State keeps tight grip on Ancora restraint details

I wanted a simple answer to a simple question.

How often does Ancora Psychiatric Hospital restrain patients who have intellectual or developmental disabilities? 

It's a fair question. An estimated 30 to 40 percent of developmentally disabled people also have a mental disorder. Sometimes, they act out violently toward themselves or others, making it challenging for them to live in the community – even in a supervised setting like a group home.

Public documents offer little detail on restraint use

I want to be clear. Most violence is perpetrated by people who don't have a mental disorder. The vast majority of those with mental illness aren't violent, and are more likely to be attacked, raped or mugged than the general population. There is an argument that many people with special needs are misdiagnosed as also having a mental illness – that perhaps their behaviors are a result of miscommunication, fear and frustration. 

Even so, some land in the state's psychiatric hospitals. There are presently 53 dually diagnosed people in state psychiatric hospitals, according to the N.J. Department of Human Services. There are 15 at Ancora, among roughly 400 patients. 

In recent years, New Jersey has increased the number of specialized units in its psychiatric hospitals for such dually diagnosed patients. According to a task force convened by the Department of Human Services, their average psychiatric hospitalization is three times as long as non-disabled patients. 

Some are nonverbal. Unable to voice complaints, to the state or even their loved ones, they are among New Jersey's most vulnerable psychiatric patients. 

How are they treated? That's not easy to suss out. 

Despite calls for change, little done on mental health

Decades ago, Courier-Post journalists could tour Ancora's psychiatric wards to find an answer. Visiting reporters ate lunch with patients when it opened in the mid-1950s. One reporter sat in on a therapy session in the 1980s.

In 1971, Courier-Post reporter Bob Herron spent nearly a month working as an attendant at the Winslow Township hospital, before writing his expose, "Inside Ancora." 

Meanwhile, the newspaper reported one horror story after another. There were multiple escapes. In the late '80s, one woman died after she was restrained for 80 hours, including one episode lasting 34 hours straight. Another froze to death in a ditch. A man was found hanged. A skeleton was discovered on hospital grounds, the remains of a patient who had wandered away, forgotten. Another patient with sickle cell anemia died after she was misdiagnosed and left untreated.

Now, health privacy laws and today's journalistic ethical guidelines prohibit such open access. To investigate mistreatment claims, journalists rely on public records, interviews with state officials, advocacy groups, and the eyewitness accounts of visitors, patients and employees. 

Let's start with the public record.

In 2015, Ancora Psychiatric Hospital briefly lost its Medicare certification after a series of failed inspections. Public records showed the state hospital recorded the most violence that year among the state's psychiatric hospitals. 

That same year, John and Margaret Murphy of Toms River sued New Jersey, Ancora, and several state employees for alleged mistreatment and physical abuse of their developmentally disabled daughter, Tara Murphy. Admitted to the hospital in August 2013, Murphy was allegedly battered, humiliated and improperly restrained during her stay, which caused permanent damage, according to the lawsuit. The matter is now before a federal judge, where it faces a constitutional challenge. 

Ancora's then-CEO, John Lubitsky, also thought Murphy was mistreated by one of his employees. He fired the worker and pressed simple assault charges against her. That much-delayed case was eventually dismissed by a Winslow Township municipal court judge, because security recordings of the incident were left forgotten in a court case file. The judge never watched them. The employee is appealing her termination. 

How are Ancora's developmentally and intellectually disabled patients treated generally? To get an idea, I decided to focus on one number: the rate of restraint use. 

Restraints are sometimes necessary to protect a patient from injuring himself or others. Even so, they are considered an expensive, violent and potentially harmful practice that can prolong recovery and raise the cost of health care, according to the federal Substance Abuse and Mental Health Services Administration. 

Research has found restraints are most commonly used to address "loud, disruptive, noncompliant behavior and generally originate from a power struggle between consumer and staff," the agency reported in 2010. "The decision to apply seclusion or restraint techniques is often arbitrary, idiosyncratic, and generally avoidable." 

It's also traumatizing. Patients who are restrained or left alone in seclusion spend longer in care and are more likely to be readmitted, according to the administration. 

