Gena Bryant, a 48-year-old Bronx native, grew up without her father Gilbert Calderon in her life. So when they reconnected during her teens, she was excited that their relationship was beginning to blossom. They started talking on the phone once, sometimes twice a week. He would call just because he was thinking of her. Over the holidays, he would take the Metro-North train from the East Bronx to her Bronxville home, arms full of gifts for her two children.
In March 2017, their relationship was cut short after her father checked himself into Montefiore Medical Center’s main campus in Norwood, a neighborhood in the Bronx, just two miles from his home. They spoke on the phone while he was there. “He said he was doing well. He said he was going to be released,” she remembered.
The following day, around six in the morning, she got a call from the hospital. She found out that her father, who was 76, hanged himself in the bathroom of his hospital room.
Bryant and her husband rushed to Montefiore. They were greeted by detectives and police officers who swarmed the room, two of them talking to her at once. She was overwhelmed.
“I felt like I was on TV in one of those murder shows. It was surreal,” she said.
So Bryant was pulled aside, where a doctor told her they’d given her father “all the possible care that he needed.” But Montefiore didn’t tell her they had made mistakes.
According to a subsequent inspection conducted by the U.S. Centers for Medicare & Medicaid Services, Montefiore, the largest hospital system in the Bronx, did not conduct a follow-up psychiatric consultation after her father was found likely to be depressed after he attended a friend’s funeral. Then, nursing staff claimed they’d completed their hourly check-ups on him, but they did not — leaving him alone when the suicide occurred.
Bryant also discovered that just a week before her father’s death, another Montefiore patient had committed suicide in the exact same manner. The patient, a 77-year-old Bronx resident suffering from cancer and seeking end-of-life care, also hung himself in the bathroom of his hospital room, according to reports from CMS, as the agency is known. The reports do not name either man, but records from the city medical examiner match the dates and circumstances in the hospital inspection reports.
Over the past decade, there have been at least five suicide attempts at Montefiore, four of which succeeded, as well as other incidents where potentially suicidal patients were insufficiently supervised and had clear opportunities for self-harm. From 2016 to 2017, inspectors found that the hospital repeatedly failed to implement changes recommended by its internal committees — such as suicide training programs for nurses, environmental safety checks, and updating policy to search patients for dangerous items.
These failures, according to the report, “resulted in patient deaths.” In the 77-year-old patient’s case, Montefiore used a bed alarm system that a head nurse acknowledged had a known problem — it could be disabled by patients, thus preventing nurses from knowing when they got out of bed. In other cases, patients were placed in seclusion without a doctor’s order and remained there, unmonitored, and sharp objects were left unobserved in front of minors and patients with suicidal tendencies.
Inspectors from CMS discovered Montefiore’s recent suicide issues after the deaths, and the agency issued a warning to the hospital that included the threat of losing millions in federal funding — which could have caused it to close. In response, Montefiore filed a corrective action plan on April 2017. Since then, there have been no reports of suicides or attempts, according to federal records.
However, following its unusual number of suicides, it remains unclear whether Montefiore has fixed all the problems inspectors cited them for. The hospital refused to answer questions regarding its suicide or patient safety issues. It also declined to make a spokesperson available, and instead emailed a lengthy statement focusing on its accomplishments and regulatory compliance.
“Montefiore works closely with key oversight bodies: the Joint Commission, CMS, and the State of New York, along with the [Accreditation Council for Graduate Medical Education],” read the statement in part. “We are dedicated to cultivating physicians who are trained to promote optimal patient quality and safety.”
Some nurses at Montefiore are wary of the hospital’s promised changes. Candice Sering, a nursing union representative, said that after Calderon’s suicide, the hospital pledged to increase its level of monitoring for patients, but hasn’t committed enough staff to see it through.
A CMS spokesperson declined to comment on suicide issues at the hospital, saying that the agency does not provide comment on inspection reports.
A healthcare giant
Montefiore Medical Center was founded in 1884 by Jewish philanthropists as a facility to care for the city’s chronically ill. In 1888, it expanded to a 140-bed facility in West Harlem, and by 1912, moved from the Upper East Side to its current location in the Bronx’s Norwood neighborhood.
Since then, Montefiore has ballooned into a dominant health care player — not just the largest in the Bronx, but one of the biggest regional health care systems in the country. In 2016, its 726-bed Moses campus — where Bryant’s father was treated — was the fourth busiest in the state by total number of inpatient discharges.
The hospital system’s reputation has also become more high-profile. Since 1963, when it began serving as the teaching hospital for Albert Einstein College of Medicine, it has become a renowned academic medical center. In 2018, Montefiore was ranked eighth of the 167 hospitals in the city’s metropolitan area by U.S. News & World Report.
