 billion hospital. But the firm also echoed some of HMA’s concerns, saying Parkland’s partnership with UTSW created “operational inefficiencies inherent in the teaching process.”

That draft report, obtained by The News, urged Parkland to seek partnerships with other health care services, with or without the support of UTSW, because it had “no substantial provider relationships beyond UT Southwestern.”

It also identified another weakness. It was imperative, the firm said, that Parkland develop quality metrics, as recommended by the national Institute of Medicine, to measure the clinical performance of doctors and to benchmark itself against other hospitals.

Parkland had been paying UTSW without rigorous methods for assessing the quality of doctor care.

By fall 2010, the hospital’s patient-care breakdowns had become widely known. The News had been investigating them since March after a UTSW surgeon alleged that lax resident supervision and absentee doctors were causing widespread harm at Parkland.

One case involved Jessie Mae Ned, a former Parkland employee whose leg was amputated after she was injured during a surgery by a UTSW resident. Following the surgery, Ned went three days without seeing a faculty doctor as she faced life-threatening complications.

Former board member Luna recalled board discussions in 2010 about changing the physician model out of fear that UTSW doctors were spending too much time at their own hospitals and transferring Parkland’s privately insured patients to the school’s hospitals.

“There was this growing concern: Are there two classes of care?” Luna said.

Anderson remained passive, he said. When such changes were discussed, Anderson would say, “It’s not provided for in the contract,” Luna recalled. “He used that a lot.”

Another board member, Alan Walne, once pressed Anderson on that point, Luna said. “We can change the contract. If it’s not right, if it’s not the best thing, we should fix it,” Luna recalled Walne saying. Walne declined to comment for this story.

Dr. Lauren McDonald, who resigned as chairwoman of Parkland’s board last year, said the board instructed Anderson to move toward developing a staff of doctors dedicated to Parkland. “The CEO did not follow through on this along with other important recommendations. You are aware of the outcome,” she told The News.

Anderson said it had been his intent to move toward a dedicated staff, with the help of UTSW. “I wanted to see it happen,” he told The News. “But it will take time to grow into that model.”

He noted that he had persuaded UTSW some time in the few years following the HMA study to agree to allow Parkland to employ and supervise a handful of its own medical directors, as well as have the chief medical officer report to Parkland instead of to both institutions.

In late 2010 a third group of experts, Chartis Management Consultants, issued a striking new finding: Roughly two-thirds of the 700 UTSW doctors assigned to Parkland were spending 50 percent or less of their time at the hospital.

The News obtained only a summary of the report, so it’s unclear whether the consultants offered any more details on the physician absences. Parkland has refused to release a copy of the full report. Chartis did not respond to inquiries.

Like previous consultants, Chartis did not say the Parkland-UTSW alliance is inherently bad. To the contrary, such hospital-school collaborations can be highly effective if both parties work more closely and openly, and ensure “a cadre of faculty physicians whose primary focus is the care of Parkland’s patients,” the firm said.

“Parkland needs a model where most of the care is provided by physicians practicing at Parkland 75 percent or more of their time rather than the current situations,” Chartis said.

Parkland “must be steadfast in its negotiations with UTSW due to the complexity and magnitude of change required,” and it must be prepared to hire its own doctors, the report said.

That fall, Parkland officials sought some changes in the contract with UTSW, though it is unclear whether the request was tied to the Chartis findings. The hospital asked for guarantees from UTSW to commit a group of hospitalists — specialists in acute hospital care — to Parkland 100 percent of the time, according to emails obtained from UTSW through an open-record request. The emails don’t make clear how many doctors would be involved.

Inside UTSW, administrators balked.

“The 100 percent dedicated Parkland hospitalist language is not something we can abide by, it’s not how we are structured, and not something we can be in 100 percent compliance on,” Dr. Ethan Halm, chief of internal medicine, wrote in an email to colleagues. “These are UTSW faculty, not Parkland employees.”

He called the negotiations a yearly “cage match” and insisted that “most of the people who split their time [between hospitals] spend the vast majority of their time at Parkland.”

It’s unclear what happened as a result of the hospitalist negotiations. But over the next two years, both sides continued to battle over staffing, revenue and control. One UTSW official said in an internal email that a “nuclear option” be considered to fire an employee appearing to side with Parkland’s effort to regain some control.

Dr. Claus Roehrborn, chairman of the UTSW urology department, emailed other school leaders in December 2010 expressing frustration over a proposal to provide additional urologists at the hospital. Parkland officials should “find themselves a urologist,” he wrote.

“None of our faculty is truly all that interested in working with a group of nurse practitioners thoroughly disinterested in their job, being reprimanded by the administrators around every turn, and having no patient of their own to follow,” Roehrborn wrote. “Plus, I really need them to all work at Aston [a UTSW ambulatory care center] and Zale. Far better for our enterprise.”

In December 2011, his last month in office, Anderson described “the vitriol of some of our medical colleagues” toward his chief medical officer. The criticism, he wrote in the CMO’s job evaluation, “is directly in proportion to [the CMO’s] pressure for needed change in supervision (amount and quality).” He also said that the current patient safety problems “have to be owned by Parkland, not blamed on UTSW.”

UTSW officials refused to disclose to The News exactly how many of their physicians work at Parkland. After they initially declined to answer a series of questions late last year, they sent a follow-up statement saying they “categorically reject” the findings of the Chartis study and did not have input into them.

In the statement they acknowledged, “While several hundred of our faculty contribute to patient care and teaching at Parkland to some degree, more than two-thirds of care is provided by a much smaller subset (about 30 percent) of our faculty.”

That subset of doctors, they said, is “essentially dedicated to Parkland and do not have appreciable practice responsibilities elsewhere.”

Wildenthal, who left his presidential post in 2008, also said in a statement that “there was a steady, progressive, and dramatic increase in the number of excellent faculty physicians rendering care and supervision at Parkland” over the last two decades. That was made possible, he said, because of the school’s ability to recruit physicians who care for both Parkland patients and UTSW patients.
n the comprehensive report last February in which federal safety monitors detailed Parkland’s many problems, including culture, they stopped short of calling for an end to the UTSW staffing model.

However, in addressing one of the most troubled areas of the hospital, the psychiatric emergency room, they wrote:

“The contractual and financial relationship between Parkland and UTSW cannot be a barrier to the imperative that there must be consistent physician coverage by doctors who are interested and committed to … promoting a new model of care. The Hospital [should] look to non-UTSW physicians for consistent coverage,” if necessary.

Federal regulators also have not directly called for an overhaul of Parkland’s relationship with UTSW. David Wright, deputy regional administrator for CMS, said that fixing Parkland’s most pressing problems — rampant unsafe practices — is the agency’s top priority.

“It’s like trying to walk through a building full of clutter,” Wright said when asked whether CMS or monitors would pursue such an overhaul. “You’ve got to get rid of all the clutter before you can see all the cracks in the foundation.”

Still, federal overseers have been helping Parkland regain control in a variety of ways.

Parkland has persuaded UTSW to commit full-time faculty doctors to the understaffed psych ER, the scene of a series of violent incidents including the death of patient George Cornell following illegal restraints two years ago Sunday. Last week, Parkland struck a deal with a private psychiatric firm to manage all mental-health services.

The hospital has developed a system to document and audit supervision of residents across the hospital but it is still being tested. And, recently, the hospital has contracted with a private company of physician-specialists to staff its urgent care center, which relieves pressure on the main ER.

The hospital also has greater authority over an influential medical executive committee responsible for evaluating doctors and developing proper clinical practices. Committee members were previously appointed by UTSW division chairmen and stacked with faculty doctors who worked primarily at other hospitals. The committee now consists of doctors who work at Parkland.

In addition, Parkland is developing a quality improvement program to measure and monitor patient outcomes and employee performance across the hospital, as required by federal regulations.

Dr. Marty Makary, associate professor of surgery and public health at Johns Hopkins University, said a safety-centered culture is fostered by an administration that measures outcomes, seeks employee input and moves aggressively to fix problems.

“Everyone agrees they know what a healthy culture looks like. But it takes time to change a culture and a business model,” Makary told The News. “In terms of a business model, you can’t fix something if you can’t measure it.”

Health care systems also must be transparent with the public about their breakdowns, said Makary, author of the new book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.

“What you don’t want is a situation where leaks to the press lead to embarrassment,” he said. “That’s a system where there is detached management, and people wait for things to blow up and they do patchwork fixes in response.”

Dr. Laurence McCullough of Baylor College of Medicine in Houston is among the few researchers nationally to study the complex power relationships between hospitals and medical schools. He says there is a need for uniform ethical standards to help oversee the partnerships across the nation. Fostering transparency between such organizations is a crucial element, he said.

Otherwise, the quality of care can be corrupted by other forces, he said.

“You have to be anticipating ethical challenges so you can manage them,” said McCullough, a professor of medicine and medical ethics. “When an organization focuses on the bottom line, it loses sight of care. That’s a formula for trouble.”

What it will take to fix Parkland’s problems, the federal monitors said, is a cultural transformation. Everyone, no matter the job, must be focused first and foremost on patient safety.

In retrospect, Dr. Shulkin said he wishes he and other Parkland board members would have taken stronger actions to protect the hospital’s mostly low-income patients.

“I would blame the skill of the medical school in being able to avoid what we were asking of them, and our not putting them to task for it,” he said. “I would demand a lot more accountability from UTSW. I would demand an investment from UTSW, an emotional investment for responsibility for patient care” at Parkland.

Dallas County Judge Clay Jenkins said Parkland needs to revisit the findings of past consultants calling for improved doctor coverage of patients and more openness.

“Parkland must require that doctors are sufficiently present at the hospital and focused on patient care,” Jenkins said after The News shared its findings with him. All contracts and internal rules “must include improving and maintaining transparent safeguards.”

http://res.dallasnews.com/graphics/2013_02/parkland/#day4main

Parkland Memorial Hospital Psychiatry Department bringing in private operator to oversee operations

On February 8, 2013February 8, 2013 By A.P.In assault, Dallas, Dallas Morning News, Dallas Police Department, Debbie Branson, Green Oaks Hospital, Joe Householder, Medical City Dallas, Parkland Memorial Hospital, Parkland Memorial Hospital psychiatric emergency room, Robert Smith, sexual abuse, Texas, U.S. Centers for Medicare & Medicaid Services, Ut Southwestern Medical Center, Winfred ParnellLeave a comment

Parkland_HORIZ
Parkland police were summoned to the ninth-floor room of a woman who complained that a doctor grabbed one of her breasts and squeezed her neck “to the point that she had trouble breathing,” according to a police report. He asked “if she liked being choked.” green_oaks

Early yesterday afternoon, Parkland Memorial Hospital officials announced that they will place their troubled psychiatric services under the management of privately owned Green Oaks Hospital in Dallas.

News of the $1.1 million annual deal, posted on the hospital’s web site, is the culmination of confidential talks since November between the two parties. It marks a potentially significant shift for Parkland amid ongoing warnings from federal safety monitors that it needs to find a solution to persistent threats to psych patients.