In short, the use of restraints and seclusion is considered a result of treatment failure, the administration found. With the passage of the Affordable Care Act, psychiatric hospitals that receive Medicare funding are required to track and report how often patients are restrained. 

Between April 2014 and March 2015, Ancora reported its patients were restrained a total of 1,362 hours, at a rate well below the state and national averages, according to an accreditation report by The Joint Commission. Ancora's restraint rate among patients older than 65 was even lower, totaling just 28 hours in restraints during the year. 

Those numbers ticked higher the following year. According to the commission's newest report, Ancora patients were restrained a total of 1,573 hours between April 2015 and March 2016, though at a rate still below the national average. 

Advocates call Ancora’s use of restraints ‘serious’

But the reports aren't broken down by individual wards, such as Ancora's specialized unit for dually diagnosed patients, or its forensic unit for patients with criminal histories. Using this measure, there is no way for the public to discern how often dually diagnosed patients are kept in restraints, unless one specifically asks.  

For the past 15 months, the state of New Jersey has not answered this question, though I have repeatedly requested documents using the state's Open Public Records Act. The records I requested either no longer existed or were protected by health privacy laws or proprietary agreements. 

In February, I asked Ancora CEO Christopher Morrison for the restraint rate in the dual diagnosis unit. Though I submitted my questions in advance, he didn't know the answer. Ellen Lovejoy, a spokeswoman for the state Department of Human Services, suggested the information would be available in April. When I followed up with an email, she replied, "CMS posts whatever info is public info," referring to the overall restraint rate.  

On Dec. 1, Lovejoy said her office does not have access to data that isn't already posted online – the information I am seeking is maintained by the OPRA custodian, she explained.

Without knowing how often patients with developmental disabilities are restrained at Ancora, I have no way to quantify how South Jersey's most vulnerable patients are treated while in the state's care. Without seeing trends in the numbers, I can't report how well Morrison's reform measures are working.

I also can't report whether those measures continue to lower violent incidents at Ancora this year, since the state has released that information only through March so far. Since it's not required by law, the department also stopped disclosing minor incidents, such as the abuse allegation that landed an employee in municipal and federal courts.  

State: Assaults down at Ancora

Here's what I have learned about restraints through other public records: 

1. State officials acknowledge privately that Ancora's restraint use is a concern, particularly in its dual diagnosis unit. I learned that after requesting internal emails shared among officials at the state Division of Mental Health and Addiction Services.

Though New Jersey won federal grant money to reduce the use of restraints in its state psychiatric hospitals, the hospital's award-winning improvements made several years ago appear to be "unsustainable," according to an internal email sent by Rosita Cornejo, the division's director of quality assurance. 

2. Ancora's restraint use was flagged in 2015 by inspectors. After examining records for a small sample of patients, inspectors noted instances when two people were restrained repeatedly without anyone updating their treatment plans to prevent future occurrences.  

3. Ancora submits patient data to the National Association of State Mental Health Program Directors Research Institute Inc. The organization analyzes the data and sends reports back to the state division. I asked for those reports, including those related to the restraint use at Ancora. 

The reports contain "patient level data" and "protected health information," according to a written denial sent by the division's OPRA custodian, Jeffry Nielsen. Additionally, he said, the reports are "proprietary" and prohibited for release, according to an agreement between NRI and New Jersey.

It took Nielsen nearly four months to deny that last request.

4. To address the restraint problem, the state hired behavioral therapists to work with Ancora's dually diagnosed patients last year, documents showed. Have outcomes improved as a result? Without being able to compare restraint rates for that population, it's hard to know. 

I have made a last-ditch effort to nail down this number, but it's a gamble. Nielsen is processing two more OPRA requests from me, filed in June and later revised in late September. They center on internal emails between state officials last July as they labored to address restraint use at Ancora.     

"Like your previous requests, I expect the captured documentation for these two OPRA requests to be voluminous, and need thorough review and (likely) significant redaction," Nielsen warned. 

I have no doubt.

Kim Mulford: (856) 486-2448; kmulford@gannettnj.com