Nicknamed “Monte,” the hospital is also a primary care provider and lifeline for Bronx residents who need emergency treatment. The Montefiore Children’s Hospital and Moses campus developed expertise in asthma and diabetes, illnesses which disproportionately affect the borough. Arthur Hopkins, a doctor specializing in internal medicine at the Montefiore Yonkers campus, said that when he worked at the Moses location, he found that the patients were sicker because “the Bronx is tough.”
“80 percent of our patients are on government programs,” he said, “You can’t just sit down and negotiate with Medicare for a better rate. The thing that has really kind of saved us is that we’ve gotten good at managing care appropriately … efficiency is something we’re very good at.”
Steven Safyer, Montefiore’s president and CEO since 2008, wields great influence over health care in the Bronx. He is chair of the League of Voluntary Hospitals and Homes and a past chairman of the Board of Governors for the Greater New York Hospital Association, an influential industry group.
In 2016, Montefiore reported employing just under 23,000 people (it is the largest employer in the Bronx) and bringing in $3.6 billion in revenue. Montefiore spent $10 million of its budget on advertising that year, even financing a feature film called “Corazón” that premiered at last year’s Tribeca Film Festival.
As Montefiore has grown, it has also snapped up other hospitals as part of its expansion strategy. In 2015 it acquired St. Luke’s Cornwall Hospital in Hudson Valley and Nyack Hospital in Rockland County, and last year, it merged with Crystal Run Healthcare, a private health system based in Orange County.
There have been other signs of trouble at Montefiore. Earlier last year, a dispute with the nurses’ union over staffing levels and Montefiore’s tendency to hold patients in hallways broke into the open, resulting in protests and calls for the city to investigate the practice. Government inspectors had previously found that from November 2016 to May 2017, between 15 and 49 emergency room patients were placed in temporary locations (day rooms, treatment rooms, and hallways) every day except for one.
The first story involving Montefiore and suicide dates to 2009, but involves a death that did not occur at the hospital. Vladimir Makarov, a 30-year-old Bronx resident who suffered from both depression and paranoia, checked into the psychiatric ward of the Moses campus on October 29, 2009. He had previously attempted suicide and was hospitalized at a different health care facility in Westchester. His Montefiore doctors failed to complete the paperwork required to keep him in the hospital, according to a lawsuit filed by the family in July 2011. When Makarov returned home in December 2009, he jumped to his death from his grandmother’s 24-story apartment building in Co-op City. “He was very depressed and needed help,” his sister, Anna Satalkina, told the Daily News in 2011. “He absolutely shouldn’t have been released.” It is unclear how the lawsuit was resolved. Court updates stop in 2014 when several doctors were dropped from the suit.
The first of the four suicides to take place on hospital grounds in recent years occurred on June 23, 2012, when an inpatient walked off a Montefiore patient care unit in the middle of the night and was later found dead on the facility’s premises. He broke a window using a fire extinguisher and jumped from the ninth floor, onto a rooftop of a different hospital section. The incident was noted in a 2012 federal report.
A national problem
Successful patient suicides have occurred in other hospitals in New York City, but Montefiore is the only hospital with more than one since 2011, according to CMS reports released to the Association of Health Care Journalists (and available on its website hospitalinspections.org.)
For example, in August of 2017, a patient at Coney Island Hospital, a public hospital in Brooklyn, was admitted to the psychiatric emergency department with suicidal thoughts. He hung himself in his room. Inspectors found that he was not monitored appropriately.
At New York-Presbyterian Hospital, a nonprofit hospital in Manhattan, a patient was admitted to the psychiatric ward for suicidal ideation in September 2016. Though his doctor’s plan called for checks every 15 minutes, records show that a few days later, he was found hanging in the bathroom.
According to The Joint Commission, an accreditor of health care organizations, suicide is considered a “never event,” or an adverse, unambiguous, and serious event that is usually preventable. Last year, it found that suicide was the fourth most-common cause of unexpected death or injury in hospitals, with 89 reported to the organization that year.
Aiming to address to lack of reliable data on hospital inpatient suicides, last September the group released a new study that it says provides the first data-driven estimate of suicides in U.S. hospitals. It found that approximately 49 to 65 hospital inpatient suicides occur each year, and among those, 75 to 80 percent are among psychiatric inpatients. Some experts believe the actual number is far higher.
“It’s a major problem, and it’s been a problem as long as I’ve been in the field,” said James Knoll, a professor of psychiatry at SUNY Upstate Medical University who studies suicide risk and prevention. “There’s no centralized tracking of this … It really is hard to compare systems across the country.”
