KALAMAZOO, Mich. (WOOD) — State investigators say two top administrators at the Kalamazoo Psychiatric Hospital failed to report alleged neglect that involved the death of a patient.
The investigation, conducted by the Office of Recipient Rights within the Michigan Department of Community Health, recommended that the state take disciplinary action against Hospital Director Dr. James Coleman and the facility’s director of nursing, Sandra Boothby.
Coleman and Boothby were both suspended in mid-May pending the outcome of the investigation. Coleman then resigned his position. Boothby and a nurse were fired.
According to a report obtained by Target 8 through the Freedom of Information Act, Coleman knew of allegations that a nurse’s failure to follow hospital procedures may have contributed to the death of a patient, but did not report the incident to the Office of Recipient Rights, as required by policy.
The incident involved the March death of Majel Joyce Youdell, 68, who had been hospitalized for pneumonia. After returned to the psychiatric facility, she was still suffering from shortness of breath.
The report concluded that a nurse, despite receiving four documented reports on Youdell’s precarious condition, failed to communicate any of those issues to the next shift of nurses.
Video surveillance shows that Youdell removed her oxygen tube to go to the bathroom. When she returned, she bent over to pick up her oxygen tube but never put it back on. She died a short time later.
The state says it was a failure of the system and the staff. Interviews included in the investigation show that “Dr. James Coleman created a culture where only he was to report any possible neglect case.”
One official included information about the possible liability of hospital staff, but that information was reportedly removed from the incident report.
“We do feel that there was a pattern. That this happened a number of times,” MDCH spokeswoman Angela Minicuci said. “That is something we are very concerned about. We acted as quickly as we could to address it.”
According to the report from the state, “Dr. Coleman claims that no one indicated to him that neglect was involved (in the patient’s death).”
But the state found evidence indicating that Coleman knew that a nurse’s failure to follow policy was related to the patient’s death, and that the incident met the criteria for suspected neglect.
“If they have any inkling that there is something wrong, they are to report it to the Office of Recipient Rights because the office is in charge of protecting our patient rights in our facilities,” Minicuci said. “And that didn’t happen.”
Youdell’s sister said the family had no idea until this week that an investigation was underway surrounding the death. She said the family was still determining what to do next.
Family members say Youdell was the youngest of eight siblings.
“My aunt’s life was in the hands of the people at the hospital and she deserved the very best care as every patient does,” Youdell’s niece Gretchen VanNess told 24 Hour News 8.
Thursday a state official greeted Target 8 investigators who visited the facility. She said that the state was looking to replace the employees whose positions were vacated in the wake of the incident, as well as the alleged failure to report it.
“We’re trying to get this back on track and transitioning,” Cynthia Kelly, Bureau Director for MDCH, said. “Getting things in order.”
“In addition to changing leadership as well as educating staff, we want to make sure the moving forward the leaders that we bring in feel they have the tools to be able to make changes to the culture at KPH,” Minicuci said.
Youdell suffered from myriad medical issues, and it’s not clear whether hospital staff would have been able to save her had the information been relayed.
24 Hour News 8’s Heather Walker contributed to this report.