03/13/09 — Patient death at O'Berry labeled 'unexpected'

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Patient death at O'Berry labeled 'unexpected'

By Phyllis Moore and Catharin Shepard
Published in News on March 13, 2009 1:46 PM

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Officials are investigating the death of a female patient Wednesday at O'Berry Center. Calling it "unexpected" and "unusual," officials say four employees have been placed on paid investigatory leave while state and federal officials look into the incident. State officials say they do not suspect patient abuse.

Four employees at O'Berry Neuro-Medical Treatment Center are on paid investigatory leave following the death of a female facility resident Wednesday evening. But, while a state report classifies the death as "unexpected," and officials are calling it "unusual," they do not suspect abuse to be the cause.

"From the information, we do not think abuse was a factor," said Brad Deen, spokesman for the North Carolina Department of Health and Human Services.

He explained that the very nature of O'Berry Center is that it is a facility for people with profound disabilities, who often are also dealing with serious medical issues requiring a higher level of medical treatment.

And, he continued, that means that deaths in and of themselves are not uncommon at O'Berry. But, he said, in this case there are "circumstances around it that are unusual."

"This is highly unusual in that in this resident's death, we are still trying to determine what happened and how this person died."

According to O'Berry's Web page, the death of a female patient on March 11 was categorized as "unexpected." Of the nine deaths reported since Jan. 29, 2008, only two were unexpected.

Two supervisors and two health care technicians directly responsible for providing patient care were immediately removed from patient care after the incident.

Citing federal and state confidentiality laws, as well as the multiple investigations, officials have not released the names of the resident or the employees, or any details about the incident. The resident's family has been notified though, Deen said.

Cherry Hospital police and the Medicaid Investigations Unit of the state Attorney General's office are looking into the incident.

"I can't say a lot because it is under investigation," Deen said.

Chief James Mitchell Jones of Cherry police and Dr. Frank Farrell, O'Berry Director, also declined comment.

"I would like to, but we have been advised to refer any inquiries to (DHHS) public affairs," Farrell said this morning.

The Office of the Chief Medical Examiner in Chapel Hill performed an autopsy and expects to have final results within 90 days.

"Law enforcement has been called in, and a thorough investigation into this incident is being conducted," Department of Health and Human Services Secretary Lanier Cansler said in a statement released Thursday afternoon. "In keeping with our zero-tolerance policy, any employee whose actions contributed to the death of this patient will be held accountable. We will also be reviewing our policies to determine if changes are warranted."

The zero-tolerance policy was instituted on Feb. 4 by Gov. Beverly Perdue to address ongoing problems of abuse and neglect of patients and the failure to make the proper notifications of any such incidents at state facilities.

Such incidents have occurred at state mental health facilities, including Cherry Hospital, Central Regional Hospital in Butner and the Caswell Center in Kinston.

"We try to run a tight ship at all of our facilities but we have had some problems," Deen said. "Some situations have been very public. One of the things that the governor herself has stressed and that we are emphasizing newly is patient safety ... we're emphasizing that abuse and neglect is wrong at our facilities. And the Secretary (Cansler) has instituted a zero-tolerance policy, so we're taking anything like this very very seriosly. We always have but we're really emphasizing that now."

O'Berry Center is a specialized residential facility for individuals with chronic medical conditions and developmental disabilities.