The media statement said Parkland’s board of managers approved the deal — with member Dr. Winfred Parnell abstaining — during a Wednesday night meeting. Prior to the meeting, the hospital didn’t follow its usual practice of posting an advance meeting agenda and information packet on its website alerting the public.

Green Oaks, owned by Nashville, Tenn.-based HCA, provides a range of mental-health care from inpatient to ER services at its site near the Medical City Dallas Hospital campus. It also runs outpatient clinics or other facilities in Dallas, McKinney, Plano and Irving.

At Parkland, Green Oaks will provide an administrative director, nursing director, performance improvement director and a community liaison for psychiatric services, the statement said. Joe Householder, a spokesman for Parkland, told me that the deal “in no way alters the relationship/contract with” UT Southwestern Medical Center. UTSW, Parkland’s academic affiliate, is paid to supply faculty physicians to provide clinical care.

“The objective of this agreement is to capitalize on the improvements we’ve already made, leverage the expertise of the leadership team we will place under contract, and continue moving behavioral health services at Parkland forward,” board chairwoman Debbie Branson said in the statement.

Robert Smith, Parkland’s interim CEO, said “behavioral health management is a core competency for Green Oaks,” adding it will help Parkland meet critical safety mandates imposed by the U.S. Centers for Medicare & Medicaid Services.

Our investigation into Parkland’s dangerous psychiatric operations — the scene of numerous patient-rights violations and a string of questionable deaths in recent years — triggered rare federal action in late 2011, placing the public safety-net hospital in its existing onsite monitoring program.

Since then problems have kept surfacing, however, despite efforts at reform by Parkland officials, including renovations to psych units and an overhaul of the staff. Onsite safety monitors recently said that the mental-health system “continues to be challenged with potential or actual patient safety events and issues,” as well as the “lack of a well-coordinated management team, particularly in the [psych ER].”

Last month, regulators told The News that major changes were in store for mental-health services but did not provide details. The hospital has until the end of April to prove to CMS that it can comply with federal safety regulations or lose hundreds of millions in federal health care funding.

Green Oaks’ corporate parent, HCA, also owns Medical City Dallas, and Parkland board member Parnell is a member of its staff. HCA calls itself “the nation’s leading provider of healthcare services.” Its website says the company has “approximately 163 hospitals and 109 freestanding surgery centers in 20 states and England.”

Green Oaks opened in 1983 “with the goal of becoming the premier psychiatric treatment facility in North Texas,” its website says. It provides mental health and chemical dependency treatment for adolescents, adults and seniors.

It’s unclear why Wednesday’s meeting agenda wasn’t posted on Parkland’s website. Householder, Parkland’s spokesperson, said the meeting was “publicly advertised” through postings at the Dallas County administration building and at the hospital. ”The board met in public session and reviewed the contract,” he said.

http://www.dallasnews.com/news/local-news/20130207-parkland-to-bring-in-private-operator-to-oversee-troubled-psych-services.ece

Alleged Sexual Abuse of Patients in Parkland Memorial Hospital Psychiatric Emergency Room

On February 5, 2013 By A.P.In Annie Molinaro, assault, Brooks Egerton, Carrie Williams, Cornelius Torrence, Crime, Dallas, Dallas Morning News, Darlene Griffin, Human Behavior, Jermaine Douglas, Jon David Schoen, Larae Huycke, Levie Smith Jr., Parkland Memorial Hospital, Parkland Memorial Hospital psychiatric emergency room, Robert Meskunas, sexual abuse, Texas, Texas Department of State Health Services, Vernell BrownLeave a comment

douglas

Caregivers in Parkland Memorial Hospital’s psychiatric emergency room suspected that their new patient had been drugged and raped. She cried, talked nonsensically and asked for a genital exam.

Levie Smith Jr. saw a fellow aide — a man not qualified to do such an exam — take the patient to a bathroom and close the door behind them. Smith alerted a nurse, who walked across the unit and opened the door.

“What the — !” the nurse cried out, his face turning “red as a beet,” Smith said. A few minutes later, the nurse told Smith what he had seen: The patient was bent over, with her pants down around her ankles. The aide, Jermaine Douglas, had his face “a few inches away from her bottom.”

Parkland police investigated the October 2010 incident one year later, their records show. Officially, they concluded that the only person who behaved inappropriately was the patient. The Texas Department of State Health Services also investigated a year later, based on a Dallas Morning News inquiry. “The state cited Parkland for failing to report the alleged sexual abuse,” hospital officials said, although DSHS did not verify patient harm.

Douglas, who remains on duty in the psych ER, denied wrongdoing to police and health care regulators. He declined to be interviewed for this story. His personnel records, which Parkland released in response to a public information request, show no sign that he has ever been disciplined for misconduct with patients.

Contradictions abound in official records on the case, raising questions about what really happened and whether Parkland responded properly. Here’s how events unfolded, according to regulators’ records, police reports and eyewitness accounts:

The nurse who interrupted the bathroom incident promptly called the psych ER manager, Vernell Brown, who was away from the unit at the time. Brown instructed the nurse not to file an electronic patient safety report. Employees are supposed to submit such a report as soon as possible after witnessing potential harm.

Instead, on Brown’s orders, the nurse made a handwritten account of what he had seen: Douglas escorted the patient to the bathroom and disappeared for “several minutes.” When the nurse opened the bathroom door, Douglas ran toward him, “was startled and stuttered, ‘I I was a checking her bruises.’”

A patient safety report was later made in Brown’s name. Dated the day after the incident, it said the patient “exposed herself to male staff. Staff stated while obtaining a urine sample from pt [patient] she pulled down her underwear wanting to show staff a bruise on her buttock.”

The report made no mention of what Smith and the nurse, Robert Meskunas, said they saw. A legally required internal safety investigation did not occur.

Smith, who quit Parkland in late 2011 and filed a federal discrimination complaint, told The News that Douglas had a habit of standing near slightly open bathroom doors while female patients provided urine samples. He said he had warned unit manager Brown about this. But Brown and Douglas were friends, Smith said, and no change in behavior resulted.

Brown now works at a desk job outside the psych ER. He did not respond to interview requests from The News. He told regulators that “Parkland police talked to the patient,” who “denied the incident.”

But none of the officers named in records obtained by The News reported interviewing the patient.

Three Parkland police officers spoke separately over time to Meskunas, the nurse who walked in on the aide and the patient. Only one, Detective Jon David Schoen, created an investigative record.

Another detective, Darlene Griffin, said Meskunas “adamantly denied” seeing anything inappropriate in the bathroom. But Griffin could not remember when their conversation occurred, did not document it at the time and took “no further actions.”

The third officer, Cornelius Torrence, said Meskunas complained about Douglas inappropriately “being inside the restroom” with a patient. “There was more than just one incident he was upset about,” the officer said, according to records. But he viewed this as an “administrative” matter and didn’t investigate further. Like Griffin, he did not remember when the conversation occurred nor document it at the time. None of the officers agreed to be interviewed.

In a recent statement to The News, Parkland claimed its police investigated the case twice, although it released only one investigative record. The statement also repeated the claim that Meskunas had recanted and told police “nothing inappropriate had occurred.”

Smith, after being shown a copy of the Parkland statement, said: “They’re trying to cover it up.” Hospital officials denied any “effort to suppress or overlook” any sex abuse allegations.

Meskunas resigned last month and declined to comment. But he told Schoen that the recantation claim was incorrect, according to an audio recording of their conversation obtained by The News.

During the November 2011 recorded conversation, Meskunas asked the detective why he had not tried to speak with the patient. “Because right now she’s not a victim,” Schoen said. “You don’t want to create a problem where there’s not one.”

Schoen also told Meskunas that he’d learned Douglas had a history of similar misconduct and had “actually been suspended for it before.”

“The police department would love to do something about it,” Schoen said. But “because it was handled administratively the first time, there’s no criminal offense.” The detective did not explain what he meant by that.

When Meskunas said it was “so wrong” for Douglas to avoid charges and keep his job, the detective replied: “I don’t disagree with you a bit.”

Schoen said he and his supervisor “tried to come up with a criminal offense that we could prove, and there’s not one” without an allegation of physical contact. They also lacked proof, he said, that Douglas’ intention was sexual gratification.

“Sexual gratification?” Meskunas fired back. “He had her bent over like a stripper with his face all in her business.”

Parkland’s website says sexual abuse “can be verbal, visual or anything that forces a person into unwanted sexual contact or attention.” According to a brochure distributed by the hospital, it includes failure to respect people’s privacy in bathrooms.

Schoen told the nurse he was “sorry that we couldn’t do something that kind of satisfied you more. I hope you understand the predicament that we’re in as a police department.”

Then the detective offered some parting advice.

“If it happens again,” he said, “you don’t have a duty to go through your chain of command to report a criminal offense. You can go straight to the police department, especially if you can articulate why you believe that it would be covered up if you went through your chain of command.”

Smith told The News that Parkland has “some great officers” who sincerely try to carry out their duties. But “they are puppets.”

“The police are there to protect the hospital,” Smith said. “It’s not about the patients.”

After interrupting the bathroom incident, Meskunas asked fellow nurse Annie Molinaro to interview the patient. Government health regulators questioned Molinaro about this during their October 2011 investigation

She recalled that the patient, when asked “if everything was OK,” said that Douglas had been in the bathroom with her and “I tried to show him.” As they spoke, Molinaro told regulators, the patient began to pull down her pants again in the dayroom — a large space in the middle of the unit where most patients spend time.

Molinaro’s account, as described in the government’s investigative report, gives no more details of what the patient said. When Schoen, the Parkland detective, questioned Molinaro two weeks later, he reported her saying “that the patient denied any inappropriate conduct by the suspect.”

In the tape-recorded conversation with Schoen, Meskunas said Molinaro told him on the day of the incident that the patient spoke of “doing what she was told.” He added that “she was very confused,” and “she was embarrassed.”

Meskunas alleged that Molinaro was trying to protect the reputation of Brown, the psych unit manager, because she was having sex with him.

“You’re not the only person that has said that,” Schoen responded. “You and I both know the relationship between Vernell and Annie, but I can’t prove that that affected her judgment or her statement.”

Molinaro is the only person interviewed by regulators or police who said that the patient tried to pull her pants down in the dayroom. She did not respond to interview requests.

Smith said he did not see this and doubted whether it occurred. If it did happen, he said, then Molinaro violated the patient’s privacy by questioning her in the presence of other patients.

According to the government’s report, Douglas said he told the patient to wait outside the bathroom while he picked up trash inside. She followed him in, began asking questions and insisted on showing him her bruises. The door was partially open. “All of a sudden the patient dropped her pants,” he is quoted as saying.

Douglas told regulators that he did not touch the woman. When they asked if he sexually abused her, he said he was turning away from her when Meskunas walked in. He “did not look at the bruises.”

Two weeks later, when Schoen interviewed Douglas, the story seemed to change. “He stated that at no time was he inside the bathroom with the patient,” according to the Parkland detective’s report.

Smith told The News that account was “a lie.”

“I saw it,” he added. “He went in after her.”

Schoen’s official report on the bathroom incident concluded: “While it does appear that the patient behaved inappropriately, there does not appear to be any evidence that a criminal offense was committed.”

