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State officials dismissed 3 after mental patient's death

Health officials say others were disciplined after the dying man was ignored for nearly a day in April.

By Michael Biesecker
michael.biesecker@newsobserver.com

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  • An internal investigative report, completed in June by Cherry Hospital, named employees who either violated policies or failed to act as Steven Sabock died. The report was not made public until last week, after The (Raleigh) News & Observer worked with the patient's widow to force its release.

    The report finds that:

    Nurse Latasha Lewis was dismissed Aug. 28, shortly after accounts of Sabock's death were first reported in the newspaper. Lewis failed to properly document or follow-up the incident during which the patient choked and fell. She also failed to assess Sabock's condition and lied to investigators, claiming she had measured his vital signs when she had not.

    Nurse Aimee Clark resigned her job July 2, according to state personnel records. Investigators cited her for failing to make her rounds during her early morning shift the day Sabock died. She also failed to ensure those she supervised carried out medical instructions to regularly monitor Sabock's vital signs and provide him fluids.

    Nurse Catherine Carraway retired from Cherry on Oct. 1. She failed to make rounds during her shift, failed to assess patients' needs and failed to supervise those under her, the report said. She also lied to investigators, claiming she had talked to Sabock and offered him a drink. The video showed she did not.

    Susan Watson, a licensed practical nurse, lost her job Sept. 27. She failed to report the incident where Sabock choked and fell, failed to respond appropriately to the accident and failed to check on the patient's condition afterward, according to the report.

    Lucretia Houston, a health care technician, also lost her job Sept. 27. She failed to report Sabock's choking and fall, failed to use caution in moving him after the accident and provided “false and misleading information” to investigators. Houston was also seen on the video dancing and being inattentive to Sabock, as well as hugging and kissing another employee.

    Rodney Best, a health care technician, left his job Nov. 1. Best told investigators Sabock refused to have his vital signs taken on the day he died, but the video showed he made “no real effort” to collect the information, the report said.

    William Mathis, a health care technician, is still on the job after returning from suspension Oct. 4, according to state personnel records. Mathis falsified Sabock's medical records to record measurements for his vital signs the surveillance video proved he never took. He also lied to investigators, according to the internal report.

    Kelvin Lewis, a health care technician, returned from suspension Oct. 2. He falsified hospital records and failed to properly care for patients, according to the report.

    Perry Butler, a health care technician, returned from suspension Aug. 19. He was cited for playing cards and having a cell phone during his shift. He also was seen on the video being hugged and kissed by Houston, conduct deemed unprofessional by the investigators.

    Anthony Green and Jennifer Kilpatrick, both health care technicians, sat and watched TV for much of their shifts on the day Sabock died. They are still on the job.

    Of five other employees named in the report, four were cited for using improper techniques to collect vital signs or failing to make rounds to assess patients. The other employee, a nurse, was cited improperly, state officials said Wednesday.

    Michael Biesecker

RALEIGH State officials said Wednesday that they fired three Cherry Hospital employees and disciplined others after the death of a mental patient who went without food, water and care for more than 22 hours. The man's widow said she cannot believe the hospital is still open.

Steven Sabock, 50, who was being treated at the Goldsboro hospital for bipolar disorder, died April 29 after he choked on medication, hit his head and was left in a chair. Hospital employees played cards and watched television nearby. Security camera footage released Tuesday shows that some Cherry employees falsified records and lied to investigators in an attempt to cover up negligence in the death.

In a written statement issued Wednesday by the state Department of Health and Human Services, officials said three employees were dismissed after Sabock's death. One received a five-day suspension, while four others received three-day suspensions. Five employees received written warnings.

Two others resigned, though it is not clear their leaving the hospital was tied to Sabock's case.

Those who remain at Cherry are undergoing a retraining program and have been moved to jobs off the ward where Sabock died. They receive weekly observation and supervision by a nurse supervisor.

Susan Sabock of Winchester, Va., who was married to Steven Sabock for 25 years, said she was able to watch only a few minutes of the video Wednesday before she started crying and couldn't bear to see more. One of the most disturbing things, she said, is that the video showing her husband's neglect would likely have never have been reviewed had he not died.

“It's very hard for me to watch, but of what I've seen, it's the most disgusting thing I can imagine,” she said. “It's like we're in a bad dream and we just can't get up. How is this hospital still open? I just don't understand.

“What kind of country do we live in where this could happen?”

The SBI, which launched a criminal investigation in August, is continuing to investigate. Though patient neglect is a crime, none of the Cherry employees responsible for Sabock's care has been charged.

Wednesday's statement was released in response to questions submitted Tuesday after requests for interviews with the hospital's director, Jack St. Clair, and nursing director Bonnie Gray were denied.

Gray prepared an April 29 report on the death of Sabock, a carpenter who had lived in Roanoke Rapids. The report, given to regulators in Raleigh and to a state medical examiner, included measurements for Sabock's vital signs that the video proves employees never took.

The nursing director's report also omitted key details of Sabock's final day, including the incident where he choked and fell, though she should have had access to internal hospital records that detailed the event.

As for Sabock's daze during the 22 hours he sat without food or water, Gray wrote: “Patient was sleepy all day, and oral intake was poor.”

Gray again declined a request for an interview Wednesday.

The state medical examiner who autopsied Sabock's body later concluded he died of a pre-existing heart condition, though the pathologist did note that his brain showed signs of “mild generalized edema,” or an accumulation of fluid that can indicate injury.

The department's statement said Cherry's administrators had been ordered to review the hospital's initial account “to determine what if any inaccurate information is contained within that report and to supplement the report in the event that additional information that is now available contradicts the report that was released immediately after Mr. Sabock's death.”

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