Then, on Dec. 1, after a hip surgery, Bent was transferred to a new unit. Despite an order for her room to be searched daily, some staff would later say they had never been told how.
Four days later, Bent locked herself in the bathroom. At first, nurses thought she was experiencing a medication’s side effects. But after about an hour, a staffer forced open the door to find Bent unconscious on the floor leaning against the wall, her head slumped over her chest, in cardiac arrest. A syringe used to shoot up a crushed cocktail of pills — including Ritalin and oxycodone — rested on her stomach. For 25 minutes, hospital staff got on the floor to administer CPR and chest compressions, but she
died before nightfall.
“Somebody dropped the ball,” Joe Bent, Jennifer’s father, said. “This could’ve been easily prevented.”
Patients at risk
Health inspection, police, and medical examiner records reveal the complexity of caring for patients like Jennifer Bent, who started using opioids in college, according to her brother, Coleman Nelson. Her death puts into sharp focus the challenges hospitals face in treating people with substance abuse problems, whether those patients show up at emergency rooms in crisis or, like Bent, are at risk during a longer stay.
The rate of hospital emergency room visits related to opioids roughly
doubled in Maine from 2007 to 2014. Less clear, however, is the prevalence of accidental deaths like Bent’s, where hospitals must reckon with their capacity to keep patients safe from their existing addictions.
Last year, Maine documented a record number of drug deaths,
with 418 statewide. As one of the states hit hardest by the nation’s opioid epidemic, one that killed nearly 50,000 Americans in 2016, Maine and its hospitals have increasingly felt the strain of patients who struggle with drug use.
“Medical systems haven’t traditionally done a lot proactively with substance use disorder,” Eric Haram, a Maine-based consultant who works with hospitals nationwide on expanding access to addiction treatment, said. “Some institutions have taken on treatment themselves.”
Last year, emergency room doctors at Mercy Hospital in Portland started encouraging every patient who overdosed to seek out addiction treatment programs. In recent months, Brunswick’s Mid Coast Hospital became the
first emergency room statewide to prescribe buprenorphine, an opioid-based medicine that can reduce cravings and the likelihood of relapse if taken as prescribed. York Hospital has launched a similar program.
These kinds of programs are a few of the ways hospitals from Maine to Arizona are trying to protect the safety of patients with an underlying opioid addiction. According to Nelson, his sister was rarely drug-free during the decade and half since she started using drugs. Before her hospitalization, she once had access to Suboxone and methadone programs. But she relapsed, Nelson said, and eventually lost full custody of her kids.
“She loved her kids, but had trouble providing financially or emotionally,” said Nelson, who also struggled with addiction but hasn’t used in nine years. “She couldn’t get to the point where she could control her using.”
At EMMC, Dr. James Jarvis, a senior vice president, said patients have experienced an uptick in opioid-related complications in recent years. In response, EMMC has assembled a multidisciplinary team tasked with managing patients who in some cases are “using until the hour they get here,” he said. It’s prompted the hospital to better monitor patients mostly likely to have a substance use disorder.
“The illness of why they’re here is related to [their substance use disorder],” Jarvis said. “We established a number of safety policies of care taking while keeping their dignities. We don’t want to criminalize them as well.”
EMMC declined to comment on Bent’s case citing privacy regulations. Health inspectors typically redact all personal information before making records public. But a series of additional records requests, compared against a database of obituaries, revealed Bent as the patient at the center of the 2016 health inspection, which spurred health inspectors to hit EMMC with four safety violations.
In Bent’s case, records show that hospital staffers experienced a series of breakdowns in communication. Likewise, the inspector also found that the hospital failed to properly document its routine searches of Bent’s room, once she was identified as a patient at risk of using unauthorized drugs. An inspector found that at least one nurse had “never been trained to search a room.” And another nurse remarked that, “it’s very tricky to approach a patient without getting the patient defensive and destroying their trust,” according to inspection records.
The medical examiner later ruled her death an accident. But Joe Bent, an antique dealer in Nobleboro, said EMMC told him his daughter’s death had involved intravenous drugs, leaving him with the impression that it was the result of a routine medical complication. He didn’t know the full circumstance of his daughter’s death until a reporter contacted him nearly a year later, in November 2017.
“They told us it was a tragic accident, nothing out of the ordinary happened,” he said. “I never got the straight story.”
Credit: Courtesy of Coleman Nelson
EMMC spokeswoman Tricia Denham said that, “even when an unforeseen circumstance arises, we are always careful to be truthful and accurate in our interactions,” but declined further comment.
Aiming for prevention
Deb Sanford, EMMC’s chief nursing officer, said the four safety violations stemming from Bent’s death prompted a review of what went wrong. Instead of blaming individual staffers, everyone from residents to hospital administrators participated in a root cause analysis where they asked: How can we prevent the same mistake from happening again? It eventually became clear that while they had monitored patients while in their rooms, staff weren’t always stopping visitors from hiding drugs for patients after they left to get medical tests elsewhere in the hospital.
A simple fix emerged: tamper tape. It’s now placed on the doors of high-risk patient rooms so the staff knows if anyone snuck inside. In addition, Sanford vowed to train nurses on searching rooms, and has since asked high-risk patients to be identified during rounds. EMMC administrators believe these improvements have not only lead to better care, but also better training for medical professionals learning inside the teaching hospital.
Without stronger efforts to help patients like Bent, her family fears that more people could be harmed. Jennifer’s family is caring for her kids. Her father has tried to go on selling antiques but can’t shake the tragedy of her preventable death. He wishes the hospital, which he said still hasn’t told him the full details about why Jennifer died, would have acted sooner to save her life. He remains haunted by the lack of answers.
“This could happen to anybody’s family,” Joe Bent said. “I never want to see this happen again.”
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