The suffocation of a state Department of Mental Health patient is now under review by the Joint Commission that accredits 80% of U.S. hospitals.
The Illinois-based private nonprofit opened its probe this week after learning from The State newspaper that 35-year-old William Avant was killed in January under a dogpile of hospital employees who were improperly restraining him.
Meanwhile, S.C. lawmakers also are interested in questioning Mental Health about Avant’s death, and groups that advocated for people with disabilities strongly criticized the agency’s handling of a longtime patient at the Bryan Psychiatric Hospital in Columbia.
Avant’s suffocation shocked the Mental Health Commission, but the agency’s board chairman, Greg Pearce, said he was satisfied last Friday when Mental Health’s acting director, Mark Binkley, explained how the agency responded to the incident.
Pearce, who was appointed to the Mental Health Commission by Gov. Henry McMaster in April, said he only found out about Avant’s death Friday, when Binkley briefed the commission on the incident in a private session and notified them The State was working on a story about it.
The department refuses to share that explanation publicly, citing patient confidentiality laws.
It won’t answer whether the 13 unnamed employees involved in Avant’s death at the hospital — including three who had not been properly trained — remain at the agency, continuing to care for some of the state’s most vulnerable residents.
That’s a “real stretch” of the patient privacy laws, according to Bill Rogers, executive director of the S.C. Press Association, of which The State is a member.
“How they responded should not be covered under patient information,” Rogers said. “The public has a real right to know what they did, what happened. I don’t think that’s an appropriate exemption.”
Avant, a Georgetown native, suffocated on Jan. 22 when hospital employees pinned him face down on a hallway floor and lay on top of him for four minutes, The State exclusively reported Sunday. The employees’ actions departed from the department’s training when they restrained him face down, lay on top of Avant’s back and failed to check his breathing.
“That’s inexcusable. I don’t understand that at all,” said Anna Maria Darwin, an attorney for Protection and Advocacy for People with Disabilities, a federally funded watchdog group for patients like Avant. “If you knew better, and you should have known better — either it’s very poor judgment or you knowingly disregarded your training — you’re not appropriate to provide direct care to people, especially vulnerable adults.”
Able SC, a 25-year-old Columbia-based nonprofit that provides independent living services to people with disabilities, said in a statement this week its leaders were “appalled to hear of this fatal mistreatment of an individual by the professionals who are trusted to provide care.”
“This is just another example of how restraints are just wrong,” Able SC Executive Director Kimberly Tissot wrote. “Restraints remain highly controversial and are dangerous measures used towards individuals with disabilities. When someone is restrained, it’s completely against their will and can often cause serious injury or death. Just like anyone — individuals with psychiatric disabilities deserve to be treated with care in a safe environment. Mr. Avant’s death was completely preventable.”
State lawmakers told The State they are interested in questioning Mental Health — possibly in future House Oversight Committee hearings — about what happened.
Some of those lawmakers said they, too, learned of Avant’s death for the first time from the newspaper’s reporting. An Oversight subcommittee has met nine times this year, but the death has not come up.
“It really troubles me to hear that we can’t even follow basic established protocols,” said state Rep. Micah Caskey, R-Lexington, a member of that committee. “It’s disgusting to hear. It’s the kind of thing that just reeks of gross negligence.”
State Rep. Mandy Powers Norrell, D-Lancaster, called the episode “horrendous.”
“The sad thing is that we learn about so many problems in our state agencies only after a death or multiple deaths like we had at (the April 2018 prison riot at) Lee Correctional,” she said.
Death under review
The Joint Commission said this week it would open a review into Avant’s death and possibly take action against any unsafe conditions at the hospital.
“After reviewing your request, The Joint Commission’s Office of Quality and Patient Safety (OQPS) determined that it was not aware of a patient safety concern … similar to what you described,” Joint Commission spokeswoman Katherine Bronk responded to The State in an email. “In accordance with our policy to review all patient safety and quality issues reported to us that have occurred in the past three years, OQPS is now reviewing the concern.”
A ruling against its accreditation would stain the agency’s reputation and affect its funding. Private insurance companies generally don’t pay for care in unaccredited hospitals, and many of those clinics end up closing.
But that outcome is unlikely.
A 2017 Wall Street Journal investigation found the Joint Commission seldom revokes accreditation, even for hospitals with major safety issues.
The commission revoked accreditation for just 1% of facilities in 2014, and more than 100 of the facilities that violated Medicare requirements that year racked up additional violations over the next two years.
In its defense, the commission has said it would rather work with facilities to fix their issues than take the drastic step of denying them accreditation.
Pearce — who became the commission’s chairman Friday — said he could not discuss details of the case or the agency’s response to it, citing the same confidentiality laws. But he said the commission’s members agreed Mental Health’s response was appropriate.
On Wednesday, after publication of this story, Pearce called The State to say he misspoke and meant only to speak on behalf of himself and not the entire commission.
Shortly after Avant’s death, the entire hospital’s staff was retrained, and department policies were revised to explicitly ban the treatment Avant received, according to records from an investigation by state health regulators.
Several staff members were suspended, regulators found. But Mental Health won’t say how many were suspended, how long they were suspended or whether the agency disciplined them any further.
“I am personally satisfied that everything was done,” Pearce said. “Unfortunately, you cannot undo these types of things when they happen. But you can deal with it very aggressively from a personnel standpoint.”
Pearce was the only Mental Health commissioner willing to comment for this story out of its four current members. The board — whose members are appointed by the governor and confirmed by the state Senate — is supposed to have seven commissioners. But three of those spots are vacant after former Commissioner Sharon Wilson stepped down on Friday, citing an employment conflict.
Of the two other vacant seats, one has been empty since December 2017, and another has been vacant since March 2018.
“I have no comment at all,” Commissioner Robert Hiott Jr., of Pickens, said when reached by phone this week. “I would just refer you to interim director Binkley. He can give you all the information.”
Told that Binkley and the department had declined to answer questions, Hiott replied that he still would not comment.
Asked why not, he said, “There’s no reason except that I will not comment.”
Commissioner Alison Evans, a professional counselor from Hartsville, also would not comment, directing a reporter to Binkley and adding, “It’s really not appropriate for us to talk about it.”
Efforts to reach Commissioner Louise Haynes and former Commissioner Wilson this week were unsuccessful.
Avant’s death was ruled a homicide by Richland County Coroner Gary Watts.
The State Law Enforcement Division investigated Avant’s death but declined to press criminal charges. Despite the investigation being closed, SLED has refused to release the investigation publicly, saying that information, because it pertains to a vulnerable adult, must remain secret.