The patient seemed to have been adequately protected, the report said. Yet it added: “A recommendation was made to review the policies and procedures for staff dealing with patients and make appropriate changes to safeguard the patients and prevent unintentional inappropriate activities between staff and patients.”

In its Jan. 22 statement to The News, Parkland said, “education was conducted in the psychiatric ER regarding incident reporting and appropriate procedures in dealing with patients of the opposite sex.”

The Department of State Health Services, which licenses Texas hospitals, produced the regulatory report for the U.S. Centers for Medicare & Medicaid Services. “There was no indication” of sexual abuse found when interviewing Parkland employees and reviewing hospital records, the report concluded.

But it noted that “some of the information received by the surveyor conflicted.” Interviews and records summarized in the report repeatedly point to possible misconduct.

DSHS spokeswoman Carrie Williams declined to comment, saying that investigative details are confidential. Texas law prohibits public release of such reports. The News obtained its copy from federal health officials, who blacked out the names of most Parkland employees and the patient.

Williams did say that Parkland’s failure to contact DSHS, and the resulting delay in investigating, “made it very difficult” for regulators to determine what happened.

Parkland learned new information during the regulatory investigation that led to Douglas’ suspension, the DSHS report says.

The new information isn’t described in the government report or in personnel records that Parkland released to The News. But Smith said he overheard a government investigator, after interviewing him, make a telephone call urging Douglas’ immediate removal from duty.

Parkland records show that Douglas was suspended that day, pending an internal investigation of “allegations of inappropriate behavior with a patient.” The records don’t show why he was put back on duty.

The Parkland detective, during the recorded conversation, said the hospital’s top psychiatric official was “frankly disappointed that she had to put him [Douglas] back on the schedule.”

That executive, Larae Huycke, was new to her management job at the time. Smith said Huycke initially told subordinates she planned to fire Douglas even if he wasn’t criminally charged. But she didn’t.

“Larae told me, ‘Levie, if this situation blows up, it could cause the psych ER to close,’” Smith told The News. He understood Huycke to mean that the unit couldn’t survive a confirmation of sexual misconduct, given what had already happened.

In late 2011, members of Parkland’s governing board revealed that they had considered closing the unit. The News had reported throughout 2011 on widespread problems in Parkland’s psychiatric ER, including the finding by regulators that psych aides had illegally restrained a patient shortly before he died. (Parkland police did not investigate that case.) The regulators went on to identify hospital-wide problems and install safety monitors.

Huycke herself was later accused of using an illegal chokehold on another psych ER patient. Parkland police quickly cleared her. But after a few weeks, the hospital said she would step down and return to full-time nursing work. Huycke hung up when a reporter recently called.

After the bathroom incident, Smith said, he was pressured to distance himself from Meskunas, the nurse who reported it. Fed up, Smith eventually quit and filed a complaint with the U.S. Equal Employment Opportunity Commission. In it, Smith said his boss, Brown, had referred to Meskunas as a “white boy” and called another nurse who reported patient safety issues a “white bitch.”

The federal agency dismissed Smith’s complaint without certifying Parkland had complied with the law. The hospital successfully contested Smith’s unemployment compensation claim.

Smith recalled that he had once reminded Brown about Douglas’ habit of lingering near female patients as they urinated. He said Brown responded: “Let him hang himself. If he’s done it once, he’ll do it again.”

PARKLAND STAFF INVOLVED IN PSYCH ER CASE
In October 2010, a nurse reported witnessing the sexual abuse of a psychiatric patient in a Parkland Memorial Hospital bathroom. Regulators and Parkland police who investigated a year later did not substantiate the allegation. Here is a snapshot of events. All job titles are those employees held at the time.

THE PATIENT
Her identity has not been released, and she was never interviewed by police or health care regulators. Hospital workers suspected she had been drugged and raped before arriving at the psychiatric ER.

JERMAINE DOUGLAS
Psych ER aide
He escorted the patient to a bathroom, where she pulled her pants down to her ankles. He denies any wrongdoing.

LEVIE SMITH JR.
Psych ER aide
He alerted a nurse that Douglas had gone into the bathroom with the patient.

ROBERT MESKUNAS
Psych ER nurse
He opened the bathroom door and reported finding the patient, pants down and bent over, with Douglas’ face near her crotch.

VERNELL BROWN
Psych ER unit manager
He received a phone call from Meskunas about the incident and told him not to file a patient-safety report.

ANNIE MOLINARO
Psych ER nurse
At Meskunas’ request, she interviewed the patient shortly after the incident. He said Molinaro told him the patient spoke of “doing what she was told.” But Parkland police said she later claimed the patient “denied any inappropriate conduct” by Douglas. There’s no record that Molinaro made such a claim to government regulators.

DARLENE GRIFFIN
Parkland police detective
She said Meskunas “adamantly denied” seeing anything inappropriate in the bathroom. She didn’t document the conversation at the time.

CORNELIUS TORRENCE
Parkland police corporal
He spoke separately with Meskunas and said the nurse complained about Douglas being inappropriately “inside the restroom” with the patient. He didn’t document the conversation at the time.

JOHN DAVID SCHOEN
Parkland police detective
He conducted the only documented criminal investigation of the incident. He did not speak to the patient but concluded officially that she “behaved inappropriately” and no crime was committed.

LARAE HUYCKE
Psychiatric executive
Smith said she vowed to fire Douglas even if police filed no charges. Schoen said privately that she was “disappointed that she had to put him back on the schedule.”

SOURCES: U.S. Centers for Medicare & Medicaid Services; Parkland; Dallas Morning News research

http://res.dallasnews.com/graphics/2013_02/parkland/#day3main

Parkland Memorial Hospital nurse accused of sexually assaulting patient

On February 4, 2013 By A.P.In assault, Brooks Egerton, Cesar Menchaca, Crime, Dallas, Dallas Morning News, Dallas Police Department, David Roth, Delesia Lacy, El Centro College, Human Behavior, Mary Eagen, Nurses Now International, Parkland Memorial Hospital, Rubin Crain, sexual abuse, Texas, Texas Board of Nursing, Texas Department of State Health Services1 Comment

menchaca-s

Of all the sex-abuse suspects whose names Parkland Memorial Hospital has disclosed, only one is known to have lost his caregiver’s license because of the allegations. And he got it back after two months.

The Texas Board of Nursing revoked Cesar Menchaca’s license in September after finding that he fondled a hospitalized jail inmate — a man who was shackled to a bed and was not his patient. The Texas agency that licenses hospitals came to a similar conclusion and cited it as one reason for fining Parkland a record $1 million last summer.

“His actions were not acceptable practice for our clinicians,” the hospital said in a Jan. 22 statement to The Dallas Morning News. “Chief Nursing Officer Mary Eagen demanded his association with Parkland be terminated.”

But Parkland police called the abuse allegation unfounded. A detective reached this conclusion after interviewing Eagen’s subordinates and the patient, according to police records.

“He said the investigation was terminated because I used the word ‘groin’ instead of ‘penis’” when first describing the incident, inmate Rubin Crain told The News. (The newspaper generally doesn’t name alleged sexual abuse victims, but Crain volunteered to be identified.) Police records do show that the detective considered this a key reason for closing the case.

Menchaca did not respond to interview requests. The Parkland contractor that employed him said he was falsely accused.

The 35-year-old man went to work at Parkland in late 2011, as federally installed safety monitors began documenting the public hospital’s many dangers. One was that Parkland had simply failed to hire enough caregivers. The shortage soon worsened, as the monitors’ scrutiny of patient care led to firings and resignations.

Menchaca was part of the crisis-control plan. He worked for a company called Nurses Now International, which brought nurses from Mexico to Dallas for additional training at El Centro College and then placed them in temporary jobs at Texas hospitals.

The nurse came with a resume listing several prior employers in Saltillo, a city about three hours’ drive from the Texas border. He had one glowing letter of reference, although it was eight years old. On his first attempt to get a Texas nursing license, he flunked the exam, doing particularly poorly in areas where authorities have repeatedly faulted Parkland: safety and infection control.

But Menchaca passed on the second try. Parkland put him to work as part of its “float pool,” which dispatches nurses to areas that need extra help.

One of those areas was the seventh floor, where patients with a variety of ailments are treated. One of those patients, beginning last April, was Crain. He had a severe infection stemming from a finger injury.

Like other Dallas County inmates who become Parkland patients, Crain was not only chained to his bed but also under guard by a sheriff’s officer. His long history of criminal convictions includes everything from marijuana possession to robbery.

That history, Crain knows, makes people inclined to doubt him, and he did not seek out news coverage. But numerous government employees — both investigators and witnesses, including a guard — have lent credence to his complaints about Menchaca.

The state nursing board, for example, declared that Menchaca twice “fondled the penis and testicles” of Crain, which “exposed the patient unnecessarily to the risk of mental and physical harm.” It reached this conclusion after the nurse failed to respond to written allegations.

oth molestations occurred in the middle of the night, Crain said, under the pretense that the nurse was checking his lymph nodes and pulses. He recalled that the first time, in late April, he tried to alert his guard — who was sleeping and “told me to go back to sleep.” Crain did nothing further at the time, fearing “no one would believe me.”

A report by two investigators from the Department of State Health Services, the hospital licensing agency, describes what happened during the second incident:

Crain’s regular nurse began a 30-minute break about 2 a.m. on May 3. She asked Menchaca to respond if any of her patients called for help. Menchaca — without being summoned — quickly went to see Crain in Room 716. A different guard was on duty, and she was awake.

Menchaca immediately violated protocol in two ways, guard Delesia Lacy told the DSHS investigators: He did not put on a “contact isolation gown,” which is designed to prevent the spread of infection, and he closed the privacy curtains around the patient’s bed, preventing her from maintaining required visual contact with the inmate.

The nurse “spoke to the patient in medical terms for a minute, and then it became very quiet,” according to Lacy. He “was behind the curtain for 10 to 15 minutes.”

Lacy had “worked at the hospital for several years and never seen a nurse come in at 2 a.m. and do an assessment on an inmate,” the DSHS report added. She “stated she believed something happened. It was just too strange.”

Crain told her after Menchaca left that he’d been molested, and she urged him to speak with his regular nurse. That nurse and a supervisor told DSHS that Menchaca had no business conducting a full physical assessment and that he had not documented anything about it in the medical record.

When state investigators interviewed Menchaca, he “changed the subject frequently and required redirection.” When asked why he didn’t document his exam, he “did not answer the question.”

Menchaca wrote a statement for Parkland police saying that Crain had been suffering from swollen lymph nodes and groin pain. Also, “I verified the status of his handcuffs that might compromise his circulation.”

He told the hospital detective that the medical record lacked documentation “because he usually gives the patient’s nurse a verbal report,” according to a police report. Menchaca claimed he went to Crain’s room without being called “because he does not want to be accused of not taking care of” patients. And he said he pulled the privacy curtain “because the [sheriff’s] officer was female.” There’s no indication in the police report that the suspect explained his failure to use the isolation gown.

