By Scott Finn
West Virginia Public Broadcasting
CHARLESTON, W.Va. -- Three clients of Northwood Health Systems, one of West Virginia's largest mental health providers, have died while under the agency's care in the last two months.
Two of these deaths and other incidents led the state Office of Health Facility Licensure and Certification not to renew Northwood's license to operate.
Clarice Hausch, director of West Virginia Advocates, said reports from state investigators suggest a pattern of abuse and neglect at Wheeling-based Northwood.
"I've been doing this work for more than 30 years, and these are some of the most egregious allegations I've ever seen," she said.
"Their lives are being put at risk. There are things in [these reports] that could have, and in some situations may have, caused people to die."
A Sept. 8 administrative order from OHFLAC Director John Wilkinson announced that Northwood's license would not be renewed as of Oct. 1 because "the center conducts practices that jeopardize the health, safety, welfare and clinical treatment of consumers."
But Northwood still is operating under that license, according to Department of Health and Human Resources spokesman John Law. OHFLAC is a division of DHHR.
Law said Wilkinson, who one month ago told Northwood to shut down, has agreed to allow Northwood to stay open.
"While those negotiations are going on, the license expiration is stayed," Law said, until the negotiations are complete.
In a prepared statement, Northwood spokesman John Culler said the organization takes its responsibility to care for patients very seriously.
"Northwood's chief executive officer and board of directors are disappointed, frustrated and angry that the poor judgment of a small number of individuals compromised the quality of care for some of our patients. The employees involved are either no longer working at Northwood, or they have been disciplined," he wrote.
Culler said he could not discuss the deaths, because of privacy concerns.
"We have privately communicated our thoughts and prayers to the families of the deceased, as well as our support," Culler said.
The three clients died in a one-month span, starting Aug. 26, when one woman died in a Northwood staff member's vehicle in Ohio County.
According to an OHFLAC report, there was no attempt to do CPR on the client, even though there should have been. Northwood's report of the incident omits the fact CPR was not performed.
On Aug. 30, a suicidal woman was found dead at a New Martinsville crisis facility run by Mid-Valley Healthcare, a subsidiary of Northwood. She was supposed to be on "suicide observation," but staff did not know she and six other clients were suicidal, according to an OHFLAC report.
Investigators said the residential crisis unit was understaffed, with only two people supervising 15 residential clients.
She was supposed to be checked every 15 minutes, but when a staff member found her at 6:45 a.m., she was not breathing and had already turned blue. Her neck was stiff and mouth clenched tightly shut.
"The fact that staff ... did not observe Consumer #1 for any sounds and/or movement from 3 a.m. to 6:45 a.m., even though she was listed as 'Suicide Observation,' was a neglectful act," the investigator's report says.
A staff member attempted to perform CPR, but failed to do any rescue breathing. Also, the CPR was performed with the woman still in bed, even though that is ineffective, because the two staff members could not lift her and place her on the floor.
For most of the night, one staff member was doing laundry and cleaning tasks instead of helping supervise clients. This, investigators said, "poses potential harm considering eight consumers were on a monitoring status of 'Suicide Observation.' "
On Sept. 21, a medically fragile woman with a developmental disability died at the Ritz Avenue group home in Wheeling, run by Northwood, according to Hausch.
She says she received that information from state regulators, although they have not yet released the investigative report on the death.
By Scott Finn
West Virginia Public Broadcasting
CHARLESTON, W.Va. -- Three clients of Northwood Health Systems, one of West Virginia's largest mental health providers, have died while under the agency's care in the last two months.
Two of these deaths and other incidents led the state Office of Health Facility Licensure and Certification not to renew Northwood's license to operate.
Clarice Hausch, director of West Virginia Advocates, said reports from state investigators suggest a pattern of abuse and neglect at Wheeling-based Northwood.
"I've been doing this work for more than 30 years, and these are some of the most egregious allegations I've ever seen," she said.
"Their lives are being put at risk. There are things in [these reports] that could have, and in some situations may have, caused people to die."
