A Warning, a delayed repair, a patient dies...
Too late, mental health agency fixed windows
By Liz Kowalczyk / Boston Globe Staff - 6/22/14
The manager of a state-owned psychiatric hospital repeatedly pressed her superiors to replace dozens of breakable glass windows with safer plastic — once when she discovered the hazard in January 2013, and again six months later, after a patient with schizophrenia made the need obvious by hurling a chair through a window.
But state mental health officials told her there was no money for the fix, according to an account she later gave investigators. Then, just before Christmas, that same patient smashed an eighth-floor window at the Dr. Solomon Carter Fuller Mental Health Center — and jumped to his death.
The funds were approved the next day.
This critical delay was described by federal inspectors who investigated the apparent suicide of Andrew Puchalow on Dec. 11. The 56-year-old, who had long suffered paranoid delusions and been institutionalized, landed on the roof of a smaller building five stories below in Boston's South End.
The US Centers for Medicare & Medicaid Services found the hospital did not provide safe care in this case.
A hospital committee had discussed the need for safety windows in patient community rooms at least five times since January 2013, according to the federal report, which was obtained by the Globe through a public records request. Even after a memo went to a deputy commissioner at the Department of Mental Health in July, explaining that a patient had recently smashed a window, the glass panes remained.
Advocates for the mentally ill said the holdup is a tragic example of the chronic underfunding of psychiatric hospitals.
“Mental health facilities are at the bottom rung of the ladder,'' said Stephen Rosenfeld, board president for the Massachusetts chapter of the National Alliance on Mental Illness.
The mental health department, which runs the hospital, would not answer questions about the reasons for the delay, other than to say the process of finding money to replace the windows began after the first window-smashing incident in June.
An agency spokesman said in a written statement that after Puchalow's death, the Patrick administration spent $170,000 repairing the windows, work that is scheduled to be completed this month.
The agency's budget this year includes $173 million for inpatient facilities such as the Fuller center. The amount has grown slightly each year since 2011, but advocates said it has not been enough to keep up with rising costs.
“Whenever they squeeze, they have been squeezing out of the inpatient facilities,'' said Timothy O'Leary, deputy director of the nonprofit Massachusetts Association for Mental Health. He said that is in part because of the growing emphasis on moving patients into smaller community treatment settings.
Suicides are uncommon in Massachusetts inpatient psychiatric facilities, despite the intensity of patients' illnesses. Two patients each year attempted or committed suicide in 2011 and 2012 in facilities licensed by the Department of Public Health. Until December, there had been no suicides in state-owned hospitals since at least 2009, the mental health department said.
Puchalow had been diagnosed with paranoid schizophrenia and had a history of assaultive behavior, according to court records. He was committed in 1986 to Bridgewater State Hospital, a medium-security prison for the mentally ill. He was eventually transferred to the Fuller center, a 60-bed locked treatment facility for people with severe mental illnesses.
There, Puchalow, who is referred to only as patient No. 1 in the federal report, “was not predictable from one moment to another'' and had episodes of extreme anger, a psychiatrist told inspectors.
The hospital's chief operating officer, who is not named in the report, told the investigators that she first asked for new windows in January 2013, when she found out that many of the windows were not made of the shatterproof material Lexan. Mary Louise White has been the chief operating officer for a number of years.
It is unclear what led to her discovery, but the Joint Commission, a national accrediting agency, had evaluated the hospital earlier that month. Alec Loftus, a spokesman for the mental health department, said in a statement that the glass windows complied with Joint Commission guidelines and that the hospital was “operating according to industry standards.''
The Joint Commission would not comment on its findings at the Fuller, but the hospital was re-accredited.
During the spring, the hospital “environment of care committee'' repeatedly discussed the windows and two managers decided to obtain cost estimates, according to meeting minutes described in the federal report.
An e-mail in May from the Executive Office of Administration and Finance to the mental health department business office indicated the state could ask for bids for the work in July “because this would demonstrate the process to install Lexan windows was in motion and resolution of the safety risk was moving forward.''
Meanwhile, on a Sunday afternoon in June, Puchalow threw a chair through a window in the eighth-floor community room, where patients gather to watch television, eat, and read. Glass rained down onto a healing garden for patients outside the third floor.
As a result, White told investigators, she “escalated her request'' for funds. White did not return a call from the Globe to further explain her efforts.
In late July, the mental health agency's area director for Boston sent a memo to a deputy commissioner, describing the June incident and again asking for funds for Lexan windows for “patient safety.''
In a written statement, mental health department spokeswoman Anna Chinappi said that after the June incident, “DMH put in process the means to secure the inpatient common areas with Lexan windows. Specifications for the window replacement in the common area were developed in November 2013 just prior to the tragedy.''
A social worker interviewed by investigators said the money was approved Dec. 12, the day after Puchalow jumped.
After his death, the agency assessed other state-owned facilities and determined the windows were safe, made of Lexan or safety glass that is difficult to break, or covered with protective screens, the mental health department said.
The hospital's correction plan submitted to federal officials said the mental health department would also improve communication with Fuller's leadership.
Even in death, Puchalow's story remains bleak. Because he was destitute and estranged from his family, the state paid for his burial in a section for poor Bostonians in Fairview Cemetery in Hyde Park, hospital staff said. His anonymous grave can be identified only by the number 36 hand-drawn on a slab of concrete.
That upset caregivers who visited the site, and the state agreed to pay for a metal plaque with his name and the words “In Loving Memory.'' Staff are deciding where to put it.