Before federal safety monitors were installed at Parkland, the hospital repeatedly broke the law by not reporting abuse allegations to DSHS. Reporting has improved since then, the state agency says, although the hospital took nine days longer than allowed to disclose the Menchaca matter. DSHS, which hasn’t always interviewed alleged victims, then spoke with Crain.

State investigators substantiated the abuse allegation, saying Parkland failed to protect his “physical and emotional health.” But the criminal case was another dead end.

Menchaca was suspended on the day of the incident and fired the next. At the time of termination, Parkland police were “considering a referral to the district attorney,” says a hospital record cited in the DSHS report.

But the Parkland detective soon declared “there was no basis” for a charge of assault — which Texas law defines as including offensive physical contact. Generally speaking, assault is a misdemeanor. It’s a felony if sexual penetration or serious injury occurs, or if the contact causes mental injury to a disabled person.

In justifying his conclusion, the detective cited both Crain’s initial description of the unwanted touching and statements by two nurses. They thought Menchaca shouldn’t have been in Crain’s room, he wrote, “but they said if he was checking” what he claimed he was, then his actions “would be one way to check.”

Menchaca’s employer takes a position similar to that of the police.

“It’s a total fabrication,” Nurses Now vice chairman David Roth said of the abuse complaint. In a September interview with The News, he laughingly mocked as “incredible” the idea that abuse could occur with a jailer nearby.

Menchaca didn’t initially respond to nursing board allegations because they were mailed to his apartment near Parkland after he’d moved out, Roth said. “He’s never had his day in court on that,” said the executive, whose company has offices in Kentucky and Mexico.

Company lawyers have since persuaded the nursing board to reconsider the matter and, at least for now, to restore Menchaca’s license. It isn’t clear when the board will decide his fate.

Menchaca recently admitted to the board that he failed to report his new address. It was in Houston, where Nurses Now sent him to work at Harris Health — another public hospital system.

Nurses Now did not disclose why he was fired in Dallas, Harris Health spokeswoman Melinda Muse said. Harris Health fired him in September, shortly after he lost his nursing license, and has refused to take him back.

Where is Menchaca now? Nurses Now representatives won’t say.

http://res.dallasnews.com/graphics/2013_02/parkland/#day1main

Choking allegations against doctor began at Parkland Memorial Hospital

On February 4, 2013 By A.P.In Alireza Atef-Zafarmand, assault, Brooks Egerton, Crime, Dallas, Dallas Morning News, Dallas Nephrology Associates, Dallas Police Department, Dallas VA Medical Center, Greg Fitz, Human Behavior, Leah Hurley, Parkland Memorial Hospital, Paul Nix, sexual abuse, Texas, Ut Southwestern Medical Center, Vernon Mullen1 Comment

zafarmand-s

By BROOKS EGERTON
Staff Writer
begerton@dallasnews.com

You look like the movie star Julia Roberts, the doctor told the hospital patient. She told police that he urged her to act — to pretend she “was sedated and begging him not to leave.”

Then the doctor grabbed one of her breasts and squeezed her neck “to the point that she had trouble breathing,” according to a police report. He asked “if she liked being choked.”

When Dr. Alireza Atef-Zafarmand came back to her room later that day in 2006, the woman called a nurse for help. The nurse called Parkland Memorial Hospital’s police force. Paul Nix was one of the officers who responded.

“She seemed very credible” and “very rattled,” said Nix, who recalled details of the matter as soon as The Dallas Morning News made a brief, general inquiry. “I believed her that something went wrong.”

But the police case — like many other sexual abuse allegations at Parkland reviewed by The News — went nowhere. “Eyewitnesses made statements that the accusations of choking and groping were untrue,” hospital leaders said in a written statement last month.

Police reports released by Parkland, however, do not support that claim. They refer to a single witness who was simply unable to confirm anything besides verbal contact. And Nix, who left Parkland in 2007, questioned whether there was a witness.

Parkland’s statement denied mishandling the police case, saying there was no effort “to suppress or overlook incidents of alleged assault.” However, it said Atef-Zafarmand committed verbal misconduct and that the hospital failed to discipline him for that.

“The evidence suggests he should have been promptly removed from Parkland,” the statement said. “We are confident that should a similar incident arise today, the offending physician would quickly be removed.”

Atef-Zafarmand told The News that he never touched the patient but did tell her she looked like the movie star.

“I asked her, ‘Do you have the same talent?’” the 47-year-old kidney specialist said. “A lot of people, they take it as a compliment.”

Atef-Zafarmand said he first spoke to the woman in a hallway and followed her to her ninth-floor room. She wasn’t his patient, he said, and he didn’t know her name or reason for hospitalization.

In the ensuing months, his medical superiors disciplined him for several incidents of misconduct that occurred outside the public hospital. Yet Parkland and its academic affiliate, UT Southwestern Medical Center, still let Atef-Zafarmand graduate from his training program in 2007.

The UTSW faculty member who oversaw the training program said Atef-Zafarmand was going to be expelled a few months before graduation, according to university records. But the faculty member was overruled by Dr. Greg Fitz, who has since become dean of UTSW’s medical school.

After Atef-Zafarmand graduated, some UTSW officials endorsed him to Dallas-area private hospitals. For example, the man who issued the expulsion warning, Dr. Biff Palmer, ranked him “excellent” in all categories, including ethical conduct.

Fitz and Palmer declined interview requests. In a written statement, UTSW said it never received reports from Parkland or elsewhere that Atef-Zafarmand “acted in a sexually inappropriate manner with any patient.” It added: “Based on the facts available at the time, UTSW acted appropriately.”

Since Atef-Zafarmand began working in private practice, two other women have told Dallas police that he choked and sexually assaulted them. He did not respond to questions about these allegations.

None of the cases has led to criminal charges or discipline by the Texas Medical Board, the state agency that licenses doctors.

After attending medical school in his native Iran, Atef-Zafarmand came to Dallas in 2004 for a three-year fellowship in kidney disease. He spent much of his time at Parkland, along with about 1,000 other doctors in postgraduate training. They reported to UTSW faculty members and worked under a Parkland contract that says harassment, abuse and disrespectful or unprofessional conduct “would be cause for immediate termination.”

But the consequences for Atef-Zafarmand fell far short of that mark. UTSW records show he was counseled three times in the first five months of his fellowship for “poor work ethic,” showing disrespect to a supervisor and “unprofessional conduct directed toward a patient.”

Trouble surfaced again in January 2006. Late one night, Parkland police got a call for help from the ninth floor. A patrol officer interviewed the female patient and soon notified Nix, the sergeant on duty. Nix re-interviewed the woman and said he heard none of the shifting, dreamlike tales that heavily medicated people sometimes tell. Nor did he hear any vague allegations or threats of lawsuit.

“She was very detailed, very specific,” said Nix, who is now chief deputy to the sheriff of Hardeman County, northwest of Dallas. “She never wavered from the story.”

Police records show that Nix consulted one of the patient’s physicians, who also found her to be credible. She “was not on any medications that would normally cause one to hallucinate,” the physician was quoted as saying.

Nix recalled alerting a lieutenant at home around midnight. A higher-level supervisor also was notified, “and I want to say they called Dr. [Ron] Anderson,” Parkland’s chief executive at the time. “It was a big brouhaha.”

Smith Lawrence, then Parkland’s police chief, said he didn’t remember the case but did recall investigating other sexual abuse allegations around the same time. “You’d catch hell for that,” he said, referring to investigations of doctors.

Lawrence retired in 2008, when he was in his early 70s, and declined to be interviewed in detail. “When I left Parkland, I made it my last mission to leave all that stuff behind,” he said.

He suggested that The News contact CaSandra Williams, who was his top aide and now heads the police department at Texas Health Presbyterian Hospital Dallas. She did not respond to interview requests. Parkland has retained responsibility for her officer’s license, state records show. It would not say why.

Atef-Zafarmand said police questioned him the day after the patient complained. “That’s impossible,” he recalled telling them. “There must be a mistake.”

An officer took him to the patient’s room, and she identified him as her attacker. He said she told him, “When you talked to me, I felt that something is getting to my brain, and I knew that you were doing it.”

The woman seemed “scared to death,” Atef-Zafarmand said. “It was a very disturbing situation.”

He said police never asked him to take a lie-detector test.

“That would have been an option,” Nix said, because Parkland frequently dealt with a contracted polygraph operator, primarily when evaluating job candidates. He said he was not involved in the case after the first night and knew no details of the investigation.

Not seeking a polygraph sounds odd, said Fred Price, who was a Parkland police detective until the year before the incident and is now a Dallas County courtroom bailiff. “They used the snot out of that polygraph when I worked there,” he said.

Atef-Zafarmand said Parkland officials told him that the patient had previously been hospitalized for psychiatric problems. Legal experts say that releasing such information could violate her privacy rights under HIPAA, the Health Information Portability and Accountability Act.

A senior hospital executive, Atef-Zafarmand said, apologized for the necessity of the police investigation and told him officials believed he was innocent. The executive also warned him not to make unnecessary remarks.

“That is one of my personal problems,” Atef-Zafarmand said. “I do a lot of unnecessary things.”

Atef-Zafarmand insisted that witnesses would have seen him if he had touched the patient. There was a second patient in the room, he said, and she had a relative visiting.

Statements from Parkland officials and hospital records contradict each other on this point. For more than a year, the hospital had refused to release police records on the case. After it finally did so on Jan. 18, officials said they were sharing copies of all police reports.

Those reports made no mention of eyewitnesses. But a Parkland statement to The News, four days later, said police had dropped the case after eyewitnesses said the assault allegation was “untrue.”

After The News asked Parkland whether it had released all records, the hospital produced a one-page document that it said had been accidentally withheld. It was labeled the “final page” of the police file and referred to a single, unnamed witness. Nothing else in the file references a witness.

This witness, described as the patient’s roommate, heard Atef-Zafarmand’s “Julia Roberts” remark and role-playing request, according to the one-page document. But “roommate could not provide any additional information to confirm the complainant’s allegation of physical contact.” There is no reference to anyone calling the allegation “untrue.”

There are other discrepancies. The “reporting officer” box on the form was left blank, meaning no one took responsibility for writing the final page. Nix said he could not remember ever seeing such an omission on a Parkland police report.

“That’s very stinky,” said Nix, who reviewed the police file released to The News.

Equally strange, he said, is the final page’s reference to a roommate. He said the patient didn’t have one when Atef-Zafarmand first visited her. She got one later that day. “[She] now has a roommate and that also makes her feel better,” says Nix’s contemporaneous police report.

That corresponds to the other records Parkland initially released. The group of reports begins with an overview, written by the first responder that makes no mention of anyone having information except the patient and the nurse she’d asked for help.

The final page said it “appears the conduct was not appropriate, but not illegal in any manner.” The criminal case was closed on Jan. 29, 2006, one day after Nix’s report.

Police records don’t show that an investigator was ever assigned to the case, although they do name one officer who began interviewing Atef-Zafarmand. That officer was Kenneth Cheatle, then a lieutenant and now Parkland’s police chief. There are no reports in the file from him.

