In this file photo, Debbie Coughlin, left, fights tears as she recalls the… (Robert Gauthier, Los Angeles…)
Diane Rodrigues sang, prayed and bounced on her bed during the night at Metropolitan State Hospital. A nurse assigned to keep her under constant watch sat by, occasionally dozing.
By 7 a.m., the 52-year-old psychiatric patient was lying motionless on the floor, her neck broken.
It took at least an hour for caregivers at the Norwalk mental hospital to glean the extent of her injuries. It took four more hours to send her to a trauma center for treatment. Rodrigues, a former kindergarten teacher, was left paralyzed after the November 2009 accident and died six months later from related respiratory complications.
Internal investigative reports in the Rodrigues case, recently obtained by The Times, detail serious lapses in medical treatment at the height of a massive court-supervised effort to improve care in the state's psychiatric hospitals. Among the findings: Staffers slept on the job, failed to conduct regular patient checks, moved Rodrigues despite what turned out to be a serious cervical injury, failed to summon timely help and lied to protect themselves and one another.
In the end, hospital investigators refused to sign the final draft because the recommendations were diluted by Metropolitan administrators, according to two sources familiar with the investigation who asked not to be identified because the process was confidential. Deleted from the report, for instance, was a proposal for mandatory staff training on head injuries. The factual findings were unaltered.
Rodrigues' case was among about a dozen cited in court documents by a federal court monitor who faulted medical and psychiatric care at Metropolitan and Napa state hospitals as part of a petition to extend a U.S. Justice Department consent judgment governing the two facilities. A judge's decision on the matter is pending. (Two other state hospitals have been released from court supervision.)
California Department of Mental Health officials have declined to discuss the Rodrigues case because it is the subject of ongoing litigation by her family. The department also denied a Times request for the results of the internal investigation into Rodrigues' injury, which had been ordered by Metropolitan administrators.
But the newspaper was able to obtain the final report and five previous drafts, all of which found evidence of "gross negligence," involving "incompetence, fraud, dishonesty, along with numerous policy and procedure violations."
Rodrigues, who suffered from schizophrenia, had been placed at Metropolitan in September 2009 by a conservator to keep her from hurting herself or others. She cycled between periods of psychosis and quiet insight and had injured herself repeatedly — at one point gouging out her right eye with her fingers.
According to the report, Rodrigues was known to hurl herself to the floor. She had been given a low bed, and the walls and floor nearby were padded with exercise mats. Since admission, she had been put under constant one-on-one supervision. But on the night of the injury, the nurse assigned to her had to be awakened three times by the shift supervisor, investigators found.
Agitated and jumping on the bed, Rodrigues had received an antihistamine injection about 3:30 a.m. to calm her. Some time after 5:30 a.m., she propelled herself to the floor. Investigators found that staff members had been reluctant to physically stop her from leaping or tie her down with restraints.
According to their report, a psychiatric technician who was supposed to check on patients every half-hour did not do his job. Instead, he spent his time filling in for other staffers while each took an hourlong nap. The shift supervisor had instigated the practice and signed forms that falsely said the checks were done.
Cecilia Velasco, the registered nurse assigned to watch Rodrigues overnight, made no note of her fall and denied witnessing it. Afterward, according to investigators, Velasco "attempted to conceal Rodrigues' injuries by placing a blue mat underneath her as she was lying on the floor." When a co-worker arrived to relieve her, she told him Rodrigues had chosen to lie there.
Rodrigues complained of pain an hour later. A nurse lifted her by the shoulders to help her swallow Tylenol, then discovered a bleeding gash on her head. A vital-sign check revealed markedly low blood pressure. Rodrigues said she could not feel her legs. An examination of the pupil in her only functioning eye showed it was slow to respond to light — a sign of head injury.
A parade of staff members went in and out of Rodrigues' room, yet communication was so poor that few seemed to know the extent of her injuries, and none summoned paramedics, according to the report