In the News - Slater Hospital Woes Part of Bigger Story of Neglect. The History, and Hope for Change
By G. WAYNE MILLER | THE PROVIDENCE JOURNAL
CRANSTON — If Eleanor Slater Hospital were a patient, it would be listed in serious, if not critical, condition. The state-run facility that treats some of the state's most physically and mentally unwell people has been afflicted with leadership mismanagement, questionable monetary practices and alleged patient negligence. Attorney General Peter F. Neronha is investigating "a multitude of pervasive issues," as a leading state legislator describes the situation.
This year has brought a cascade of developments and disclosures about Slater that have shaken confidence in the ability of the hospital, which has campuses in Cranston and Burrillville, to care for and protect patients. Consider some of the many recent events:
In August, a patient was seriously injured in an eye-gouging incident that triggered a review by the federal Centers for Medicare & Medicaid Services.
In October, a patient with a history of self-harm was found face-down in a bathroom with a hospital gown string around her neck. The patient had swallowed part of a razor blade and was taken to Rhode Island Hospital, where the blade was removed.
And in May, documents confirmed that Slater administrators knew about leaking oxygen valves for many years before deciding to relocate oxygen-dependent patients who were living at the Burrillville unit, Zambarano.
These and other incidents at the hospital have brought scrutiny not only from Neronha's office but also from other state agencies, the federal government, the federally funded Disability Rights Rhode Island organization, and other authorities. They have angered
advocates and brought public calls for system-wide reform. In March, for example, state Mental Health Advocate Megan N. Clingham called the continuing discharge of Slater patients, some to circumstances that guardians and relatives described as inadequate for their needs, as "inhumane." Laurie-Marie Pisciotta, executive director of the Mental Health Association of Rhode Island, said, "the state has not invested in the full continuum of behavioral health care, and we are left with a dilapidated, broken, insufficient system."
James McNulty, executive director of Providence-based Oasis Wellness & Recovery Centers, added, “The system really needs a redesign from the bottom up, carefully ensuring adequate resources to meet the needs people have now.”
And in June, the Joint Commission for the Accreditation of Health Care Organizations documented dangerous conditions and abusive language at the Zambarano unit, prompting state Sen. Jessica de la Cruz, whose district includes Burrillville, to call the findings "shameful." She added: "I am appalled and dismayed by the shocking findings in this report."
This year has been the culmination of years of missteps at Slater as politics, bureaucracy and diminishing public support combined to transform a facility once considered a model hospital into an institution now in deep trouble. Some responsibility rests with the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, BHDDH, which runs the hospital, which this fiscal year has a budget of $523.6 million, provided primarily through taxpayer dollars. This fiscal year, the hospital itself has a budget of $115.9 million.
Also implicated, advocates contend, are the Department of Children, Youth and Families, the Department of Corrections, and the criminal-justice system generally — and, they assert, governors and state legislators who in recent years have rarely placed the needs of some of Rhode Island’s most vulnerable residents near the top of the agenda.
“Mental health advocates have been meeting about the situation at the Eleanor Slater Hospital,” advocate Charles Feldman of the Oasis Wellness & Recovery Centers of RI told The Journal. “We know people who have required hospitalizations of a significant length, and who have used their stays at Slater to move on to recovery. Lately, people have been discharged before they are ready, with no adequate place to go, or they have not been admitted to Slater at all.”
Sen. Lou DiPalma, chairman of the state Senate's Rules, Government Ethics and Oversight Committee, sees the decline of Eleanor Slater Hospital as part of “a multitude of pervasive issues, which have existed for years, throughout the entirety of the mental health care, behavioral health care and developmental disabilities systems."
Lou DiPalma, chairman of the state Senate Rules, Government Ethics and Oversight Committee, told The Journal: “There are a multitude of pervasive issues, which have existed for years, throughout the entirety of the mental health care, behavioral health care and developmental disabilities systems. Additionally, there are a myriad of challenges at Eleanor Slater Hospital, which have languished for years and without resolution.”
Once, RI was a national leader in mental health, It has not always been thus
In the 1980s, Rhode Island politicians and department officials, with the support of taxpayers, began a move away from the dark days of institutionalization toward a model system of care built around reputable state hospitals and associated community services that would be hailed as a national leader.
In the 1990s, the Institute of Mental Health — where patients had been warehoused for decades under inhumane conditions — closed, with its last patients moved into the community or Eleanor Slater Hospital. During the same period, the Ladd Center in Exeter, where people living with developmental and intellectual disabilities had suffered under similarly barbaric mistreatment, also closed, its last residents moved to group homes and other community settings.
And then, slowly at first, the systems began to fracture. Many legislative champions left office or found other causes. Governors shifted their priorities elsewhere. Needy individuals and their families and allies, including the offices of the state's child and mental health advocates, began to sound alarms, but the broad coalition of the 1980s and '90s had dissolved. The advent of the opioid epidemic was largely met with arrests and incarceration, not preventive and recovery care. Funding was cut.