The Joint Commission study also found that hanging accounted for more than 70 percent of suicides, and one half of them occurred in the bathroom. The most commonly used fixture point for hanging is a door, door handle, or door hinge. Experts have long suggested that hospitals could make great strides in suicide prevention if “ligature points” like door handles are replaced with “ligature resistant” types.
Questions about care
Between January 2011 and the end of last year, CMS inspectors documented 57 violations at Montefiore, the most of any New York hospital, according to data from the agency. (Though Montefiore has several campuses in the Bronx, the government counts them as one hospital.)
Montefiore’s most recent deficiency was a “patient safety” violation in September 2017 for failing to adequately respond to episodes when patients removed their own breathing tubes or catheters.
Based on data obtained directly from CMS, since 2011, Montefiore has been cited for placing patients in “immediate jeopardy” four times. Only two other hospitals in the state have been cited over that timespan for that many “immediate jeopardy” situations: St. John’s Episcopal Hospital at South Shore in Far Rockaway, and Arnot Ogen Medical Center in Elmira.
An “immediate jeopardy” designation is the most severe of warnings from CMS and indicates that a hospital’s noncompliance has or is likely to cause serious injury, harm, impairment, or death to a patient. If a facility does not correct issues that triggered the warning, it could lose Medicare and Medicaid funding within a month. For Montefiore, which relies more heavily on federal dollars than other city hospitals, that could have been be a deadly blow.
Over the past eight years there have been more than 1,000 findings of “immediate jeopardy” affecting nearly 750 hospitals around the country, although only 19 facilities have registered four or more such reports, according to data provided by CMS.
In the year before Bryant’s father died in March, Montefiore’s Bronx campuses had been cited by inspectors for failing to follow internal recommendations for depressed or suicidal patients, which allowed additional suicide attempts and suicides to occur.
In June 2016, for example, a patient reported to her psychiatrist that she had been feeling depressed for about seven months and had felt suicidal for the past three weeks at the hospital. In May, her care team noted that she was “teary eyed and upset” and “did not want her family to know she was HIV positive.” On June 23, 2016, she stated she wanted to die, and refused to take any medicines. Later that day, she was found with a telephone cord wrapped around her neck.
The next day, a nurse discovered that the patient had removed her dialysis catheter. Blood gushed out of her body, and she entered hemorrhagic shock. The patient later died. She was supposed to be watched around the clock.
Several months later, in October 2016, a patient with a history of substance abuse, depression, and suicidal thoughts was admitted to a medical unit. He too was supposed to be continuously watched by a staff member to prevent him from attempting suicide, and was supposed to have his belongings checked for hazardous items. But on October 14, nurses found blood on his left wrist from an attempted suicide using shaving razors he retrieved from his bag, where two other razors were also discovered. The patient did not die.
In response to the October incident, an internal group called the Performance Improvement Committee recommended changing hospital policy to remove dangerous items like razors from patients’ belongings, and advised implementing an electronic training program for all nurses. A different group, the Nursing Peer Review Committee, determined that the cause of the incident was poor instruction given by a senior nurse. According to a government report, a managing nurse had instructed a nurse assistant to leave the patient alone.
In February 2017, the Quality Peer Review group recommended another set of steps for preventing future suicides, which included a manager checking to ensure that suicidal patients were being watched around the clock, and that staff understood the rationale for such observation.
That same month an 11-year-old girl was brought to the emergency room after attempting to commit suicide by overdosing on oxycodone, a powerful narcotic. She was supposed to be constantly watched for suicide, but she was not.
While her care providers weren’t looking, a different 13-year-old girl in the emergency room — who had previously attempted suicide by hanging herself — passed her a box cutter knife. The knife was discovered by the patient’s mother, and there was no evidence of self-harm from it. Neither patient was searched prior to entering the ER, and government inspectors found other instances where suicidal pediatric patients were not continuously watched.
The following month, on March 20, 2017, a patient with a history of schizophrenia was admitted to the ER after overdosing on Tylenol and Seroquel, a strong antipsychotic medicine. A day after, inspectors found him in the emergency department within arm’s reach of a lab cart with needles and other equipment for drawing blood, completely unattended. He did not attempt suicide in the emergency room.
The next day, on March 21, 2017, the 77-year-old Bronx resident committed suicide by hanging himself in his bathroom. There was no indication that the bed alarm that would have alerted nurses to his movements was activated, and Montefiore continued to use the system, even though it knew it could be disabled by patients.
Dizzy, then dead
A week later, Bryant’s father Gilbert Calderon committed suicide.
On March 25, 2017, feeling dizzy and overcome with grief after attending a friend’s funeral, Calderon checked himself into Montefiore’s Bronx emergency room, according to government reports. At the time, his physician documented that Calderon was a “patient with very depressed affect.” The next day, the physician noted that Calderon had “recently been under a lot of stress due to medical issues and personal issues.”