A Sept. 8 administrative order from OHFLAC Director John Wilkinson announced that Northwood's license would not be renewed as of Oct. 1 because "the center conducts practices that jeopardize the health, safety, welfare and clinical treatment of consumers."
But Northwood still is operating under that license, according to Department of Health and Human Resources spokesman John Law. OHFLAC is a division of DHHR.
Law said Wilkinson, who one month ago told Northwood to shut down, has agreed to allow Northwood to stay open.
"While those negotiations are going on, the license expiration is stayed," Law said, until the negotiations are complete.
In a prepared statement, Northwood spokesman John Culler said the organization takes its responsibility to care for patients very seriously.
"Northwood's chief executive officer and board of directors are disappointed, frustrated and angry that the poor judgment of a small number of individuals compromised the quality of care for some of our patients. The employees involved are either no longer working at Northwood, or they have been disciplined," he wrote.
Culler said he could not discuss the deaths, because of privacy concerns.
"We have privately communicated our thoughts and prayers to the families of the deceased, as well as our support," Culler said.
The three clients died in a one-month span, starting Aug. 26, when one woman died in a Northwood staff member's vehicle in Ohio County.
According to an OHFLAC report, there was no attempt to do CPR on the client, even though there should have been. Northwood's report of the incident omits the fact CPR was not performed.
On Aug. 30, a suicidal woman was found dead at a New Martinsville crisis facility run by Mid-Valley Healthcare, a subsidiary of Northwood. She was supposed to be on "suicide observation," but staff did not know she and six other clients were suicidal, according to an OHFLAC report.
Investigators said the residential crisis unit was understaffed, with only two people supervising 15 residential clients.
She was supposed to be checked every 15 minutes, but when a staff member found her at 6:45 a.m., she was not breathing and had already turned blue. Her neck was stiff and mouth clenched tightly shut.
"The fact that staff ... did not observe Consumer #1 for any sounds and/or movement from 3 a.m. to 6:45 a.m., even though she was listed as 'Suicide Observation,' was a neglectful act," the investigator's report says.
A staff member attempted to perform CPR, but failed to do any rescue breathing. Also, the CPR was performed with the woman still in bed, even though that is ineffective, because the two staff members could not lift her and place her on the floor.
For most of the night, one staff member was doing laundry and cleaning tasks instead of helping supervise clients. This, investigators said, "poses potential harm considering eight consumers were on a monitoring status of 'Suicide Observation.' "
On Sept. 21, a medically fragile woman with a developmental disability died at the Ritz Avenue group home in Wheeling, run by Northwood, according to Hausch.
She says she received that information from state regulators, although they have not yet released the investigative report on the death.
The woman was supposed to be checked on a regular basis, Hausch said.
Hausch said one more thing makes this death particularly egregious - it occurred after the state sent Northwood a letter saying it was refusing to renew its license to operate.
Hausch also pointed to several non-lethal but still disturbing incidents in other parts of these OHFLAC reports, most of them conducted starting in May.
On May 15, witnesses told police they saw Northwood employee Patricia Wheeler of Wheeling hitting and cussing at a client who is blind and has dementia and Down's Syndrome.
According to the criminal complaint filed in Ohio County Circuit Court, one witness saw Wheeler yelling "Get in the f--ing wheelchair" and forcibly hitting the elderly woman's back and arm with the wheelchair, and striking her on her arm with her hand.
The alleged victim, Mary Ann Kaib, and four witnesses confirmed the assault, according to the criminal complaint by Officer Sara Throckmorton of the Wheeling Police.
But Ohio County assistant prosecutor Shawn Turak said Thursday the charges were dismissed. Turak said Wheeler admitted she was yelling and swearing at Kaib, but she did not hit her.
Turak said Wheeler received a good character reference from Northwood, and witnesses gave conflicting statements about what happened.