Parkland would not give The News written statements from the patient, roommate or suspect, even though the newspaper agreed to have all patient-identifying information blacked out.

“The whole investigation,” Nix said, “is completely missing.”

A few months after the choking report, Atef-Zafarmand faced trouble again. These accusations came from another hospital where UTSW doctors work, the Dallas VA Medical Center. He was moonlighting in its urgent care center, earning extra money while doing kidney research.

This time Atef-Zafarmand was accused of harassing female co-workers — other doctors in residency training and at least one hospital employee. VA officials terminated him and notified UTSW, according to medical center records that the Texas attorney general ordered released to The News. (UTSW tried to withhold the records, saying they belonged to a medical committee that needed secrecy to promote frank evaluation of trainees.)

“Dr. Atef made sexually suggestive remarks,” said a June 2006 letter from the VA to the physician’s lawyer, “and, in every instance, attempted to or did in fact make inappropriate physical contact with the residents under the guise of a ‘study’ that he was doing.”

When top UTSW lawyer Leah Hurley released the VA correspondence, she said she had produced all public records related to sexual misconduct allegations against Atef-Zafarmand. The News twice responded that records appeared to be missing, leading Hurley each time to disclose more documents.

These documents included material showing that UTSW had placed the doctor on probation because of the VA matter. In doing so, his fellowship supervisor warned that “any other allegations of this nature or similar in nature would not be tolerated and would be grounds for dismissal.”

Atef-Zafarmand said UTSW helped replace the VA income by giving him moonlighting work at Parkland and the university’s own St. Paul hospital.

In late 2006, he submitted a required annual report to the Texas Medical Board. On it, according to records released by Parkland, he said he had not been disciplined by any health-care entity. He signed his name next to a warning that it’s a crime “to submit a false or misleading statement to a governmental agency.”

Atef-Zafarmand did not respond to recent News questions about the submission. But earlier, he did tell the newspaper he understood that adverse actions must be reported to the medical board.

More trouble surfaced in early 2007. Records say Atef-Zafarmand approached a young radiology technician in the gift shop of UTSW’s other hospital, Zale Lipshy. He asked if she was interested in psychiatry and invited her to participate in a study. She agreed and went with him to his nearby office.
“You asked her a series of questions such as ‘Can you act like someone else?’” says a reprimand letter that UTSW gave Atef-Zafarmand. “You asked her to take deep breaths and to picture herself in a place that made her feel completely relaxed. You moved her arms and legs to make sure that she was completely relaxed.

“She reports that she ultimately fell to the floor.”

According to the letter, Atef-Zafarmand never obtained UTSW’s permission to conduct such research or the young woman’s written consent to participate. Federal law generally requires researchers to meet both conditions.

The letter notes similarities between the incident and the VA findings. It also mentions a prior complaint at Parkland, without details.

And it raises the possibility of other incidents: “Although we have not been able to verify this information, we have received reports from at least one woman unaffiliated with UT Southwestern that you approached her at a local bar and made similar statements” to those made to the radiology technician.

Atef-Zafarmand’s conduct at Parkland, the VA and in his office was “unprofessional and will not be tolerated,” the letter says. He was warned not to contact the technician, not to invite anyone to his office for research participation, and “not to engage in the activity of hypnotizing anyone while on the UT Southwestern campus.”

The letter says Atef-Zafarmand denied asking the woman to take part in a study. “You indicated that you had a personal interest” in her and “had been very straightforward with her regarding your intentions.”

That’s absurd, the woman told The News. Roxann Neal said the doctor approached her again, in her work area, to ask that she leave with him. He said he wanted to “buy a gift for me to tell me thank you for helping” with the study.

Neal recalled realizing early in their first encounter “that something was wrong,” leading her “to play along and get out of there.” She said the state medical board should strip Atef-Zafarmand of his license. “I don’t think he has the morals that a physician needs to have.”

Texas law generally prevents the medical board from revealing whether it has received complaints about a doctor.

Atef-Zafarmand did not appeal the reprimand at the time but later sought to minimize it and, in 2010, tried unsuccessfully to have it rescinded, other UTSW records say. An email from Atef-Zafarmand said the woman “had no concern about issues such as sexual harassment” and mistakenly suspected he was conducting research not related to kidneys.

The email attributed these statements to Vernon Mullen, who headed UTSW’s office of equal opportunity and minority affairs. He “told me that the issue was a misunderstanding and there was nothing to worry about,” Atef-Zafarmand wrote.

Mullen retired in 2011, UTSW said. He did not respond to an interview request.

Atef-Zafarmand told The News he never harassed or engaged in sexual misconduct with anyone and never touched fellow trainees. He said he did invite some of them to try breathing exercises that promote relaxation but did not bother those who declined.

He also said he had tried for several months, without success, to obtain all of UTSW’s records about him.

“I am talking to you right now as a victim, not as the person who did the offense,” Atef-Zafarmand said in an interview late last year. “I think that the way they have it structured over there, when you get on the spot on something, they ruin your brain.”

That, he said, is why he decided to speak with the newspaper. “That’s why when you called me about abuse, I said, ‘Yeah, there is abuse, but not what you think.’ I was the abused one.”

He said his experiences at Parkland and UTSW “changed my personality,” leading him to fear being open with hospital co-workers and unwilling to date them.

Atef-Zafarmand finished his training in June 2007, receiving a Parkland certificate saying he “discharged the duties with honor.” The document was signed by Palmer, his UTSW training program director; Anderson, the hospital’s CEO; and Dr. Lauren McDonald, then chair of Parkland’s governing board.

Later that year, Atef-Zafarmand went to work for McDonald’s employer — Dallas Nephrology Associates, a prominent group of kidney specialists. McDonald said she played no role in hiring him and was unaware of any misconduct allegations. The group’s chief executive issued a statement saying he, too, knew nothing about them.

Dallas Nephrology helped Atef-Zafarmand get permission to treat patients at several Dallas-area hospitals, he told UTSW. But in applying for these privileges, he failed to disclose the reprimand to at least some of them. The reprimand letter had cautioned that it would be part of his permanent UTSW file and “subject to disclosure to requesters such as medical boards, potential employers etc.”

Atef-Zafarmand acknowledged this failure in a 2008 email that asked Palmer for help. “In two places, Baylor and Presby Dallas, I did not get a chance to fix the applications ahead of time before they brought it up to me,” he wrote. He attached an email he previously sent to Presbyterian that said he didn’t know he was ever on probation and added: “I did not try to hide any fact from you.”

Palmer responded that he couldn’t help with the disclosure failure, but “I can attest that you have successfully completed the program.”

Later, when another faculty member took over as training program director, she asked Palmer how he responded when hospitals and prospective employers asked about Atef-Zafarmand’s history. “I have generally put he is qualified in all categories,” Palmer responded. “When asked whether he was ever in trouble during fellowship such as probation, I report he received a letter of reprimand.”

“Letter of reprimand for unprofessional behavior, correct?” the new director asked.

“I never specify, but yes,” Palmer wrote back.

Baylor Health Care System ultimately awarded Atef-Zafarmand privileges at its Garland hospital. When The News asked why, the system gave a written answer: “All of this physician’s professional references recommended him.”

There is no indication in medical board records that he was ever allowed to treat patients at Presbyterian. Its officials declined to comment.

The two most recent abuse allegations against Atef-Zafarmand arose from encounters outside hospitals. Both were reported to Dallas police within 24 hours.

In July 2010, a 21-year-old woman said he attacked her after they had lunch at his condo near downtown. He “started rubbing her shoulders,” according to a police report, “and then started choking her from behind.”

The woman said he forced her to the floor, pulled her pants off and raped her. He “pressed both his thumbs on the veins in her neck,” she told police, causing her “to come in and out of consciousness about three times.”

In July 2011, an 18-year-old woman said he reached into her shorts at a Dallas nightclub and penetrated her with a finger. She had agreed to spend the evening with him for $400 but had not been paid and had not consented to sexual contact, a police report says.

“She told the susp[ect] to stop,” according to the report, then vomited and was ejected from the club. Atef-Zafarmand walked her to his car, where he allegedly put out a cigarette on her chest and choked her. “She does not remember what took place after that and woke up” at his condo, the report says. A detective later photographed injuries to her neck, arms and one breast.

Records released by Dallas police show no sign that the doctor was questioned in either case. Both accusers ultimately decided not to pursue prosecution, the records say.

In 2011, Atef-Zafarmand left Dallas Nephrology. He has since worked a series of temporary jobs, both in the Dallas area and in North Dakota.

http://res.dallasnews.com/graphics/2013_02/parkland/#day1main

Dallas Parkland Memorial Hospital caregivers accused of sexually abusing patients

On February 3, 2013February 3, 2013 By A.P.In Arlo Tabada, assault, Ben Click, Brooks Egerton, Crime, Dallas, Dallas Morning News, Dallas Police Department, David Wright, Debbie Denmon, Duane Stubbe, Human Behavior, Khasro Hasan, Kye R. Lee, Manuel Rodriguez, Mike Malaise, Parkland Memorial Hospital, sexual abuse, Texas, Texas attorney general, Texas State Department of Health Services, U.S. Centers for Medicare and Medicaid Services, Underwood NewsomeLeave a comment

Parkland Memorial Hospital is the nation’s largest healthcare facility ever forced into federal oversight to remedy patient-safety dangers. How did the landmark Dallas County public hospital reach this precipice? The problems have been years in the making.

By BROOKS EGERTON
Staff Writer
begerton@dallasnews.com

The nurse aide was accused of raping a grandmother who could barely walk. Doctors moved her from Parkland Memorial Hospital to another facility, where caregivers caught the man trying to track her down. Parkland fired him for “unsatisfactory work performance” and moved on.

Hospital police overlooked or ignored potential evidence and never filed charges. Hospital administrators failed to alert state regulators, as required by law. And Manuel Rodriguez went to work for a hospice company, caring for dying people in their homes. He denies wrongdoing, and Parkland said its police force found no evidence to support the rape allegation.

Parkland Memorial Hospital faces an April 2013 federal deadline to prove it is safe. How did Dallas’s landmark public hospital reach this precipice? Read First, do no harm, a compilation of The Dallas Morning News’ coverage of Parkland’s patient-safety crisis. The case is one of at least 25 in recent years in which patients accused Parkland caregivers of sexual abuse. Parkland’s in-house police force — which controls all criminal investigations of hospital staff — made no arrests. One caregiver was ticketed and fined.

Parkland has made it difficult to see how the cases were handled. The public hospital has sued the Texas attorney general in an effort to shield records. For a year, hospital officials refused to release any police investigative reports to The Dallas Morning News and would not answer most questions. Last month, they again declined interview requests, but did release a four-page statement and a selection of police records.

But the newspaper, using other sources, had already pieced together extensive details about several cases. All showed signs of poor police work, with one going officially uninvestigated for a year. Some patients and front-line workers involved in the cases alleged cover-ups.

Parkland adamantly disagrees. “To suggest that there has been a systemic or even inadvertent effort to suppress or overlook incidents of alleged assault at Parkland is to suggest a falsehood,” hospital leaders said in their Jan. 22 statement to The News.