But after his admission, inspectors found there was no evidence Montefiore did a further exploration of his feelings or developed a psychiatric plan of care to address his depressed affect. When interviewed by inspectors, the Director of Psychiatry admitted that not providing Calderon with a psychiatric consultation was a “missed opportunity.” “He presented as someone who was probably likely depressed given what happened at his friend’s funeral,” said the director, “and yes this would have been an appropriate consult to have received.”
During an interview with inspectors, Calderon’s emergency room physician said he had attributed Calderon’s “depressed affect” to his living in the Bronx. “When I wrote that the patient had a very depressed affect I meant that he seemed like most people who live here in the Bronx … you know life is hard and it’s not easy for people who get older and have health issues to live here,” the physician said. “I didn’t refer him for a psychiatric consult because he didn’t say the words ‘I want to harm or kill myself.'”
The report also revealed that Calderon’s nurses failed to complete their hourly rounds, leaving him alone in his room for hours. It identified numerous “gaps and inconsistencies in the hourly nursing documentation,” where nurses claimed they’d checked on Calderon around the clock. Yet video tape of the hallway outside his room showed that his nurse did not enter his room during a few crucial hourly check-ups. The next time they entered at 4:32 a.m., he was found hanging in the bathroom.
After investigating Calderon’s death, government inspectors also concluded that in eight of 12 medical records they reviewed, Montefiore “failed to ensure that potentially suicidal patients were appropriately screened, assessed, and /or monitored.” Three of those patients were not screened for suicide risk, according to nursing triage documentation. The Director of Nursing for Professional Practice told inspectors that nurses were not trained on suicide and depression risk screenings when they transitioned to EPIC, the new electronic medical records provider.
Hopkins, the Montefiore doctor, said that the health system’s rollout of the new software provider was “very, very fast.” “Basically we went live at three major campuses over the space of a year and a half,” he said. “Every time you go live with new software, you have to implement new stuff. You can never anticipate every single thing.”
He added that the entire health system uses standard depression screening tools. “We screen pretty much every patient,” he said. “We’re trying not to miss the folks who are depressed, who are gonna go home and hurt themselves.”
A March 2017 report also determined Montefiore had “failed to provide a safe environment in the Emergency Department for patients with Mental Health Disorders.”
Eventually, the problems and deaths culminated in an “immediate jeopardy” warning from the government, and the hospital’s fourth overall. According to a report obtained through a Freedom of Information Act request, in April 2017, CMS declared that Montefiore had placed patients in immediate jeopardy of harm or death for failing to adequately care for potentially suicidal patients in its medical units.
Later that month, Montefiore submitted documents detailing promised changes. Its corrective action plan included revisions to its suicide screening and behavioral management policy for suicidal patients in non-psychiatric units, and training all staff on the new policies. After a brief delay, federal inspectors accepted that plan. There is no evidence of any subsequent threat to Montefiore’s federal funding.
After hearing Montefiore’s track record, Knoll, the SUNY suicide risk and prevention specialist, said its issues and “rash of deaths by suicide” were concerning.
“It’s simply never acceptable for the person to die by suicide in the hospital. That’s what they came there for,” said Knoll. “Does it happen? Yes, and it usually happens due to human or institutional error.”
‘I still don’t understand’
Bryant is still angry over what happened with Montefiore, and says they never apologized to her.
“If he had the proper care and treatment, this could have been avoided,” she said.
Her father’s death also reverberated across his community. He was a lifelong New Yorker and longtime Bronx resident. He was also a drug counselor who had been sober for about 30 years when he died.
“I remember him as caring. He was thoughtful, and he tried really hard to make up for not being around when I was younger,” said Bryant.
In February, a month before he died, he was also in love. He and his fiancé were planning their wedding. In April, his fiancé was planning his funeral arrangements.
The service was held at a funeral home on Morris Park Avenue in the Bronx, where people he had treated spoke about how he helped them change their lives. Members of the church he regularly attended, St. Helena on Olmstead Avenue, remember him as soft-spoken and friendly.
“To this day, I still get phone calls from people telling me ‘I still don’t understand, I can’t put it together,'” said Bryant. “He was a force in his community.”
Montefiore, in its emailed statement (read it in full here), said that it had more than 50 multidisciplinary quality committees and a system-wide quality performance group that aims to “continuously improve quality and ensure safety.”
“We practice a ‘Just Culture’ environment predicated on learning, and flagging potential or actual errors,” the statement continued, “This model supports a balanced, rigorous multidisciplinary approach that looks for root causes of problems within the system and addresses them.”