Federal regulators declared a state of “immediate jeopardy” at the University of Minnesota Medical Center last month because the hospital allowed a 13-year-old boy diagnosed with bipolar disorder to run away from one of its psychiatric wards two days after a suicide attempt.
Fairview tightened security practices following the Dec. 5 incident, according to a Medicare inspection report released this week, but the boy’s parents remain upset about the boy’s escape and other hospital missteps they say endangered their son.
“Just problem after problem after problem,” said Ryan Jancik, a longtime boyfriend of the boy’s mother who has power of attorney over the child’s care.
The boy disappeared when a therapist took him and other patients out of the hospital’s locked pediatric psychiatric unit to go for a swim at a nearby pool. He was later found shoeless and in his hospital scrubs a mile away, on the Franklin Avenue bridge. A hospital courier spotted him after being alerted along with all other hospital staff to the disappearance. The driver had the boy in a headlock while waiting for officers to arrive, according to a police report.
The incident is the latest in a series of controversies regarding behavioral health at the university’s primary teaching hospital, including allegations of coercing patients into research, that have resulted in new leadership and ethics policies.
A Medicare finding of “immediate jeopardy” at a hospital is rare — other examples include security lapses related to a shooting at St. Cloud Hospital in 2015 and a medication error last fall at Abbott Northwestern Hospital in Minneapolis during a nursing strike.
Most hospitals respond to the sanction with immediate changes, because the alternative is being dropped from the federal Medicare program and losing millions of dollars in patient revenue.
Apparent suicide attempt
Fairview declined to make a behavioral health expert available to address the Medicare report or Jancik’s complaints but said in a written statement that “patient safety is of the utmost importance to us.”
Jancik said he and the boy’s mother went public about the incident in hopes of producing changes and more accountability from the hospital. They spoke on condition of withholding the identities of the mother and son, neither of whom were named in the Medicare report.
Medicare investigators pointed out the ease with which a therapist took the boy from his unit, just two days after he was found in his hospital room with a sweatshirt stuffed down his throat and a blanket wrapped around his neck.
The boy was described in the Medicare report as discolored due to asphyxiation. He told his parents he lost consciousness, but hospital workers told Medicare officials that the boy removed the sweatshirt and blanket himself.
After the apparent suicide attempt, a psychiatrist ordered that the boy not be allowed outside the unit and be checked on every 15 minutes.
Those orders were in place when a recreational therapist took him to the pool two days later. A charge nurse wasn’t around to approve the trip, so the therapist checked nursing records and found no indication that the boy was barred from going, the Medicare report said.
After he ran away, the boy told hospital workers he didn’t know where he was going and that he walked to the bridge to try to get home, not to hurt himself. But Jancik said it was “very dangerous” to allow an impulsive and unstable teen to reach a bridge over the Mississippi River.
Minnesota law requires hospitals to report certain “adverse events” involving patient harm, but Fairview determined that it wasn’t required to conduct an analysis of this event because a review is mandated only if a patient disappearance results in a death or severe injury. The incident consequently won’t show up in the state’s tally of adverse events. (Hospitals have reported nine disappearances since 2005, including two from the U hospital that resulted in patient injuries.)
Fairview officials nonetheless ordered changes last month in security, before and after Medicare made its “immediate jeopardy” declaration on Dec. 12. Changes included an immediate suspension of off-unit activities for pediatric psychiatry patients. Hospital officials then imposed tighter rules on who can authorize off-unit trips, clearer requirements for documenting which patients can leave the unit, and a higher ratio of staff to patients on these trips. The therapist who took the boy was reprimanded.
The boy involved in the runaway also has autism and has spent more than 200 days in psychiatric hospital wards or residential treatment facilities.
Jancik accused Fairview of other shortcomings, including a failure to conduct 15-minute checks during the times when he was visiting the boy. He also faulted the hospital for giving the boy the antipsychotic drug Zyprexa, because the family had asked that it not be given due to the dangers of interactions with other drugs and the risk of causing heart problems.
He also faulted Fairview for discharging the boy on Dec. 12 to a residential treatment center in Austin, Minn. Two days after the boy arrived at the Gerard Academy treatment center in Austin, Jancik received a call that the psychiatrist there thought Fairview had discharged the boy prematurely. He had tried to run away twice and fought with staff when they restrained him.
The boy was transferred to the Children’s Hospital emergency room in Minneapolis, where he waited five days until a bed opened up at the PrairieCare child psychiatric hospital in Brooklyn Park.
The boy has now been there for 39 days as doctors adjust his medications to address ongoing hallucinations.
Staff writer Brandon Stahl contributed to this report.