Parkland Feb. 1, 2013 email statement to “opinion leaders and media” Parkland stressed that the Rodriguez case was “discussed with the Dallas County district attorney’s office.” It did not mention that the discussion occurred in December, nearly two years after the rape report. Parkland police officials met with prosecutors only after The News asked the district attorney’s office whether it had been consulted about any of the accused caregivers. It had not, and the DA’s office did not do any official investigations, its spokeswoman Debbie Denmon said.

Parkland’s statement also said the hospital now asks the district attorney’s office to review every sexual assault allegation, “regardless of whether the police believe it is substantiated.”

The investigative records that Parkland released last month show that detectives took logical steps in several cases and amply documented reasons for dropping them. For example, some accusers made vague, shifting allegations, and some seemed delirious.

But other cases were closed with little or no investigation, deemed to be medical procedures or bathing assistance that patients misunderstood. In the four cases about which The News had already pieced together the most information, the newly released investigative records raised further questions about police conduct.

PARKLAND AND CMS

Mike Malaise, senior vice president/external affairs, Parkland Memorial Hospital, in a Feb. 1 statement:

“In the normal course of regulatory oversight, the U.S. Centers for Medicare and Medicaid Services and the Texas State Department of Health Services investigate incidents such as those under review by the Morning News. In reviewing some of these cases, those agencies did find deficiencies in reporting, documentation or procedures surrounding the incidents. At no time did those agencies suggest that police handling of the incidents was insufficient or inappropriate.”

David Wright, deputy regional administrator, U.S. Centers for Medicare and Medicaid Services, in an email response to The News later that day:

“We have neither the authority nor expertise to review the adequacy of law enforcement investigations from any jurisdiction. Our investigations focus solely on the hospital’s compliance with the Medicare Conditions of Participation.” The Parkland statement did not address questions asked of hospital leaders: How many sexual abuse cases have come to light recently, since the newspaper last sought police records under the Public Information Act? What were the allegations? How did Parkland respond?

There has been at least one new case, the newspaper learned. Government regulators found in December that a psychiatric aide had been inappropriately touching a patient. Hospital police filed no charges.

These are the first accounts to emerge alleging deliberate mistreatment at Parkland, which collects about $425 million annually from Dallas County taxpayers. The News’ three-year investigation of the hospital previously documented harm stemming from error, under-staffing, lax supervision or, occasionally, psychiatric aides’ violent reaction to combative patients.

U.S. health officials intervened in 2011, putting Parkland under a rare form of probation that could force it to close unless systemic change is documented in the next three months. Federal monitors have reported significant progress by the hospital in some areas as well as ongoing patient-safety breakdowns. They have said nothing publicly about possible crimes committed by caregivers.

In late 2011, when the newspaper began researching sexual abuse allegations, Parkland said there had been 15 such complaints against employees in the previous four years. Abuse, as defined by Parkland, ranges from verbal or visual sexual harassment to rape — it’s “anything that forces a person into unwanted sexual contact or attention.”

Police substantiated no wrongdoing in 13 of the 15 cases, said Dr. Thomas Royer, who was Parkland’s interim chief executive at the time. The other two “were found to be assaults but not sexual,” he added. “Those people have been dealt with through the HR process.”

Records show that in one of those cases, the suspect was not a caregiver but a patient. In the other case, Parkland police accused a nurse aide of improperly touching a patient near her genitals and ticketed the man in 2011 for Class C misdemeanor assault. He was fined the maximum $500 penalty by a justice of the peace.

It’s a Class A misdemeanor to intentionally or knowingly make offensive physical contact with people who are “substantially unable” to protect themselves because of disease or injury, Austin criminal justice expert Eric Nichols said. It’s a first-degree felony if such contact causes serious mental or physical injury to a disabled person.

Three women recall their suffering at the hands of Manuel Rodriguez, a nurse aide accused of raping a patient at Parkland Memorial Hospital. In general, such misconduct “is judged very harshly by jurors and members of the community,” said Nichols, a former federal prosecutor and former Texas deputy attorney general. The maximum penalty for a Class A misdemeanor is a year in jail. The maximum for a first-degree felony is life in prison.

The aide resigned from Parkland — which failed, as it did in the Rodriguez case, to make a required report to regulators.

There’s no good way to compare the number of abuse cases at Parkland to those at other hospitals, most of which are private. In Dallas County, the DA’s office says it does not keep statistics on the types of cases filed by different police departments.

But sexual abuse of patients has been documented around the country since at least the 1970s. And predators in health-care settings, experts say, are the same as predators everywhere: They choose victims who are particularly vulnerable — physically or mentally or because their credibility can be questioned. They take advantage of institutions with a culture “of not paying attention,” said Boston College nursing professor Ann Wolbert Burgess, who co-edited a textbook on patient exploitation.

Patients are doubly vulnerable, she said. Predators have extraordinary access to their bodies. Hospital managers may assume that accusers — because of illness or medication — imagined or misunderstood a caregiver’s actions.

Burgess, a consultant on patient-abuse issues, said criminal prosecutions can be difficult or impossible because of limited evidence and victims’ disabilities. Another reason “is the hospital does not want negative publicity.”

Courtney Underwood Newsome, the Dallas area’s most prominent advocate for sex-crime victims, reviewed Parkland records obtained by The News and said she could not believe all the cases were unfounded. She cited research showing that most sexual abuse allegations are never reported to police and, of those that are, fewer than 10 percent are false.

“They [Parkland] are fighting to survive,” Underwood Newsome said, “and no one wants to see them fail.” But “there appears to be an egregious lack of action,” one that will “lead people to question what, in addition to criminal behavior, is being swept under the rug.”

Underwood Newsome co-founded the Dallas Area Rape Crisis Center and has led efforts to expand the number of hospitals offering victims full forensic examinations, which seek evidence such as an attacker’s bodily fluids. Until 2010, Parkland was the only place in Dallas County providing this service.

She questioned whether Parkland police should handle serious criminal allegations against their fellow employees. “There is always going to be a question regarding the conflict of interest,” she said.

In-house police forces like Parkland’s also face questions about whether they have the time and expertise for specialized investigations, former Dallas Police Chief Ben Click said. There are times when they should ask for outside help but don’t, he said, because “egos come into play.”

State records say Parkland has 59 licensed officers — more than some Dallas suburbs, such as Highland Park and University Park. The hospital’s force includes one veteran officer with his own history of sexual misconduct: Duane Stubbe, who served deferred-adjudication probation for exposing himself to a Collin County girl.
Parkland officials acknowledged knowing about Stubbe’s misdemeanor criminal case. Separately, they have praised their police department for preventing sex crime. In 2009, a magazine for Parkland employees said officers monitor “potentially dangerous individuals” who have medical appointments.

“Whether you’re running errands or going to your grocery store, predators can be anywhere,” the magazine quoted Lt. Rick Roebuck as saying. “I’m glad that at least while they’re here, we can make sure Parkland remains safe.”

Fred Price, who retired as a Parkland detective in 2005, said his fellow officers were generally “sincere.” But “you just knew you walked on eggshells” when investigating insiders.

Co-workers “would definitely try to cover up” for each other, said Price, who’s now a Dallas County courtroom bailiff. And management “would always believe any employee, especially a doctor, over any policeman.”

Here’s how Manuel Rodriguez got a nurse aide job in 2010 on Parkland’s eighth-floor neurology unit, according to hospital records:

He made the lowest possible passing score on a basic math test. No one else was considered for the position. Another male aide was in the process of being terminated — after being accused, for the third time in three years, of sexually abusing female patients.

Rodriguez’s personnel file shows no sign that he underwent a background check or provided any work history. He was 53 at the time and, after a career as a printer, had just spent a few weeks training at Parkland to become a certified aide.

His boss tried to fire him within 90 days, citing emails in which he complained about understaffing and accused nurses of not helping patients who’d lost control of their bowels. “Our unit’s patients and staff do not need an employee such as this,” the boss wrote to a personnel official. “I made a poor decision in hiring him.”

For reasons not explained in the personnel file, Rodriguez kept his job. And, in March 2011, the disabled grandmother was delivered to his care after fainting at a workers’ compensation hearing. A conveyor belt injury had left her in chronic pain and largely unable to use the right side of her body, including her dominant right hand. She lost her job, car, home and ability to live independently.

Rodriguez was her most helpful caregiver at first. “He brought me blankets,” said the woman, who is in her mid-50s. “He gave me a lot of attention.”

But the aide soon began to seem too familiar with his hands, “using lots of talcum powder.” And late one night, after she’d been in Parkland about a week, “he said he was going to give me a bath, and I told him, no, I didn’t want to.”

“He dragged me to the bathroom,” the woman told The News. Then, through sobs, she described how she refused when he “tried to put his thing in my mouth,” and how he went on to pin her down in bed and vaginally rape her.

Afterward, she said, he cleaned their genitals and put her bed sheets in the linen drop.

Police records say the woman tried to cry out during the attack but couldn’t make much noise, both because of her medical condition and because Rodriguez put his hand over her mouth. She remembered being restrained by terror, too: Rodriguez, she said, showed her that he had access to her medical records, so he knew where she lived with relatives. A Parkland detective verified that Rodriguez had looked up her address in the computer, a police report says.

“He threatened to kill not just me but them,” she said. “I didn’t know what to do.”

So at first, she told no one. Doctors sent her for therapy related to her workplace injury at UT Southwestern Medical Center’s Zale Lipshy hospital, next door to Parkland. There, she said, she finally felt safe enough to tell an employee what Rodriguez had done.

A Parkland police officer was summoned to her Zale room. It was the afternoon of March 29, 2011 — six days after the alleged rape, according to a Parkland police report.

KYE R. LEE/The Dallas Morning News

A disabled Dallas woman says she was raped last year by Manuel Rodriguez, a nurse aide at Parkland Memorial Hospital. Parkland fired the man, but its police force filed no charges. The woman’s daughter was present when a hospital police officer first responded to the rape complaint and described him as ‘really rude.’ She tried to get help from Dallas police instead, to no avail.“The policeman was really rude,” recalled one of the woman’s daughters, who was present for the interview. He raised his voice repeatedly, she said, demanding to know “why didn’t she say anything before.”

The daughter told him she was going to contact the Dallas Police Department, “and he said there’s no point in calling them because they have no jurisdiction over us.” She later called anyway and found out that Parkland was, indeed, a law force unto itself. DPD says it gets involved only if it responds first to a major crime in progress or if Parkland seeks help.

Hospital police did not immediately arrange for a physical examination of the woman, ask her to undergo a rape exam or refer her to a counselor. At the daughter’s insistence, Parkland agreed to see the woman two days after she reported being raped.

Two Parkland officers escorted her from Zale back to their hospital to have a rape exam done, police records say. But a Parkland nurse told them that “because of the extended time that had elapsed, the test could not be performed.” The hospital did test her for possible exposure to sexual diseases.

In its statement to The News, Parkland said a rape exam “only has clinical or evidentiary value within 96 hours after an alleged assault.” Underwood Newsome, the Rape Crisis Center’s co-founder, called that claim “completely unfounded.”

