Tucson rehab center fined over patient's suicide

After investigating a Sierra Tucson patient’s Jan. 23 suicide, state officials have fined the upscale rehab facility for failing to follow its own rules on keeping track of patients.

The Arizona Department of Health Services also placed Sierra Tucson on a provisional license through Oct. 31, making it subject to frequent monitoring.

Sierra Tucson agreed to pay the fine but did not admit any wrongdoing.

The patient, a 55-year-old Pennsylvania man, was found on the floor of his room at 12:41 p.m. on Jan. 23, an autopsy report from the Pinal County Medical Examiner’s Office says. He was pronounced dead at 1:13 p.m.

Sierra Tucson has a policy, “to ensure resident safety ... by tracking resident movement 24 hours a day, seven days a week.” If patients are 15 minutes late for an activity, staff is supposed to activate its “locating procedure.”

Investigators with the Department of Health Services, which also licenses the facility, found no evidence that the patient had attended any of his scheduled activities that day, nor that any staff members had seen him at all that morning.

The man, who hanged himself with a belt, was the third patient to die at Sierra Tucson in 13 months and the fourth since August 2011.

Though the patient died Jan. 23, the state did not receive written notification until Feb. 4, the report says. State law requires that deaths be reported within one working day.

Sierra Tucson’s quality and risk management director told state investigators that she’d faxed the information on the day it happened — but to the wrong fax number — and was unaware it had failed to transmit.

Sierra Tucson, a for-profit facility owned by Tennessee-based Acadia Healthcare, agreed to pay the state $7,500 in civil penalties for, among other things, failing to implement policies and procedures for keeping track of its patients. A handwritten note on the agreement with the state says officials signed, “without any admission of violation, wrongdoing, or liability.”

The Star submitted seven questions related to the fine, the suicide and the state’s report. Sierra Tucson’s chief executive officer, William D. Anderson Jr., responded with the following statement:

“Due to federal and state patient privacy and confidentiality laws, I cannot comment on any patient matters. All of our clinicians and staff are committed to patient safety and continuously work to improve patient safety and provide high quality, clinical care.

“As part of our continuous process to improve patient care, we have implemented numerous measures designed to improve patient safety in our residential programs and recently conducted extensive employee training on patient tracking, hand-off communications and additional patient safety measures.”

The state’s report on the suicide detailed several breakdowns:

There was no documentation that the patient attended any of his scheduled morning activities. He did not hand in a self-assessment of his mood called a “feelings sheet” by 8 a.m. as required.
The registered nurse who was supposed to assess the “feelings sheet” said he told the clinical technician to have the patient turn it in. The nurse told state investigators it was not his job to find patients who don’t turn in their feelings sheets.

“The patient comes to the nurse,” the nurse told investigators.

The clinical technician in charge of the patient’s unit said the patient was not present at breakfast that day, but that he responded to her from behind a closed bathroom door at 7:30 a.m. that he was using the restroom.
Though the patient was reported absent from his Getting Motivated for Change group at 8 a.m., there was no documentation of attempts to find him. Employees told investigators the patient also didn’t attend his 10 a.m. Mind Over Mood class, but the absence wasn’t documented.
An employee said she did a round of room checks at 10:30 a.m. and did not see anyone in the patient’s room. She checked in the bathroom and shower, and checked in drawers and closets for contraband, she told investigators.
The same employee went to the patient’s room again at around noon after noticing that the patient wasn’t at lunch. She partially opened the door and “hollered his name,” the report says, but could not see anyone in his bed. She told investigators she could not see behind the door or in the closet area but when he did not respond, she “assumed he was not in there.”
Staff members said they were confused about who was responsible for tracking attendance at activities and for ensuring that absences were reported.

Dev Sethi, a Tucson attorney for the patient’s family, declined to comment last week.

The patient was an engineer and business analyst who had recently been on short-term disability due to chronic pain that left him depressed. He went to Sierra Tucson at the urging of family members. Through Sethi, the family asked that his name not be released.

Sierra Tucson has had numerous leadership changes since 2009. Anderson was named to the director’s position on March 26.

Other deaths at the facility:

A 20-year-old East Coast man, who had been in Sierra Tucson for drug rehabilitation, died April 13, 2014, of acute drug toxicity. An autopsy said it was unclear whether the lethal drug mix was intentional or accidental.
On Jan. 2, 2014 a 59-year-old patient with a history of depression and anxiety hanged himself with a shoelace from a shower head. He died three days later at Oro Valley Hospital.
In 2011, Dr. Kenneth Litwack, a 71-year-old Orange County physician with anxiety and depression, disappeared from Sierra Tucson. Two weeks later he was found dead near Sierra Tucson’s stable, about a quarter-mile from the main building. An autopsy could not determine how he died.

Sierra Tucson is the flagship facility of California-based CRC Health Group, which was recently acquired by behavioral-health giant Acadia Healthcare.

The facility is situated on a 160-acre site at 39580 S. Lago del Oro Parkway along the Pinal/Pima County border. It has 124 beds, plus 15 acute level beds.

In October 2014, Acadia bought CRC Health Group from private equity firm Bain Capital for $1.2 billion, according to Becker’s Hospital CFO Report.

Publicly traded Acadia has inpatient behavioral health facilities in the U.S., England and Puerto Rico. The company’s profit and revenue are up. Its stock price as of Aug. 21 was $73.68, up from $50.26 on Aug. 21, 2014.