Leaders of a patient advocacy group learned that a corrections officer pepper-sprayed a naked, defenseless woman at Riverview Psychiatric Center shortly after it happened in December but waited months to report it to state abuse investigators.

The Disability Rights Center employs two federally funded patient advocates who work inside Riverview in Augusta, and critics say the group should have done more.

An attorney with the rights center said the group tried to persuade hospital administrators to report the abuse to the state’s Adult Protective Services. After more than two months of back-and-forth with Riverview’s administration and frustrated by the lack of action, the group reported the abuse in February, attorney Helen Bailey said.

That apparently occurred after it already had been reported by someone else. According to a state investigatory report, a hospital whistleblower was the first to alert authorities.

The Disability Rights Center’s failure to immediately notify Adult Protective Services let down the abuse victim, critics said.

“To just not report it because they could not urge others to do so is unacceptable,” said Rep. Richard Farnsworth, D-Portland, chair of the Legislature’s Health and Human Services Committee. “This report should have been made within 48 hours.”

On Dec. 2, a corrections officer pepper-sprayed a nude patient who was in her room and not threatening employees, and then restrained her for hours afterward. The incident was kept secret until a former Riverview nurse reported the abuse to Adult Protective Services in late February. The state immediately investigated and concluded that abuse had occurred. One Riverview employee was fired as a result of the incident, and a contract worker was no longer allowed on Riverview grounds.

Bailey said it is counterproductive for her group to report abuse when it is the hospital’s legal duty to do so.

“If we do it for (Riverview), then they don’t learn how to do it themselves,” Bailey said. “They don’t get the point that these events are abuse if we do it for them.”

But Farnsworth said it was particularly important to quickly report the December case to investigators because the patient was vulnerable, and the longer nothing was done, the more emboldened her abusers could become.

The pepper-spraying was not disclosed to state inspectors for months, according to a state investigatory report, even though numerous medical professionals knew about it. Hospital employees are mandated by law to immediately report abuse, but failed to do so in this case and altered records to downplay the incident, according to the report.

The Disability Rights Center is not required by law to report abuse, but its mission is to advocate for patient rights.

Bailey said meetings with former Riverview Superintendent Mary Louise McEwen proved fruitless.

“We pressed her to report it, but her typical response was, ‘Thank you very much.’ There was not much engagement,” Bailey said.

The Disability Rights Center operates with a $2 million budget, with about $160,000 devoted to patient advocacy at Riverview and the other state-run mental hospital, Dorothea Dix Psychiatric Center in Bangor.

Jay Harper, Riverview’s acting superintendent, was a Disability Rights Center patient advocate through Dec. 31, a few months before he was hired to lead the hospital. He was not directly involved in the pepper-spray case, Bailey said. Harper did not respond to requests to comment for this story.

Bailey said there was confusion about exactly what occurred in the pepper-spray case because of incomplete documentation in the patient file.

Disability rights staff finally became so frustrated that they called the Division of Licensing and Regulatory Services, which works with Adult Protective Services on abuse cases, but the licensing officials already seemed to know about the case, Bailey said. She couldn’t recall exactly when that call was made, but it was likely in February.

On Feb. 27, former Riverview Director of Nursing Jeanne Carroll reported the pepper-spray case within 24 hours after she learned of the abuse and viewed surveillance video of the incident, according to the state investigatory report and a letter Carroll wrote to the state nursing board. Riverview fired Carroll in July for an undisclosed reason.

Arlene Edson, the victim in the pepper-spray case and still a patient at Riverview, said she does not believe patient advocates did much for her, and she has not talked much with the advocates about the incident or other problems at the hospital.

“I try to stay out of everyone’s way,” Edson said.

She said that after stories about her case began appearing in the media, Harper visited her at Riverview to apologize to her personally for what happened. But Edson said she still does not trust anyone at the hospital.

Riverview is a 92-bed hospital that serves both forensic patients – those sent there by the criminal court system – and civil patients. Riverview lost $20 million in federal funding after inspectors with the U.S. Centers for Medicare and Medicaid Services in September 2013 found the hospital lacking in a number of areas, including providing substandard care and using stun guns and handcuffs on patients.

Harper has said reforms are underway at the hospital, including better training for employees and reducing the reliance on restraints and seclusion. He also has taken steps to minimize the role in patient care of the police and security guards who have replaced the corrections officers once employed by the hospital.


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