Patient complaint urged hospital investigation
Institute administrators disagree over commission’s poor
rating
By Donna Wong
Daily Bruin Senior Staff
The investigation resulting in UCLA Neuropsychiatric Institute
Hospital’s probationary standing this year was prompted by a
patient complaint to the Joint Commission on the Accreditation of
Health Organizations, hospital administrators said.
Currently, the neuropsychiatric hospital, which continues to
remain accredited, disagrees with the findings of the initial
investigation and is in the process of clarifying reports, hospital
Director Don Rockwell said on Wednesday.
"We happen to believe that the findings of that survey are
inaccurate, and we’re in the process of working with the joint
commission to get those (things) clarified  and until (then),
we are still clearly accredited," Rockwell said.
Last week, confidential documents were released to a Daily Bruin
reporter indicating that a special survey conducted by the
accreditation commission had knocked the neuropsychiatric
hospital’s standing down to the bottom 8 percent of all accredited
hospitals reviewed by the commission.
The cause of scrutiny was a patient complaint, according to the
hospital’s understanding from the joint commission, Rockwell
said.
"It’s not unanticipated when you have a complicated environment
(such as a hospital). There are going to be patient complaints, and
they often complain to outside agencies," Rockwell explained. "And
we respond to them as appropriate," he added.
Any connections made to an alleged neuropsychiatric patient
suicide in November 1993 is only speculation, Rockwell said.
However, he stated that the investigation’s main concern
appeared to be related to the alleged patient suicide on Nov. 30,
1993. The patient allegedly hung himself in a closet with a
belt.
"We don’t know what the complaint was, but from what they’ve
looked at, they were concerned about the patient suicide," Rockwell
said.
When the accreditation commission was asked to verify the reason
of inquiry, officials declined on the basis of a privacy policy
that restricts the commission from confirming that the inquiry is a
random unannounced survey, or one initiated by a complaint.
And due to its regulations, it would be very unusual for the
commission to reveal the reason for a special survey, said Suzanne
Gylfe, communications representative for the commission.
During the hospital’s examination in June, surveyors arrived
unannounced and cited the hospital with a number of "type one"
recommendations, which must immediately be followed up with
progress reports or a focused survey.
Once the joint commission made its decision on the
neuropsychiatric hospital’s status, hospital administrators were
notified of its low rating by the commission in October 1994 and
given the opportunity to respond. At that time they requested a
December 1994 validation survey of the commission’s findings.
According to the hospital, the commission cited closet door
roller attachments as potentially lethal objects, and therefore a
safety issue for the hospital.
However, the devices have been at the hospital for a prolonged
period of time, and it would be nearly impossible to kill yourself
with them, Rockwell said.
"That’s blatantly an error," he argued.
One recommendation that has already been implemented is the
clearer documentation of UCLA medical resident supervision.
Although the commission criticized the hospital for its lack of
documentation, the facility’s residents have always been supervised
on a daily basis, and this has been documented by faculty-resident
shift schedules, Rockwell explained.
But overall, the hospital believes that there were errors in the
commission’s report. As an example, Rockwell cited a seclusion and
restraint order that he said the commission believed had been
written by a resident. However, a faculty attendant had actually
written the order, he said.
Despite this alleged mistake, the commission was unwilling to
change its report, Rockwell said.
The accreditation commission could not verify such citations
because of their confidentiality requirements on hospital
reviews.