Also, according to OHFLAC investigative records:
In March at Northwood subsidiary Mid-Valley Healthcare, an employee used a chair to barricade a man with a developmental disability in his bedroom.While trapped, the report says he ate a portion of his own adult diaper, according to a state investigative report. Northwood denies this, saying in a statement, "There is no evidence our client had anything in his mouth like the material described by the disgruntled former employee."
Staff also dressed this male client in a female bathing suit and bra and posted photographs of him in his living area - a place where management visited and therefore "knew or should have known of their existence."One staff member dressed up as a client for a Halloween party.In April, a staff member had one client lick cake icing off his face. Pictures were taken and e-mailed to others.One staff member taught a client to insult other clients with sexual slang.Police responded to a call about a client sitting in a pickup truck that was not his. He had wandered away from his house, where an employee was fixing a toilet. During that time, the employee billed Medicaid as if he were watching three clients, when in fact two of them were at a day program.A client in the Ritz Avenue facility in Wheeling had an MRSA infection, which is contagious and highly resistant to treatment, but the facility failed to treat it properly, and was not taking sufficient precautions to prevent the disease from spreading, according to an OHFLAC report.On July 3, one client was left alone in a Northwood van for an hour as an employee made a personal errand. Employees had been allowed to use company vehicles for personal errands, although a supervisor said she put an end to it - on July 6. Northwood says the client was left alone, but the employee was visiting another client at the hospital, not on a personal errand.On June 17, a Subway employee called Northwood "concerned about how a staff member had treated" a consumer, and that the staff member was yelling and pushing the consumer. Northwood said its internal investigation showed the employee was actually trying to protect the client by preventing her from pulling a rack of potato chips down on top of herself.Hausch received most of those reports Thursday morning, and tears came to her eyes several times as she discussed them later that afternoon.
"There's blatant and intentional abuse in some of these allegations of very vulnerable individuals," she said.
"At one point I had to stop reading because I was crying. I really wanted to put the whole thing down and not finish reading it because it was so upsetting," she said.
Law downplayed the incidents cited in OHFLAC's reports.
"I don't know if this is above and beyond the usual concerns. We do OHFLAC surveys all the time. This just happened to come up at a time when their license was to be renewed," Law said.
Law said the decision to extend Northwood's license was made by OHFLAC, and that DHHR Secretary Patsy Hardy or other high-ranking DHHR officials did not influence that decision.
He says it is common to work with providers "past their licensure period" to correct deficiencies.
These deaths and incidents have not been reported in the media before now, although the issue of Northwood's license non-renewal has.
Northwood spokesman Culler told WTOV-TV in Wheeling "that the issues the state identified are relatively minor," according to the television station's Web site.
"He would not specifically name the problems, but said they can range from physical issues to record keeping to patient care issues," the Web site says.
On Thursday, Culler said in a statement, "We take very seriously the three deaths that have occurred at Northwood.
"Northwood serves a population that is at risk, often both physically and emotionally. Many of our clients are not in the best of health, and some are elderly and have a wide range of health problems. Based on the information we have, the deaths that occurred were a result of natural causes," Culler said.
Hausch said she didn't know if shutting Northwood down would do more harm than good. But she said she wants to hear DHHR and Northwood officials admit there's a serious problem.
"The most disturbing thing for me is there is an organizational culture that is seeing the people with disabilities that they are serving as having no right to dignity, no right to privacy and no right to respect," she said.
"They're being treated as objects, not as people."
West Virginia Public Broadcasting reporter Keri Brown contributed to this story, which is part of a collaboration between WVPB and The Charleston Gazette.
To hear an audio version of this story, go to www.wvpubcast.org/news.
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My wife and I saw at the Moundsville Wal-Mart tonight, a mother yelling, screaming, pulling the the child by the arm. I can see the headlines now ALL MOTHERS LOSE CHILDREN FOR ABUSE.
Those employees should be held accountable and I sure Northwood like any other company would not of hired those employees, and would never of thought someone would do such things. Maybe these are the people who don't care and are only there for a paycheck, no matter how little it may be.
I'm sure 99% Northwood employees care including the CEO!