WSAZ Investigates | Hospital tests new procedure for patient safety

Published: May. 3, 2022 at 7:23 PM EDT
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HUNTINGTON, W.Va. (WSAZ) – In January, we first reported about a man with dementia who went missing from Cabell Huntington Hospital.

In late February, Charles “Chuck” Carroll, 70, was found dead in an outbuilding just blocks away. Police say he was still wearing his hospital bracelet.

Since then, we’ve been looking into what could have been done to prevent Carroll’s disappearance and death -- and keep others who suffer from dementia and memory issues safe during hospital visits.

The hospital is testing a new procedure that might spare others the heartache Carroll’s family experienced after he walked out of Cabell Huntington Hospital on Dec. 30.

A brother, a friend and a decorated football player, Carroll was loved by many. In late March, more than 100 people -- many from the 1969 class of Ravenswood High -- celebrated his life and legacy.

“You know we all cried ... watched this on the news... And hoped he would be found,” a funeral attendee said.

Carroll was taken to Cabell Huntington Hospital by EMS from an assisted living facility. More than six weeks after he went missing, Carroll was found dead just blocks from where he was last seen -- still wearing his hospital bracelet.

“He was there alone -- in the cold -- and he was sick,” said Carroll’s niece Jacqui and his sister Brenda Lee.

Since Carroll was reported missing, WSAZ’s Sarah Sager has been calling and emailing police and the hospital, trying to get surveillance video police say showed him walking out of Cabell Huntington -- in hopes someone might have seen him.

Over the course of a month, we asked for the video nearly a dozen times but were told by police there was an encryption problem, then there was a passcode on the video, then further problems preventing the video from being sent.

So, we filed a Freedom of Information Act requesting the video.

But it wasn’t until the day after his body was found that WSAZ received the video. The 10 clips show about four hours of Carroll’s time in and around Cabell Huntington Hospital.

In all, seven of those video clips show Carroll coming into contact with someone at the hospital. But given many of those likely did not know his condition, he was able to eventually walk down Hal Greer Boulevard away from the hospital and out of frame. That’s the last known time Carroll was seen alive.

“I’m trying not to be angry,” said Brenda Lee, Carroll’s sister. “I feel like there’s so much injustice that’s been done to him. I feel helpless. I don’t know where to turn. I don’t know what I can do to make sure nobody has to go through this again.”

Since Carroll’s death, WSAZ has been looking into how the hospital and the state are working to prevent any other family from experiencing the pain his family has felt.

We asked the West Virginia Department of Health and Human Resources if the Office of Health Facilities and Licensures (OHFLAC) had staff at Cabell Huntington Hospital and if it was regarding patient safety after this incident.

WVDHHR officials told us they conducted a survey at the hospital, but the process can take several months.

As for Cabell Huntington Hospital, WSAZ obtained an internal newsletter from April 18 to Cabell Huntington Hospital workers, informing them of a new trial -- purple patient gowns to be worn by patients who are confused or at a high risk of elopement.

The newsletter states “if you see a patient in a purple gown wandering in the hallway, please assist them back to their room or contact security.”

So, we asked a spokesperson with the hospital to verify this information and for an interview about the new procedure.

They declined our request for an interview but responded in part saying, “We are trialing the gowns that we learned of from other hospitals around the country, as an additional measure to the procedures we follow.”

When we asked if the gowns were in response to Carroll’s disappearance, the spokesperson replied, “the trialing of gowns is in response to our ongoing performance improvement efforts.”

We asked at what point the patient receives the gown; they say that happens when the person is admitted.

So, we called Carroll’s sister to talk with her about this new measure.

“Alright, well that shows me that they’ve had some sort of a track record on things like that with other states that lets them know it works,” Brenda Lee said. “Had Chuck been wearing one of those gowns on the night he disappeared, this security guard passing Chuck just before he walked out of the hospital at 6:06 might have noticed and alerted someone. Or if Chuck was wearing the purple gown here at 8:17, this staff member who spoke with him in the atrium of the hospital might have recognized the potential for cognitive issues and walked him back to the ER. Or even when he’s walking through the parking lot or down the sidewalk, a passerby might have noticed Chuck and called 911 or security.”

Sarah Sager: Do you think the hospital would have taken this step on their own?

Brenda Lee: “I don’t think they would have. I think there was enough questions and people, including myself, investigating some of the things that went wrong. I can’t imagine if they hadn’t had people like yourself and our good friend Debbie. I’m not sure anybody would have gone the extra mile to even come up with the idea of the purple gowns.”

While Carroll’s sister believes the gowns are a start, she said more needs to be done to protect those who need it most.

“He should have never been alone at any point in time without the person who was in charge of him, regardless of who it might be, whether it be an EMT or someone from the facility he was staying in -- just someone,” Lee said.

We asked the American Hospital Association if they are aware of any other hospitals using a certain colored gown for patients who may be confused or at risk for wandering away. They say they have not heard of this practice, but that doesn’t mean it’s not happening elsewhere. A spokesperson with the WVDHHR says the centers for Medicare and Medicaid services is not ready to release the report from the survey conducted at Cabell Huntington Hospital.

Sager also asked if any changes are being considered at the state level to protect patients at any hospital across the state, but we’re still waiting for a response.

For our previous coverage, see the stories below:

WSAZ Investigates | Seeking answers in case of man missing for weeks

WSAZ Investigates | Family of missing man whose body was found speaks out

WSAZ Investigates | Looking into timeline of man’s disappearance

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