Timberlawn Psych Hospital's Funding at Risk After Patient Hangs Herself

By Jessica Huseman

Dallas Morning News, June 5, 2015

Brittney Bennetts checked herself into Timberlawn Mental Health System in Dallas as she struggled with another bout of dissociative disorder that left her suicidal.

There, in her room, the 37-year-old hanged herself from a closet doorknob with a torn bedsheet.

Five months before Bennetts' suicide on Dec. 3, Timberlawn officials had been warned by an internal survey that such doorknobs posed a potential "ligature risk," meaning they could be used by patients to hang themselves.

But the doorknobs weren't fully replaced until Feb. 19, the hospital told authorities. That was two days after the first in a series of unannounced safety inspections.

Follow-up inspections by the U.S. Centers for Medicare & Medicaid Services uncovered numerous safety problems and led regulators to threaten to take the rare step of cutting off millions in funding at Timberlawn unless it makes fixes by this month.

In a letter to Timberlawn's CEO in late May, agency officials said the deficiencies were "of such a serious nature" that they "substantially limit your hospital's capacity to render adequate care."

CMS, as the agency is known, gave Timberlawn until June 8 - Monday - to submit a plan to correct the problems and until June 18 to have improvements in place. A final inspection will happen sometime between then and July 13, CMS wrote.

The stakes are high at Timberlawn, part of the Pennsylvania-based Universal Health Systems hospital chain. Roughly a third of its $65 million in total patient revenue came from Medicare and Medicaid in 2013, according to figures from the American Hospital Directory.

CMS' funding threat is the latest safety-related trouble for Timberlawn. Founded nearly 100 years ago, Timberlawn says it was the first residential treatment center for mentally ill people west of the Mississippi River, and with 144 beds, it remains one of North Texas' biggest psychiatric hospitals. But since 2009, regulators have cited it multiple times for violations, such as injuring patients, leaving them in "immediate jeopardy" of harm and providing lax care.

CMS declined to comment on the latest problems, saying more specifics would become public after Timberlawn had a chance to turn in its correction plan.

Shelah Adams, Timberlawn's CEO, declined to answer specific questions about Bennetts' case, citing patient confidentiality and privacy laws. She also declined to discuss the inspections.

In a series of written statements, Adams said that "patient safety is our top priority." She noted that the doorknobs in question did not violate any regulations. She added Friday that Timberlawn was still preparing its correction plan.

"We are confident that our plan will address any deficiencies and that we will be able to demonstrate compliance" during the final inspection, Adams said.

Bennetts' family knew for years that she suffered from a dissociative disorder and other illnesses, but her death still came as a shock. The family has since hired a medical malpractice attorney specializing in inpatient suicides but has not filed suit.

"It's not really about the money," said Collette Riel, Bennetts' sister. "It's about holding them accountable for what they did."

Riel said she was "devastated and stunned" after learning about Timberlawn's safety issues.

"We've all been sitting here dealing with the tragedy," she said, "and after reading what we read, it's clear as day that this is just negligence."

'Loving, caring'

Bennetts had hoped to help others: She graduated with a master's degree in counseling from Southwestern College of Santa Fe in December 2013. She started working as a hospice counselor for Frontier Hospice in Kalispell, Mont., last June.

Her sister said she was usually "completely normal and productive." She had a near-perfect GPA and was a "loving, caring and wonderful person," Riel said.

But for many years she had been dealing with a dissociative disorder, a psychological condition in which, Riel said, she would "check out" and come to hours later, not knowing where she had been or what she had done.

"She would come home after work, get into a hot bath to relax, and then she'd essentially wake up hours later and the water would be ice cold and she wouldn't know what happened," Riel said.

Bennetts' family said she shared very little information about her psychological health. Calling her a "very private person," Riel said her sister "never wanted to worry" anyone by sharing the seriousness of her condition. But shortly before her death, Bennetts said she had been dealing with her dissociative disorder for about seven years, Riel said.

While Bennetts was still in school, her dissociative issues became more severe as her stress levels rose, said her brother, Brett Bennetts.