An early sign of the troubles ahead came in March 2007 during a hearing of the House Finance Committee, which was considering then-Gov. Donald Carcieri’s proposed budget. It included flat funding for the predecessor agency to BHDDH (the Department of Mental Health, Retardation and Hospitals) — and a savings of $5.4 million at Slater by outsourcing and privatizing housekeeping and dietary jobs.
“It would have an awful impact on the economy and everything else,” said Frank Beazley, the longtime Zambarano resident and nationally renowned disabilities-rights advocate who died in 2012.
“To put a dollar factor on quality of life is really a shame,” testified Bill Feole, who had been at Zambarano for almost two decades.
Years of decline in a 'deeply troubled system'
The ensuing years brought further decline, of sufficient magnitude that the federal government took notice: In January 2014, a U.S. Department of Justice investigation found civil-rights violations in BHDDH’s day programs for about 3,600 adults with intellectual and developmental disabilities. The department entered into a consent decree, which is still being overseen in U.S. District Court.
The need for change was acknowledged, but little positive happened. A 2014 Journal investigation, “Mental Health in Rhode Island,” chronicled pervasive problems in the system serving people with psychiatric and substance-use disorders. If more evidence was needed of what some were calling a disaster, it arrived in December 2015 with the release of the so-called Truven report, a year in the making.
"Although Rhode Island allocates significant resources to its behavioral health delivery system, the service, financing, and organizational accountability mix may not be distributed in a manner that leads to optimal, cost-effective, outcomes," the study authors wrote. "Without the glue that ties these services together, children experience toxic stresses that put them at high risk for the development of behavioral health disorders. Individuals may cycle into and out of hospitals, choose not to take their medications, develop physical illnesses such as diabetes and hepatitis, become homeless or imprisoned, and are at much higher risk of early death."
A later Journal investigation in 2016 concluded that “years of budget cuts and failed government leadership have diminished Rhode Island’s system of care for intellectually and developmentally disabled people from a national model two decades ago into a deeply troubled system today, where financial considerations, not quality of life, often are the deciding factor.”
Meanwhile, the problems at Slater Hospital continued to intensify, as state police investigated the apparent physical abuse of three unidentified patients with profound disabilities and the hospital was faulted by a national accrediting organization for suicide risks to patients.
A steady churn in the leadership ranks
Leadership churn has exacerbated the situation. Over the last 20 years, several BHDDH directors have come and gone. They include Kathryn Power, who served twice; Jane Hayward; Kathleen Spangler; Craig Stenning; Maria Montanaro; Rebecca Boss; and Womazetta Jones, secretary of the Executive Office of Health and Human Services, who served on an interim basis as her agency studied the factors behind Slater's troubles. Currently, Richard Charest heads the agency.
A staffing crisis recently in agencies serving the homeless and individuals with behavioral health and opioid-use needs also has compounded the situation. At the same time, people including Rafe Sweeney, who lives with bipolar and schizoaffective disorders, are "boarded" at exorbitant cost at private hospitals because there is no place for them in a less expensive community-based setting.
In February, 28-year-old Aiyana Milton was charged with setting a fire at an apartment complex in Warwick that displaced 60 residents. Diagnosed with schizoaffective disorder as a child, Milton had been discharged from Slater after being a patient there for seven years. Her mother told The Journal that the discharge was because Slater was attempting to lower its population.
And in September, BHDDH spokesman Randal Edgar confirmed that the federal Centers for Medicare & Medicaid Services is investigating an incident during the summer in which a Slater patient was seriously hurt in a self eye-gouging incident using a utensil that "was not retrieved from the patient by the assigned staff after his meal as per policy and procedure," according to a memo obtained by The Journal.
Neronha's probe of Slater continues.
"Our review of the situation at the Eleanor Slater Hospital, particularly as it relates to patient care, continues," spokeswoman Kristy dosReis told The Journal in late October. "To date, we have reviewed thousands of documents and interviewed numerous personnel regarding past and ongoing operations at these hospitals. This is a complex investigation involving both the Medicaid Fraud Control and Patient Abuse Unit in the criminal division and the Health Care Advocate in the civil division. We will announce our findings when the investigation is complete."
Meanwhile, limited options for treatment of children and adolescents with behavioral health needs have angered Family Court Chief Judge Michael B. Forte and Judge Lia Stuhlsatz. In a November hearing, Stuhlsatz was highly critical of DCYF, which has responsibility for people under the age of 18. Speaking to an agency lawyer who described "a shortage of placements," the judge said: "You’re supposed to do something because you know it’s a problem, to get out in front of it, not just be a referral agency. This is not like I dropped my stuff at the dry cleaners and it hasn’t come in yet. ... This is: you got to build your own dry cleaner. I’m no clinician, but the trauma of just being stashed in the first bed available has got to be as bad as waiting for a bed. We are almost becoming numb to the disservice.”
