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The Hartford Courant
April 18, 2000
Author: DWIGHT F. BLINT; Courant Staff Writer
Instead, the 30-year-old Bozrah woman was placed on a four-hour room restriction, commonly known as seclusion. She was checked once by hospital staff, at 5 p.m., and was thought to be sleeping.
When the staff checked again, more than two hours later, Beninato was barely breathing. She would be pronounced dead soon afterward, the victim of acute mixed drug intoxication.
In response, federal regulators said Monday they have taken the extreme step of placing the hospital on a “termination track” that will result in the loss of Medicare and Medicaid funding unless significant reforms are made by June 7.
“You had people missing everything,” said Margaret Leoni, a branch chief for the U.S. Department of Health and Human Services, whose agency has cited the hospital for what she described as “very serious and substantial” violations.
Although state regulators have yet to take any public action in the case, the federal agency has cited hospital staff for failing to develop an adequate treatment plan for Beninato, and for failing to properly monitor her condition.
“I wouldn’t call it abuse, but a lot of [it] bordered on neglect,” Leoni said Monday. “It was very serious — not to mention, the poor woman died.”
Barbara Beninato had problems. She was admitted to the hospital Nov. 21 after state police found her driving up the wrong side of a highway ramp while sniffing gasoline and smoking. Court records show her family felt compelled to seek restraining orders against her last year.
Among Beninato’s problems was “med-seeking behavior,” according to the preliminary state report that describes her last days and hours. Along with a variety of psychological disorders, Beninato had a history of substance abuse.
So when a St. Francis psychiatrist discussed cutting back on medications, Beninato threatened to “go off on her.” Instead, by “self-reporting” symptoms, Beninato persuaded the psychiatrist to increase the number and dosage of her medications.
Hospital records, the state report found, did not provide justification for the increased dosages.
The drugs given to Beninato are common. They are described as tranquilizers, anti-anxiety agents and muscle relaxers used to modify behavior.
Mary McCormick, administrative director of the Connecticut Poison Control Center at the University of Connecticut Health Center, said last week that she would have been concerned about the quantity and dosages given Beninato.
McCormick said she would need to know more about the patient, but that her instinct would be to reduce some of the medications.
“I can’t tell you that this combination would imply death,” said McCormick, whose expertise is in pharmaceutical sciences. “But several of these medications would cause sedation, so I would be concerned about over-sedation.
“But that could have been the effect they were looking for.”
Hospital staff missed crucial opportunities to intervene that New Year’s Day. When Beninato was checked at 5 p.m. — about two hours after being placed on room restriction — the nurse did not try to awaken her for dinner or administer her usual allotment of medications.
This, the state investigation found, should have raised a red flag. Beninato had never before slept through dinner, and had never missed her medications.
Yet no assessment would be done for another two hours and 20 minutes — when Beninato’s life was very nearly over.
By 7:20 p.m., when Beninato was checked again, she had “slowing respiration.” By 7:25, she had no pulse or blood pressure. By then, CPR did no good.
The incident raises questions as to whether the hospital followed new state laws regarding seclusion. The law requires patients in seclusion to be checked frequently.
Staff may also have failed to adhere to the hospital’s own policy. Typically, hospital policy calls for patients in seclusion to be checked at least every 15 minutes.
Beninato’s death is the first in Connecticut related to restraint or seclusion since the high-profile death of 11-year-old Andrew McClain at this same institution two years ago.
McClain’s death prompted the state to place the St. Francis facility under a one-year consent decree, and prodded federal officials to enact regulations governing the use of restraint and seclusion.
Peter Mobilia, a spokesman for St. Francis, declined comment.
The hospital did acknowledge last month that it was cited in connection with Beninato’s death. At the time, St. Francis announced that it had fired two top-ranking hospital administrators, made other administrative changes and submitted a plan of correction to the state.
State Department of Public Health officials have refused to discuss the case thus far, and have turned down The Courant’s requests for a copy of the citation, the state investigative report and other related documents. The state’s investigative report was provided to The Courant by federal regulators.
William Gerrish, a public health department spokesman, said the case is still being investigated and his agency cannot discuss the matter while it is pending.
But documents provided by the Department of Health and Human Services indicate that the state has filed a complaint against an unidentified member of the hospital staff. The state could also seek yet another consent decree against St. Francis.
The hospital might face more pressure from the federal government.
If the hospital does not comply with federal guidelines by the June 7 deadline, the Department of Health and Human Services will cut Medicare funding to the facility and withhold matching dollars to the state for Medicaid patients.
Such a decision, involving so much money, could effectively close the hospital.
James McGaughey, the executive director of the state patient advocate’s office, said he is pleased the federal goverment is taking Beninato’s death seriously.
“My concern is, given the mixture of medications, what information was given to [Beninato] or any surrogates about taking so many medications at the same time,” McGaughey said.
But McGaughey, whose office is charged with investigating violations of patient rights, said he’s concerned by the lack of information from the state Department of Public Health. He said his office has received only limited information from the state.
“At this point we’re sending [the Department of Public Health] a letter,” he said. “We want to know what they’ve got.”
Overall, McGaughey said, he’s concerned that the state’s psychiatric environment overemphasizes the use of medication — while being unable to spot the symptoms of drug intoxication.
That, he said, seems to be what happened to Barbara Beninato.
The symptoms of her over-medication were mistaken for behavioral problems. So when Beninato needed an assessment of her physical condition, what she got was a room restriction.
St. Francis, he said, “has got some serious work to do to improve the quality of their program.”