Texas law says police must request a rape exam when an accuser comes forward within 96 hours; after that, “the law enforcement agency may request” one. Experts say it often makes sense to perform rape exams beyond 96 hours, especially if the accuser, like the one in this case, has had limited physical activity.

“It is important to remember that evidence collection beyond the cutoff point is conceivable and may be warranted in particular cases,” says an evidence protocol published by the U.S. Justice Department.

A basic physical examination “should be performed in all cases of sexual assault, regardless of the length of time which may have elapsed,” says a Texas attorney general’s protocol. One reason is to check for internal injuries. Also, “evidence may still be gathered” — for example, by taking photographs of bruises.

While waiting for the two officers at Zale, the grandmother’s room phone rang. It was Rodriguez, taunting that he had been to court before and “nothing happened to him that time either,” a UTSW police report quoted the woman as saying. In the same call, she told The News, he also made the sound of a gun.

Nurses moved her to a different room and put her on the “no info” list, preventing anyone from knowing where she was unless she told them. She spoke with a Parkland counselor, whose notes describe her as tearful, fearful and intensely depressed.

Bruises on a Parkland patient’s arm, photographed in 2011 at a Parkland counseling center two weeks after the victim was allegedly raped by Parkland nurse aide Manuel Rodriguez. The photo comes from her medical records.“Don’t leave me,” she begged the counselor. “I feel like I’m dying.”

Parkland suspended Rodriguez the following day, April 1. On April 2, according to UTSW police records, he showed up at Zale, apparently unaware she had already been discharged. Dressed in street clothes and a white ball cap, he asked to see the woman and gave nurses his name. They refused to help him and alerted police, but Rodriguez left before officers arrived.

Marsha Newberry, who is a friend of Rodriguez’s and one of his ex-wives, said he called her about the suspension. He denied wrongdoing, described the patient as “crazy” and said “she claimed that he was trying to track her down in another building. He was like, ‘I’ve never even been in that building.’”

One example Rodriguez gave of the patient’s behavior: “She would just, like, not have any clothes on and open up the sheets and try to pull him down on her, and he was like, ‘I can’t do this. I’m here to take care of you.’” According to Newberry, Rodriguez said he also received a love letter from the patient but didn’t show it to anyone before destroying it.

Rodriguez, who has never been convicted of a crime, declined an interview request. He referred The News to his longtime lawyer, Dennis Croman, who said the patient had “mental problems” and might not be “altogether competent.” He did not elaborate.

For months before her hospitalization, the woman was treated by a psychiatrist at Parkland’s outpatient Victim Intervention Program. He diagnosed her with major depression and post-traumatic stress disorder, including nightmares and flashbacks, which he said stemmed from her work injury, disability and pain. He saw her again on April 7 and noted that she was “distraught” because of a sexual assault at Parkland that had “significantly exacerbated symptoms.”

Other therapists who later saw the woman briefly offered varying diagnoses, according to her medical records, which she let The News review. One said she talked about a childhood belief in “aliens.” Another said she described elaborate visions, but he thought she was faking mental and physical symptoms for financial gain. The woman told The News that doctors, generally working through translators, had asked her to visualize as part of stress-reduction therapy. She said she knew the difference between the imaginary and the reality of rape.

During the April 7 visit, Victim Intervention Program staff took photographs of the woman in a wheelchair — the only photos that appear in medical records she’s been able to obtain. Two weeks had passed since the alleged rape, but bruises were still visible on her calves and upper arms. Parkland also gave her a brochure from the Texas Association Against Sexual Assault that explains how vulnerable the disabled are to sexual abuse. The association offers a similar pamphlet for police that urges patience with the disabled, who are often reluctant to report abuse for fear of losing health care and may be “considered less credible.”

On April 8, intervention program staff contacted the detective assigned to the woman’s case. The detective wrote a report saying that she learned two things from the call: “The patient was being treated for a work-related shoulder injury that was traumatic,” and had previously been sexually assaulted without reporting it to police. There is no mention of her bruises in this report or any other police records released by Parkland.

The detective, Darlene Griffin, closed the case that day. “We have no physical evidence to support a sexual assault against the victim,” she wrote.

“Investigation believes that there are inconsistencies with the statement of the patient,” she added. “However, investigation cannot conclude that an offense did not occur.”

Griffin’s report gave no examples of inconsistencies and made no reference to the patient’s mental status. The News, in hours of interviews with the patient over several months, detected no inconsistencies. It found no sign in her medical records that caregivers doubted the truthfulness of her rape report.

The newspaper did find, deep in a box of her personal papers, hospital menus from the day after the alleged rape. “I am dirty,” says a note she scrawled near references to peach halves and grilled chicken breast. The note curses Rodriguez by name and adds, “He raped me.”

Griffin’s report noted that Rodriguez, during the week of the alleged rape, had accessed personal contact information for another of his female patients. He called her after she was discharged and said he was sorry “he couldn’t help her with her bath,” the report says.

An unsigned memo dated April 12 told Rodriguez to return to duty. “Although the allegations were determined to be unfounded, you are strongly cautioned to exercise prudent judgment so similar situations are avoided,” his boss wrote. “However, should we substantiate any of these allegations in the future or continue to receive additional complaints, further corrective action may be taken not to exclude termination.”

That week, the neurology boss also drafted a memo for all of her staff. It decreed that aides could no longer care for patients of the opposite sex unless another caregiver was present.

A nursing administrator responded by noting that problems could also arise when caregivers worked alone with patients of the same gender. Parkland’s patient relations department, the administrator wrote, “is currently investigating a complaint by a male patient against a male provider regarding inappropriate touching.”

Rodriguez was fired in late April, ending an 11-month tenure at Parkland. Records released by the hospital do not detail reasons for the firing beyond his “unsatisfactory” job performance.

“He said something about how they fired him because he wouldn’t write down a statement” admitting he violated a procedure, Newberry said. He told her he refused because “I did everything I was supposed to do.”

She said he was “heartbroken.” “He was just like, ‘I cannot believe I’ve lost my job because of some stupid woman.’”

Croman, Rodriguez’s lawyer, said he talked with two Parkland detectives during the criminal investigation.

“We tried to cooperate with them and give them what information we knew,” Croman said. “They just determined that it wasn’t worth pursuing.”

The detective’s report contradicts this. “The suspect has been non-cooperative,” Griffin wrote. “Investigation did not receive communication from the suspect attorney.”

The International Association of Chiefs of Police says sexual assault investigations should be treated not as “he said, she said” cases, but as “he said, they said” matters. Detectives should look for a pattern of unreported crimes “by interviewing the suspect’s social circles, current and former partners,” says the association’s list of recommended best practices.

OTHER PARKLAND ACCUSATIONS Here are other examples of sexual abuse allegations against Parkland Memorial Hospital caregivers. Parkland’s police force filed charges only in the first case.

KHASRO HASAN

Position: Nurse aide
Background: He told Parkland that he worked as a nurse in Iraq and as a translator for U.S. military officials.
Tenure at Parkland: Seven months in 2010-11
Accusations: In January 2011, a patient accused him of groping her breast and pubic areas “more than once.”
His response: He denied wrongdoing to Parkland police and The Dallas Morning News. He told the newspaper that a vindictive co-worker manufactured the accusations. According to police records, he admitted touching the patient’s abdomen and head without consent. He said he was trying to help her with pain. An aide’s duties don’t include treatment.
Outcome: Hasan quit his job. Parkland police later charged him with Class C misdemeanor assault. He was convicted in a justice of the peace court and assessed the maximum penalty: a $500 fine.
Today: Parkland did not make a required report to regulators. Hasan avoided being put on the state’s list of aides who are unemployable because of abuse. He said he is no longer working in health care.
PETER SARMIE

Position: Neurology unit nurse aide
Background: He told Parkland that he studied to be a mechanic in the West African nation of Liberia before becoming a certified aide in Texas.
Tenure at Parkland: 2007-10
Accusations: He put his hand in a patient’s vagina while bathing her in 2010. “This is the third complaint received for the same type of behavior,” Parkland told him.
His response: “All of it was investigated and employee was found not guilty,” he wrote to his superiors. Sarmie reiterated these denials in an interview with The Dallas Morning News. Male aides, he said, are vulnerable to false accusations when assigned to female patients who need assistance with bathing and dressing.
Outcome: He was fired for “repetitive at risk behavior/reckless conduct that jeopardizes the life and/or welfare of another individual.”
Today: He lives in Rhode Island and said he is working as a nurse aide.

ARLO TABADA

Position: Intensive care unit nurse
Background: His resume says he worked as a physician in his native Philippines before getting a U.S. nursing degree in 2008.
Tenure at Parkland: 2008-12
Accusations: In January 2012, a patient said, Tabada woke her in the middle of the night, while she was intubated, for bathing. “I felt a pinch on my nipple,” she told the nurse’s supervisor. Then he “started to rub my back” with a hot towel and “had his hand on my pubic area.” The patient added that she’d never been bathed by a male nurse before.
His response: Tabada and an aide, who helped with the bathing, denied wrongdoing to Parkland. He reiterated that denial to The News. Having female caregivers bathe female patients “might be the best scenario,” he added. But “sometimes it’s just not practical” given Parkland’s “heavy load” of patients.
Outcome: Both caregivers returned to work after a one-day investigation by Parkland police. A psychiatrist said the patient’s allegations were “likely due to delirium given that she was on propofol,” a sedative and hypnotic agent. Tabada told The News he agreed to take a polygraph test, but police “didn’t pursue it.”
Today:Parkland fired Tabada in July 2012 for seizing an emergency-call button from another ICU patient. He said the patient was repeatedly demanding painkillers ahead of schedule, disrupting care of others in the short-staffed unit. “I made a mistake,” Tabada told Parkland. He still has his Texas nursing license and would not say whether he is currently working as a caregiver elsewhere.

MORE INCIDENTS

Because Parkland withheld or blacked out large portions of many records, it’s impossible to identify most of the other accused caregivers and their jobs. Here are examples of patients’ accusations and how hospital police responded:
December 2010, second floor: A caregiver performed an invasive exam without consent. The patient grabbed the caregiver’s hand “and pulled it out.” Records released by Parkland show no sign that any police investigation resulted. Ten months later, the supervisor of criminal investigations created a report that declared, without elaboration: “This was a medical procedure not an assault.”
February 2012, emergency room: A clothed caregiver pressed his erect penis into the patient’s genital area during an exam. The patient was upset and terminated the exam. Here’s why a Parkland detective said he closed the case as unfounded: The caregiver “would have to slouch or get on his knees” to do what he was accused of, and the patient said he was standing.
March 2012, emergency room: A caregiver “fondled the nipple on her left breast three different times” while attaching testing equipment to her chest. The caregiver denied touching any part of the breast. Both parties agreed to take a polygraph. “After interviewing both parties and polygraphing one, we came to the conclusion that there was no assault,” a detective wrote. “The polygraph showed there was no deception.”

SOURCE: Parkland police and personnel records; Dallas Morning News research. Records released by Parkland don’t show whether its police followed this advice. But The News found a pattern of abuse allegations in Rodriguez’s past and support for what he allegedly told the disabled grandmother — that he’d been to court before.

