One in three safety violations at Philly-area Pa. hospitals involved shortcomings in mental health services. How can hospitals do better?

A patient died on the floor of a behavioral health unit at the Hospital of the University of Pennsylvania’s Cedar Avenue facility because staff didn’t know how to respond.

Children experiencing mental health crises were required to wear lime green scrubs at St. Christopher’s Hospital for Children in violation of their privacy rights.

A patient with schizophrenia and other mental health issues fled Crozer’s Taylor Hospital without her shoes or a working phone because staff didn’t monitor her closely enough after a previous attempt to leave, and was missing for six days.

One out of every three safety citations issued to Philadelphia-area hospitals by Pennsylvania health inspectors since the beginning of 2022 have involved patients receiving treatment for behavioral or mental health concerns. Hospitals in Philadelphia, Bucks, Chester, Delaware, and Montgomery Counties were cited 28 times, forcing hospitals to reevaluate how they are managing their care.

Inspection reports reveal inadequate staffing, lack of proper emergency protocol, and insufficient training on how to help patients experiencing a mental health issue. These problems contribute to basic oversights, such as failing to properly screen and watch patients at risk of suicide and update their treatment plans.

Hospitals acknowledge that they need to better meet patients’ complex medical needs. In the Philadelphia area, several health systems have increased staff training. Others have stationed specialized social workers in their emergency departments and added more psychiatric beds to accommodate a growing demand for behavior health services.

Patient safety advocates fear the problem will only get worse if hospitals don’t step up, said Carla Sofronski, executive director of the Pennsylvania Harm Reduction Network, a nonprofit that helps people access mental health and substance abuse treatment.

“It’s so important that, right now, more than ever, they get it together,” she said.

Hospitals have been challenged by an increase in emergency department visits by people experiencing a mental health crisis, said Jennifer Jordan, the vice president of equity and behavioral health for the Hospital and Healthsystem Association of Pennsylvania, an industry group.

Many of the association’s 235 member hospitals statewide report seeing patients with more serious mental health issues, who are seeking treatment for a more complex mix of mental and physical needs, she said.

The number of people with mental and behavioral health needs has grown precipitously over the past decade, and now about 22% of adults experience some form of mental illness. Yet half do not receive treatment, either because they don’t know how to access care, are reluctant to seek help or aren’t able to find a provider with openings, according to the National Alliance on Mental Illness, a nonprofit advocacy organization.

The organization notes that people with a mental health problem are also more likely to experience cardiovascular and metabolic disorders, such as heart disease, stroke, and Type 2 diabetes. And about a third of people with a mental illness are using drugs or have experienced a substance use disorder, according to NAMI.

Many end up at a hospital in medical crisis. Symptoms can escalate, putting patients at risk of becoming agitated or aggressive, or walking out before receiving treatment, if staff do not respond appropriately, said Sofronski, of the Pennsylvania Harm Reduction Network.

The bright lights, loud noises, and lack of privacy in emergency departments can worsen symptoms for people with anxiety or depression, said Deborah Cunningham, the vice president of behavioral health at Main Line Health, a nonprofit health system with four hospitals in Philadelphia’s western suburbs.

“Being in a busy emergency department is really the worst place for them to be,” she said.

Philadelphia hospitals also see patients with substance use disorder who need treatment for deep, slow-to-heal wounds caused by xylazine, a horse tranquilizer that is increasingly found in drugs sold on the street. They may need to be treated with antibiotics for days or may require an amputation.

» READ MORE: Xylazine, the animal tranquilizer contaminating Philly’s opioid supply, causes serious wounds and withdrawal that many providers don’t know how to treat

Main Line Health is responding to rising demand by expanding specialized services for behavioral health patients. It is also training staff who provide more general care, such as in the emergency department, in how to recognize and respond to psychiatric emergencies.

Main Line doubled its number of behavioral health beds to 40 in 2022, in response to growing demand.

» READ MORE: The Philly region has few beds for behavioral health patients — and intense demand

Main Line has also opened day programs, where patients can receive services during the day without being admitted to the hospital. The day programs are an alternative to intensive, inpatient psychiatric care.

At each of Main Line’s emergency departments, a psychiatric clinical social worker is on duty around the clock to help quickly triage patients with behavioral health needs. The system owns Lankenau Medical Center, Bryn Mawr Hospital, Riddle Hospital, and Paoli Hospital.

The system’s goal is to intercept patients with mental health needs before they become so urgent that they need emergency care, Cunningham said.

But even as the health system expands its mental health services, emergency rooms continue to receive a steady stream of between 40 and 50 of these patients a week.

So Main Line has increased training on how to interact with patients experiencing a mental health issue, how to de-escalate problems, and what to do in an emergency. Every employee wears an ID lanyard with a button they can press to call for medical help.

“We have to continuously reeducate ourselves about what’s going on,” Cunningham said.

Health systems must invest in hiring enough staffers to care for behavioral health patients and ensure that they’re properly trained, as well as prioritize their employees’ own mental health, said Nito Gan, chair of the department of psychiatry at Crozer Health.

Crozer also wants to improve doctor-patient relationships to make hospitals safer for patients and staff. Patients who trust their providers will be less likely to become agitated and a lower risk for leaving the hospital against medical advice.

Crozer has a 24-7 crisis center and last year opened an outpatient center for substance abuse and mental health disorders, both located at Crozer-Chester Medical Center in Upland. Gan wants Crozer to be known as a reliable and safe place to come for mental health.

“We want to make sure we’re doing everything in our power to make it known that Crozer is where to go for your mental health needs,” he said.

» READ MORE: Taylor Hospital cited after a medically vulnerable woman went missing for six days

Inspection reports show what’s at stake when staff aren’t prepared to treat patients with mental and behavioral health needs.

In January, an elderly patient experiencing mental health problems walked out of the emergency department waiting room at Thomas Jefferson University Hospital and was missing for hours before anyone noticed. State inspectors issued one of the state’s most serious warnings after finding that staff had failed to check on the 71-year-old nursing home resident every two hours as required.

Jefferson Einstein Philadelphia Hospital was cited in early 2023 after inspectors found that five patients attempted to hurt themselves at the hospital because they were not properly screened for suicide risk in the emergency department.

» READ MORE: Nurses left patient to die at Penn Medicine hospital. State inspectors issued a severe warning.

A patient at HUP Cedar Avenue’s behavioral health unit waited four days for doctors to splint their broken wrist in November, following another patient’s death earlier the same month. Inspectors and hospital administrators said “diagnostic overshadowing,” referring to providers dismissing a patient’s symptoms because of bias, could have affected care in both cases.

Penn convened its top administrators to discuss how to address diagnostic overshadowing. People with a history of mental illness and older people are most at risk of their concerns being ignored.

Sofronski, who advocates for substance abuse and mental health disorder treatment, thinks hospitals should invest in ongoing education for staff. Simulation training could help health-care workers better understand how people experiencing a mental health problem often feel misunderstood or judged when they seek help.

“They just need to treat people with dignity and respect,” she said, “and think about how much it took that person to just walk through the doors.”