Paragraph 30 reads: "The records also show Keene’s psychiatric history, and that she had been prescribed anti-depressants. "

http://www.wsls.com/sls/news/local/article/carilion_rmh_faces_multiple_investigations/17493/

By Mollie Halpern
Investigative Reporter
Published: September 23, 2008

When Jennifer Foley married the love of her life, she chose another great love to be her maid of honor—her mother, Cheryl Keene.

Years later, Keene became a proud grandmother of four.

Foley says her mother didn’t look like the typical granny—despite her struggle to overcome drug addiction—she was beautiful.

Jennifer Foley, Keene’s daughter, says, “She’s battled a lot of things but she’s always had the strength to make it through it.”

Keene’s strength was put to a final test back in July. That’s when an ambulance rushed her to the emergency room at Carilion Roanoke Memorial Hospital after she claimed she fell and hurt herself.

Roanoke Memorial Hospital (RMH) medical staff tested Keene for both brain and bone injuries. The test results showed she had none.

But Keene was far from healthy.

WSLS 10 On Your Side obtained internal documents from the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services, and RMH with the help of Keene’s family. The documents raise serious questions about Keenes’ health, and whether hospital staff gave her adequate care.

One report shows that while Keene was in the ER, she used a broken mirror to try to slash her wrists after learning she was going to be discharged.

The doctor said Keene was demonstrating drug seeking behavior. In other words, he believed Keene came to the ER looking to get prescription medications.

Foley says Keene’s friend called to tell her that her mom was in the hospital. Foley says when she got to the ER, her mom was crying. “Nobody would help her she felt, she felt that nobody understood and that nobody wanted to be there for her,” Foley told us.

According to Virginia Mental Health Documents, the ER doctor asked that an employee of Blue Ridge Behavioral Health (BRBH) evaluate Keene. The BRBH prescreener says Keene was “clearly in distress,” despite her claim that she wouldn’t try to harm herself again.

Keene would go back on her word. According to RMH nurse notes, at 10:00 p.m. that night, Keene said she wanted to leave and quote “go slit her wrists”, again.

Foley was trying to comfort her mother. “I hugged my mom and I told her that I loved her and that everything was going to be ok,” Foley told us.

Documents show the prescreener determined that Keene was enough of a danger to herself, that a court order was necessary to have her detained in a psychiatric unit. The same documents show Keene had been placed on “medical hold,” which means staff would be watching her and not allow her to leave.

Foley believed her mom was in safe hands, so she decided to go home to her children.

Later that morning, Foley got a phone call from the ER doctor, one she wishes she never would have had to answer. At 10:23 a.m., Keene was found on the floor, with no pulse.

She was placed in the bed. Again, no pulse.

A team began CPR.

14 minutes later, at 10:37 a.m., 44-year old Keene was dead.

Foley says, “I’m going to live without my mom for the rest of my life!”

Keene’s autopsy results from the chief medical examiner’s office show the cause of death was ruled a suicide.

Keene’s death certificate shows that she “hung (her)self using an electrical cord.”

But how was she able to do that without anyone noticing?

According to RMH documents, Keene was sleeping and a security officer was at her bedside at 9:17 a.m. By 10:23 a.m. when a nurse was called to her room, Keene had hanged herself.

Foley claims the doctor admitted to her, that her mom was left alone. Foley says that her mom had asked for privacy, and staff granted that request because Keene seemed talkative and the lights were bright.

But Foley says those weren’t good enough reasons. Foley says when staff *closed* the curtain around her mom’s bed, they *opened* an opportunity for her to kill herself.

“The safest place is supposed to be the hospital. I understand that doctors and nurses are not God, but they are responsible,” Foley told us.

What’s more, the medical staff apparently *knew* or at least suspected the fragileness of Keene’s mental state. Not only had she tried to slash her wrists in the ER, medical records show Keene was at RMH on July 7th, 8th, 9th, 10th, 11th, 12th, and on the 17th and 18th. That’s 8 *other* days *before* she was admitted the final time.

The records also show Keene’s psychiatric history, and that she had been prescribed anti-depressants.

So how did this happen? That’s a question we put to Carilion spokesman, Eric Earnhart.

Mollie asks: “What could have possibly happened with all that information that the doctors knew and given the rarity of it anyway, that would’ve allowed this to happen?”

Earnhart answers: “I understand your interest and your question, I’m not at liberty to discuss any patient’s specific case.”

Earnhart would not say whether any hospital staff has been disciplined, or if policies have been changed as a result of Keene’s death. He does tell 10 On Your Side, that the hospital is conducting an internal review of Keene’s case to see if there is anything it could have done better.

Mollie asks Earnhart: “Would you admit fault in this situation? Obviously a woman died, obviously you didn’t do the best that you could do.”

Earnhart replies: “Well, we’ll review this situation as we would review any situation and if in this situation there’s something we could’ve done, something we could’ve fixed, we’ll acknowledge it and we’ll fix it.”

That’s not the only investigation RMH faces.

10 On Your Side called The Joint Commission, which accredits and certifies U.S. health care organizations, to ask about Keene’s suicide.

But, the commission wasn’t aware of it.

Since our call, the commission has launched an investigation into Keene’s suicide at the hospital. The commission requires hospitals to follow standards of care when treating patients with self-destructive behaviors. But the commission doesn’t specify how to do that.

Neither does the state.

The Virginia Department of Health allows hospitals to make their own policies and procedures to meet patients needs. The department licenses hospitals, and has also launched its own investigation.

Earnhart says the hospital is cooperating with all the investigations.

But, whatever the findings, Foley says it won’t change the fact that she’s left with only the memories of her mother.

We talked with a spokesperson with the “Centers for Medicare and Medicaid services”—that’s the federal agency which administers medicare and medicaid.
The spokesperson tells me that an August inspection showed that carilion is *not* in full compliance with medicare regulations.
As a result, the federal agency has put Carilion “On Notice”...meaning that the hospital is required to put together an agency-approved corrective action plan.
The hospital must implement that plan within a certain timeframe.
Carilion has 90 days to come back into compliance—so that will be early next year.
In the meantime, the hospital is facing another “full survey” in relation to its medicare compliance --- which is more comprehensive than an inspection.
If Carilion does not come back into compliance—there will be repercussions.
The federal agency says the hospital’s federal medicare payments will be terminated.
Also just today- Carilion acknowledged to me that it has --quote- “already made changes to prevent a similar incident from occuring.”
But—it still won’t say what those changes are.
Keene was on medicare.
Of course, we will continue to follow this story and as soon the results of the investigations are available, we will bring them to our viewers.

Resources are available to those with depression and thoughts of suicide. It is encouraged to contact any of these websites or phone numbers for help:

National Alliance of Mental Illness - http://www.nami.org
Virginia Department of Mental Health Mental Retardation and Substance Abuse Services - http://www.dmhmrsas.virginia.gov
Mental Health America - http://www.nmha.org
American Foundation For Suicide Prevention - http://www.afsp.org
National Suicide Prevention - 1-800-273-TALK or 1-800-273-8255
TTY for “National Suicide Prevention” is 1-800-799-4TTY (4889)
The suicide rate doubles the number of murders in the Commonwealth—but they are *rare* in hospitals.
Click here for a map that shows where suicides in hospitals have taken place across the state.