Oralia “Lala” Boatright, a divorced mother of two, lived with Rodriguez in the early 1990s, in his hometown of Irving. Police there arrested him twice after she accused him of assault.

In 1991, according to a police report, he grabbed her by the throat when she tried to leave him. An officer took him to jail after she said she “was afraid if the police left, the assault would continue.” Municipal court records show the case was dismissed but don’t say why.

A 1992 police report said he pinned her down on a bed with his knees to keep her from leaving home, then pushed her into a glass table. Hospital records say she received treatment for a gash near her right eye, in the company of an unidentified man.

That man was Rodriguez, Boatright told The News. She recalled a nurse asking whether she’d been assaulted and being so afraid that she claimed it was just an accident. Three days later, after moving out of his house for good, she gave police a written statement. It said he had previously held her at gunpoint.

“He kept an old antique shotgun that his dad gave him behind the bedroom door,” Boatright said in an interview. “He pointed it at me and says, ‘You’re not going anywhere. Do you understand?’” Her response: “OK, OK, I promise. Don’t do anything — my son’s in the next room.”

She said he put the gun down and taunted her: “I broke you, didn’t I?”

Police deemed the 1992 case serious enough to send to the district attorney’s office for prosecution. A judge found Rodriguez innocent, for reasons that county records don’t explain. Boatright said she didn’t know the case went to trial, because she went into hiding and didn’t leave a forwarding address.

Rodriguez called Boatright a “maniac” who deliberately injured herself, according to his friend Newberry. “She told him she was going to get him put away” and “jumped into the glass coffee table,” Newberry said, recounting his story. “He said, ‘I didn’t touch the girl.’”

Newberry was married to Rodriguez for about eight years. When filing for divorce in 2004, she accused him of cruelty and adultery. The cruelty, she told The News, was strictly verbal. “He was never physical with me.”

Rodriguez was briefly married in the mid-1990s to Sandy Jackson, who accused him of harassment while their divorce was pending. When she contacted Irving police, she said he had called her about 25 times that day and knocked on her door, trying to get her to move back in with him.

An officer told him to leave Jackson alone, according to police records, prompting Rodriguez to reply: “But I want to talk to her.” He agreed to stop bothering her but did not, records say. Police then referred the matter to the city attorney, but Irving officials recently said there was no record of prosecution.

Jackson told officers that Rodriguez “was violent towards her during their marriage,” but she did not call police then. She told The News that she feared complaining would lead to more violence and that she spoke up only after securing a place of her own.

“One time I thought I was going to end up in the bottom of Grapevine Lake because he hit me so hard,” Jackson said in an interview. They were in his sailboat, she explained, and he was barking orders while doing no work. When she protested, “he hit me right on the pelvic bone,” and “half my body went over the railing.”

Jackson said Rodriguez sometimes bragged that his common names and lack of a middle name made him hard to track. “He was very bold about that,” she said. “He would just tell me, ‘How the hell is anybody ever going to catch up to me?’”

The News learned of the Parkland rape allegation in late 2011, about eight months after it was made. The newspaper sought information from the Texas Department of State Health Services, which licenses hospitals and which Parkland should have notified within 48 hours.

DSHS said it had never been notified and began investigating. It isn’t clear what steps the state agency took, but it did not interview Rodriguez and found no fault with Parkland.

Agency spokeswoman Carrie Williams said she could not discuss investigative details. But in general, she said, Parkland’s past failures to report abuse allegations made it difficult for DSHS to determine what happened and contributed to the agency’s decision to fine the hospital a record $1 million last year.

“They really protect the workers there,” Rodriguez’s accuser said of Parkland. “And the patients, where does that leave us? In their hands, where they can do what they want.”

Rodriguez went to work in early 2012 for a home-health firm based in Arlington. Officials there said he wanted more work than was available and quit after a few months. He gave no notice, they said, and simply failed to show up at a home where a patient was waiting for help.

Since then, he has been working for Hospice Plus, a Dallas-based company that cares for the terminally ill. Its chief executive, Dr. Bryan White, said he knew of no problems with Rodriguez. He declined to comment on whether the company received information from Parkland about the aide. “We followed our policies and procedures,” White added.

The Parkland patient who accused Rodriguez began to cry when told of his hospice work. She said she suspects the hospital views her as someone who just wants money.

“I don’t want money. I don’t want any of that. I want justice,” she said, sobbing. “I want justice so this doesn’t keep happening to so many other women.”

Police officer remains on Parkland’s force after sexual misconduct findings
He served probation for indecent exposure and was later fired, but the hospital hired him back.
By BROOKS EGERTON
Staff Writer
begerton@dallasnews.com

Parkland Memorial Hospital police officials promoted Officer Duane Stubbe after his first incident of sexual misconduct. They warned him after the second. They fired him after the third.

And two months later, they gave him back his gun, badge and previous salary. He remains on Parkland’s police force today, enforcing the law at primary-care clinics.

The troubles date to 1996, when Stubbe was arrested for being naked in front of three middle-school girls during a slumber party at his home. In 1998, he was found not guilty on two misdemeanor charges of indecent exposure and agreed to plead no contest to a third. A Collin County judge put him on six months of deferred-adjudication probation.

Parkland Memorial Hospital
Duane Mark Stubbe, a longtime Parkland Hospital police officer, is shown in a 1998 booking photo from Collin County. He was arrested in 1996 for indecent exposure, and again in 1998 for a probation violation.Stubbe was required to leave home, undergo sex-offender treatment and submit to polygraph testing. When tested, he “failed when asked his sexual intent during the commission of the offense,” court records say.

Prosecutors sought to revoke his probation. Stubbe sought to withdraw his plea, claiming he hadn’t understood its consequences or the evidence against him. He had always “maintained his innocence,” his lawyer argued.

A judge rejected both efforts in early 1999. Stubbe completed probation with no conviction record.

The Texas Commission on Law Enforcement Officer Standards and Education then moved to suspend Stubbe’s license. It got a late start because Stubbe had failed to make a required report of his arrest; he didn’t disclose the criminal case until after his probation began.

Parkland intervened on the officer’s behalf. Kenneth Cheatle — then his lieutenant and now Parkland’s police chief — wrote a letter praising Stubbe. So did CaSandra Williams, who was assistant chief at the time and now heads the police department at Texas Health Presbyterian Hospital Dallas.

Smith Lawrence, then Parkland’s chief and now retired, went to Austin and testified before an administrative law judge. He said he’d recently promoted Stubbe to a supervisory job “entirely based on merit.” The officer “enjoys the support of both his superiors and peers.”

The three supervisors did not respond to requests for comment.

Stubbe, who declined to comment for this story, also testified in Austin and gave this version of what happened at the slumber party: He was sleeping naked and unaware of the sleepover when a noise from his stepdaughter’s room woke him. He went to investigate, opened her door and saw the girls. “He immediately closed the door,” he said, and two of the three girls did not see him nude.

But two of the girls, who are now young women, told The Dallas Morning News that they did see full frontal nudity. They said Stubbe entered the room naked, told the girls to quiet down and then briefly lingered there. The two did not testify in Austin.

Parkland Memorial Hospital
Image from the Parkland Hospital newsletter, released in Sept. 2012, showing Officer Duane Stubbe, a member of Parkland Memorial Hospital’s police force, who has his own history of sex crime: He was sentenced to six months of probation in 1998 for indecent exposure, and state regulators later suspended his officer’s license. Stubbe has worked as an officer for the hospital since 1994.In his testimony, Stubbe said “he has learned his lesson and is truly remorseful,” the administrative judge wrote. The police officer said suspension would cost him his job and hurt his family.

It would also hurt Parkland, Stubbe asserted, because he was the hospital police force’s only member specially trained to deal with mentally ill people.

The law enforcement commission agreed to a six-month probated suspension, which began in early 2000 and allowed Stubbe to keep working.

By late 2000, he was in trouble again. Parkland supervisors cited Stubbe for refusing to help a patient who’d lost her purse. And in early 2001, he was written up for failures including an “unsatisfactory” report on the use of force and not telling the Secret Service when a psychiatric patient threatened President-elect George W. Bush.

Stubbe received a “final warning” in April 2001, for sexually harassing another officer. He grabbed the man, according to personnel records, and made comments such as “You need to quit looking at me like you want me to … [expletive] you.”

The records show that Stubbe was fired the following month for similar sexual comments. He told a fellow supervisor, for example, “I’ll do it if you [perform oral sex on me].”

Termination paperwork also cited “inappropriate incidents” with his Parkland-issued gun, such as taking it out during a meeting, sliding it across a table and telling a subordinate, “You shoot him.”

There is no sign in records Parkland released that Stubbe denied doing any of these things. Nor is there any explanation for why, two months after his firing, he was rehired. He appealed his firing, the hospital said in a statement to The News, and Lawrence “agreed to allow him back onto the police force.”

Stubbe, 48, has received excellent evaluations in recent years.

That is little consolation to the two young women who attended the slumber party. Both said they were upset to learn that Stubbe was still working as a police officer. One said she worked in health care and had considered getting additional training at Parkland.

Now, she said, she’s afraid to go there. “You don’t know you’re safe.”

http://res.dallasnews.com/graphics/2013_02/parkland/#day1main

Cheeus

On April 8, 2012April 6, 2012 By A.P.In Cheesus, Cheetos, Christianity, Dallas, Religion, TexasLeave a comment

In Dallas, Texas Dan and Sarah Bell discovered a Jesus shaped Cheeto in 2009. Nicknaming the Cheeto “Cheesus,” Sarah noticed that one of the chips looked oddly familiar “I was putting them in my hand and I had eaten most of the ones in my hand, and one was left lying there. And I said, ‘Oh my gosh, look at this. It really looks like a person in a robe praying.”

CBS News reported the Cheeto in question is about 2 inches tall and missing a right arm. Other than that, one might see a distinct robe, long hair and a man praying.

The couple looks at the Cheeto as memento as a momento from god of how blessed they are. For now they are keeping the “Cheesus” in a plastic box and contemplating a possible eBay auction. In the past, a piece of toast with the likeness of Mother Mary ingrained in the bread sold for $28,000. The Bell’s said they just be happy with $25.

http://www.manolith.com/2009/05/18/cheesus-jesus-likeness-found-in-cheetos-bag/

It's Interesting

Category: Dallas

Parkland psych ER is again scene of patient abuse

As Dallas hosts Washington on Columbus Day weekend for Sunday Night Football, Washington Redskins state their name is a term of honor and not a racial slur

Dallas Parkland Memorial Hospital built wealth as patient care conditions worsened

Parkland Memorial Hospital blaming affiliated UT Southwestern Medical Center doctors for problems with patient care

Parkland Memorial Hospital Psychiatry Department bringing in private operator to oversee operations

Alleged Sexual Abuse of Patients in Parkland Memorial Hospital Psychiatric Emergency Room

Parkland Memorial Hospital nurse accused of sexually assaulting patient

Choking allegations against doctor began at Parkland Memorial Hospital

Dallas Parkland Memorial Hospital caregivers accused of sexually abusing patients

Cheeus