Family Court Judge Lia Stuhlsatz has been highly critical of DCYF over its limited options for treating children and adolescents with behavioral health needs, saying at a hearing this month: "We are almost becoming numb to the disservice.”
Some successes amid the setbacks
To be sure, there have been successes. Some patients and clients of state-run and government-funded private programs praise the quality of their care. A July report by a team from the Hospital Association of Rhode Island and Care New England gave overall good grades to the care provided at Slater, while warning against “wholesale” discharges of patients.
The state's community-based behavioral-health triage center and 24-hour hotline, BH Link, has received near-universal acclaim. Programs such as a new one from Thrive Behavioral Health and CODAC Behavioral Healthcare that expands medication-assisted treatment for people living with opioid-use disorder also have been praised.
Enough progress has been made toward bettering the lives of Rhode Islanders living with intellectual and developmental disabilities that U.S. District Court Judge John J. McConnell Jr. on Oct. 21 accepted a plan of action to bolster services and support. He called the development in the long-running federal civil rights case "historic."
'Disjointed and underfunded system of care'
Those hoping to right the ship feel frustration. Said Laurie-Marie Pisciotta, executive director of the Mental Health Association of Rhode Island and a woman who lives with PTSD: “It’s not surprising that we have a disjointed and underfunded system of care. Rhode Island is one of seven states that does not have an Olmstead Plan or cohesive strategy for people with disabilities, older adults, and youth.”
Olmstead Plans result from a 1999 U.S. Supreme Court ruling that “states have a legal obligation to ensure that people with disabilities can live, work and receive services in the least restrictive setting permitted by their disabilities,” Pisciotta said. “Rhode Island is 20 years behind the times.”
Ben Lessing, president and CEO of Community Care Alliance and one of the leaders in a statewide effort to resolve a workforce crisis in behavioral health care, said: "Overall, we need systems that are compassionate, utilize best practices and are supported by public and private partnerships between state agencies and community-based nonprofit organizations. The General Assembly needs to become more informed as to how such systems of care can work effectively."
"Overall, we need systems that are compassionate, utilize best practices and are supported by public
and private partnerships," said Community Care Alliance president and CEO Ben Lessing.
Morna A. Murray, executive director of Disability Rights Rhode Island, told The Journal that included among "the serious problems" the organization sees are "wrongful denials of eligibility for services from BHDDH; individuals stranded in inappropriate settings such as psychiatric facilities and nursing homes due to the lack of community-based residential options; mistreatment of highly vulnerable individuals within inappropriate settings; and individuals having to go out of state, away from family and friends, to access appropriate services."
Are better days on the way?
Are improvements finally coming? Possibly. The new director of BHDDH, former Landmark Medical Center president and CEO Charest, took office in May declaring, "We have an opportunity to make meaningful change to a critical state department that is decades overdue."
He was appointed by Gov. Dan McKee, who said, “We are confident that Richard’s decades of experience in the health care field have prepared him to lead this department which provides vital services and support to some of Rhode Island’s most vulnerable populations."
After a top mental-health job in the nation's capitol, Dr. Elinore F. McCance-Katz returned to Slater a few weeks ago as chief medical officer. Oasis Wellness & Recovery Centers of RI advocate Feldman, who is in recovery from schizophrenia, is encouraged, telling The Journal, "We hope that under the new leadership of Elinore McCance-Katz, that things will turn around and Rhode Island can once again be a champion in mental health care.”
Another "positive step by BHDDH," at the recommendation of Disability Rights Rhode Island's recommendation," Murray said, "was to fund a comprehensive analysis of the needs and available services for people with mental health needs and intellectual/developmental disabilities."
Charest has submitted to McKee a proposed budget of $585.9 million for the fiscal year that begins in July — an increase of $62 million over this year's. And more help could come from Rhode Island's $1.1-billion share of federal American Rescue Plan Act funding. On Oct. 19, The Rhode Island Foundation's Make it Happen study recommended spending $255 million on a variety of behavioral health initiatives.
"The goal is to address the long-standing systemic issues that are contributing to growing mental health and substance use disorder challenges, including record overdose deaths; increasing depression and anxiety, and rising suicides and domestic violence incidents, all of which have especially affected the communities of color most impacted by COVID-19," said Neil D. Steinberg, foundation president and CEO.
Sensing possibility, DiPalma said: "What is sorely lacking in the state is a continuum of care to support people in the most appropriate and least restrictive setting, including comprehensive home and community-based care. "The time for study and analysis is over. We need to act."
Providence Journal staff health writer G. Wayne Miller has covered behavioral healthcare and developmental disabilities since the 1980s. With reports from staff writers Linda Borg, Katherine Gregg, Tom Mooney and Jack Perry.