She selected Timberlawn from a number of hospitals she had researched, and started going there in 2011, her sister said. Bennetts kept going back because the hospital's trauma unit specializes in dissociation and trauma-related disorders and she said she was unable to find a facility closer to home that met her needs, Riel said.

"She would disconnect from school and go to Timberlawn," her brother said. "She had done a lot of research, knew what she had and knew what she faced and knew she had a fight on her hands. She was actively trying to participate in it."

While the family was aware of her dissociative issues, Brett Bennetts said, they had "no idea" she had been suicidal during those periods. Although he said he was aware that his sister had attempted suicide in her early teens, he was unaware that the behavior had continued 20 years later.

The morning after the suicide, Riel got a phone call from the hospital counselor, and Brett Bennetts heard from the police.

"We didn't know she was suicidal at all. ... I assumed she'd been in a car wreck," he said. "I was totally blown away."

Timberlawn knew.

'Previous attempts'

Records from CMS quote Brittney Bennetts' medical records as saying she had attempted suicide "a lot of times," by both overdose and hanging. Her autopsy report revealed that Timberlawn was aware of her "multiple previous attempts at suicide" and that at previous admissions to Timberlawn, Bennetts had arrived with "ligature marks on her neck."

"Everybody down there knew all along about her suicidal tendencies - she'd tried it there before," said her father, Jim Bennetts. "This was the only place she really trusted and turned to for help, and they just didn't do their due diligence and give her proper care."

In the hours leading up to her death, CMS records show, Bennetts threatened suicide frequently - specifically by hanging herself - to the staff at Timberlawn.

Greg Jacobson, a Boston-area expert on inpatient suicide prevention, said "a wide scale" of hospitals have been transitioning to anti-ligature doorknobs for a decade. He said the transition began when The Joint Commission, which accredits hospitals nationwide, including Timberlawn, began recognizing suicide as one of the top causes of preventable deaths in hospitals.

James Knoll, a professor of psychiatry at SUNY Upstate Medical University and a specialist in suicide-risk assessment, said inpatient suicides account for about 6 percent of all suicides in the U.S. And the most frequent means of suicide in psychiatric hospitals is hanging, according to The Joint Commission.

The commission has recommended anti-ligature doorknobs in its research for years. The Texas Department of State Health Services, which inspects hospitals across the state, requires private hospitals such as Timberlawn to use hardware that is "appropriate to prevent patient injury."

Knoll said such suicides happen most frequently in hospitals that have inadequate risk assessment and fail to appropriately classify patients as suicidal, or fail to follow through with appropriate monitoring.

"The public and the law view people who are in inpatient units as being owed a greater duty because those who treat them have greater control," he said. "I think that's fair."

In Bennetts' case, the staff checked on her at about 15-minute intervals - the normal gap for checks on all patients at Timberlawn, according to the CMS documents.

On the day of her suicide, records show, a check by the nurse on duty was initially marked as 6:30 a.m. It was later crossed out and changed to 6:36 a.m., the time at which the nurse removed Bennetts from the doorknob and unsuccessfully tried to resuscitate her. The hospital declined to comment on the change, and the nurse did not return phone calls.

Knoll, the SUNY specialist in suicide-risk assessment, examined the CMS records. He said the intervals between checks on Bennetts represent a dangerous level of supervision.

"Someone can kill themselves three times by hanging in the standard 15 minutes," said Knoll, adding that serious brain damage can occur after only two minutes of suffocation.

Jacobson also said 15-minute observation intervals are, by themselves, "not sufficient" to protect a patient from suicide.

The CMS records show that a member of Timberlawn's staff responsible for Bennetts' care acknowledged he was aware of her suicidal intentions and the high risk she posed to herself. But he "never thought [she] would hang herself" and did not order more frequent checks, according to the records. "Looking back at it," the record reads, he "wished he had ordered a higher level of monitoring."

Knoll said Timberlawn should have been aware of the "tremendous risk" of suicide given Bennetts' symptoms, which records indicate included rapid mood shifts, hearing voices, paranoia and depression.

