Nursing staff at a state mental hospital watched television, slept and lied about making bed checks while a Chevy Chase woman lay dead in her room after she was strangled with shoelaces, a state investigation found.

Administrators at Clifton T. Perkins Hospital Center call the incident a fluke and say they have put a plan into place to ensure the safety of patients.

Maryland's Office of Health Care Quality, which monitors hospitals and clinics, interviewed Perkins staff, and reviewed video, hospital policies and procedures two days after the Sept. 25 death of Susan Sachs, who was committed to the hospital in 2004. The office sent the result of its investigation, a Statement of Deficiencies, to the hospital Dec. 28 and the hospital provided its Plan of Correction on Jan. 27.

Nursing staff found Sachs, 45, dead in her bed around 8:30 a.m. Sept. 26 with "string ligature around her neck," according to Maryland State Police. Charging documents filed by police show officers believe fellow inmate El Soudani El Wahhabi — also known as Saladin Taylor, 46 — entered Sachs' room and strangled her with shoelaces.

Both El Wahhabi and Sachs were committed to the Jessup mental hospital after being found to be unable to face trial on unrelated murder charges. Their rooms were in the same hallway in a medium security wing of the hospital.

El Wahhabi was transferred from the all-male maximum security section of the hospital in July, according to the Statement of Deficiencies.

Sachs was declared mentally incompetent to stand trial by a Montgomery County Circuit Court judge after she was charged with first-degree murder in the 2004 killing of Joyce Hadl, 71, of Chevy Chase, a psychiatrist who was Sachs' landlord at the time of her death.

Family of Sachs could not be reached.

The Statement

of Deficiencies

An unexpected death at any state-run mental facility triggers an investigation by the Department of Health and Mental Hygiene, under which the hospital and the Office of Health Care Quality both fall, according to its website.

The investigation showed that staff on duty the night of Sachs' death did not follow hospital procedures such as locking the doors to patients' rooms overnight, a lapse which allowed El Wahhabi to enter Sachs' room without notice at 10:50 p.m. and go back to his room 9 minutes later. The doors were locked by 11:30 p.m. when Sachs' roommate tried to enter her room, according to the Statement of Deficiencies.

When staff unlocked the door, the roommate did not notice anything unusual when she saw Sachs with "covers over her head" since Sachs usually slept that way.

Nursing staff on duty Sept. 25 falsely claimed to have performed the security checks required to be taken every half-hour in the wing and were seen on closed-circuit cameras watching television and napping, according to the Statement of Deficiencies. Nursing staff signed the "rounds boards" every half-hour from 9:15 p.m. to 7 a.m. though they did not check on the 24 patients in the wing, according to the report.

"At 1 a.m., lights in the nursing station were turned down," according to the report.

They were turned up again at 7 a.m. and the first round of checks was performed at 7:48 p.m., according to the report.

It wasn't until 8:15 a.m. that a nurse tried to wake Sachs, who was found "cold to the touch, and without a pulse."

The shoelaces were still around her neck.

Reaction from Perkins

Administrators were "extraordinarily dismayed ... to see staff acting like that," said Wendy Kronmiller, chief of staff and assistant secretary for regulatory affairs for the Department of Health and Mental Hygiene.

She said the actions of staff that night do not represent how the hospital is run, calling it an "aberration."

Perkins administrators were required to outline a Plan of Correction to ensure similar incidents do not occur or face a fine of up $10,000 per day, Kronmiller said.

The hospital changed procedures to prevent patient on patient attacks in the medium-security wing such as working to segregate patients with a history of predatory behavior — like El Wahhabi — and having security officers randomly check on nurses working at night to ensure they are performing bed checks, wrote Sheilah Davenport, CEO of Perkins, in a Jan. 27 letter to Renee Webster, the assistant director of the Office of Health Care Quality.

In a Jan. 13 letter to Webster, Davenport wrote that disciplinary action was taken with staff as a result of the investigation. Kronmiller said she could not comment what that action was, claiming personnel decisions are kept confidential.

The hospital's Plan of Correction was approved by Webster on Feb. 4.

Davenport, who announced this month she plans to resign Feb. 25 from the CEO position she has held since 2006, said despite the incident she was not willing to go against her policy of limiting use of restraints and seclusion on patients — practices primarily used on those deemed dangerous or who refuse treatment — and instead needed to focus on ensuring that current procedures are followed.

"We have created an environment where we are using, I think, more effective techniques for managing patients," she said.

Davenport said her decision to resign was not influenced by Sach's death, which is the first "intentional killing" in Perkins' 50-year history, according to state police.

Susan Steinberg, director of the Office of Forensic Services within the Deputy Secretariat for Behavioral Health and Disabilities, will serve as CEO of Perkins until a permanent replacement can found, according to a memo from Renata J. Henry, deputy secretary of the Department of Health and Mental Hygiene.

El Wahhabi was indicted for first-degree murder in October in Howard County Circuit Court. El Wahhabi is being assessed by private and county-sanctioned mental health professionals to determine if he is capable of facing trial, said Wayne Kirwan, a spokesman for the Howard County State's Attorney's Office.

aruoff@gazette.net