"You had a woman who came in who was complaining of suffering from suicidal thinking, and not only that, but she has a plan in mind - she's enacted the behavior before," Knoll said. "That's one of the strongest risk factors [for suicide] we have."

'Immediate jeopardy'

When federal inspectors arrived on Feb. 17, more than two months after Bennetts died, they found that shortcomings left Timberlawn patients in "immediate jeopardy" of harm, according to CMS' letter to Adams, the Timberlawn CEO.

"Immediate jeopardy" is the most serious warning from CMS. Inspectors cited, among other things, the "continued presence of unsafe items accessible to psychiatric patients for potential harm which included plastic liners in trash cans, electrical cords and phone cords."

Timberlawn submitted a plan in March to remedy safety issues. It said the hospital "had all closet doors without anti-ligature doorknobs removed" and ordered replacement, anti-ligature doorknobs - which are shaped to make hanging anything from them nearly impossible.

The plan also indicated that staff members had been retrained in patient safety procedures and that all items patients could use to harm themselves had been removed.

Records also show Timberlawn's administrators performed a "comprehensive safety sweep of the hospital" on March 9 "to identify and remove items that a patient could possibly use for self-harm."

CMS removed the "immediate jeopardy" warning on March 25. But the agency found Timberlawn remained out of compliance in areas broadly referred to as "patient safety" and "quality assurance and performance improvement."

The Texas Department of State Health Services, which conducted a follow-up inspection that same day on behalf of CMS, said it could not comment about why Timberlawn's improvements were insufficient.

The agencies conducted follow-up inspections again in May. Timberlawn still hadn't come into compliance in the same problem areas - and was found to be further deficient in three others. Those were generally described as competency of the nursing staff, psychiatric record keeping and specific staff requirements for psychiatric facilities.

While the months of inspections and corrective action may eventually make Timberlawn safer, Bennetts' relatives are "devastated" by what they say is a lack of concern for her well-being and insensitivity in dealing with them.

The family's lawyer, Skip Simpson, called the circumstances surrounding Bennetts' suicide "absolutely appalling" and the hospital's failure to change the doorknobs beforehand "completely reckless."

"This hospital needs to go ahead and put a sign up in front of their building that says 'Not safe for suicidal patients,'" he said.

If the family sued and won, medical malpractice laws in Texas would cap any damage award at $500,000.

Learning that there were safety problems at the hospital revived feelings of grief the family had been working hard to overcome, Brett Bennetts said.

"Nothing changes anything in the end - she's gone," he said. "I think we all really felt that if she could have gotten through that, then she could have had a lot to give to the world."

Jessica Huseman is a freelance writer based in New York. She is a recent graduate of the Stabile Center for Investigative Journalism at Columbia Graduate School of Journalism.


Safety regulators have cited Dallas' Timberlawn Mental Health System several times in recent years for patient-care failures. Those have included everything from keeping incomplete records on medical treatment to injuring patients while restraining them. Among the violations:

Inspection date: Nov. 6, 2014

A guardian wasn't properly informed that a patient would be put into a straitjacket and given medication.

Inspection date: May 10, 2013

Staff didn't properly monitor or treat patients with risky blood-pressure readings.

Inspection date: April 11, 2012

A nurse failed to get doctor approval and document a reason for not giving medication to a sleeping patient.

Inspection date: Dec. 21, 2011

Staff put patients in "immediate jeopardy" by leaving them unprotected during a male patient's attack. Staff barricaded themselves in a nursing station after he assaulted two of them. Left alone, the man went into another patient's room and kicked her repeatedly in the head until she was unresponsive.

Inspection date: Oct. 20, 2010

A patient with dementia was improperly restrained while placed in seclusion and suffered a cut to his eyebrow. He required transfer to a full-service hospital.

Inspection date: April 23, 2009

A patient suffered a head injury when taken to the ground and was restrained improperly by a staff member.

SOURCE: The U.S. Centers for Medicare & Medicaid Services

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