RICHMOND, Va. -- A second government investigation into HCA Healthcare's Chippenham Hospital has faulted the facility in its handling and release of a mentally ill patient who was later shot and killed by police.
The Centers for Medicare and Medicaid (CMS) requested that the Virginia Department of Health (VDH) conduct an investigation into whether Chippenham Hospital complied with federal health and safety standards related to the care it provided to Charles Byers.
Byers was a 34-year-old man suffering a mental health crisis who was involuntarily admitted to Chippenham's Tucker Pavilion under court order two days before his death.
The findings of the investigation,obtained by CBS 6, showed Chippenham Hospital failed to protect and promote Byers' patient rights and failed to maintain a safe environment of ethical, high-quality care for a patient who was incapable of making his own medical health decisions.
“Charlie was harmed by this by this system. He was not helped, and there were people there who could have helped him. Where were they?” said Byers' father Michael Byers in an interview with CBS 6.
Paul Curley, the attorney for the Byers family, said the results of the inspection underscore the claims they made in a $35 million lawsuit against HCA Healthcare and the Richmond Police Department (RPD), alleging both entities violated Byers' federal patient rights.
“HCA Chippenham, in combination with the RPD, deprived Charles Byers of his federally guaranteed right to receive mental health care in a safe environment," Curley said.
As CBS 6 has previously reported, Byers had schizoaffective disorder and suffered an episode on July 5, 2023, so his mother took him to Chippenham's emergency department.
While there, a Richmond Police officer found Byers appearing delusional and wandering the halls. After the officer placed Byers under an emergency custody order, a Richmond Behavioral Health Authority evaluator recommended Byers be placed under a temporary detention order (TDO).
A Richmond magistrate authorized the TDO on July 6, which meant Byers was legally ordered to receive mental health treatment for up to 72 hours, because he was incapable of caring for himself.
Byers was admitted to Tucker Pavilion, but he was arrested and removed three hours later by Richmond Police.
Body camera footage obtained exclusively by CBS 6 showed that medical staff were trying to move Byers to a different floor after becoming "aggressive toward staff," but Byers refused to get on an elevator multiple times.
At one point, video appeared to show a nurse physically reach for Byers, but Byers resisted being touched. A struggle then ensued between Byers and the nurse and RPD officer.
During the interaction that played out in a hallway, the nurse told Byers to let the officer "cuff" him, because he was "done talking."
Byers resisted being handcuffed, and allegedly kicked the nurse. The nurse reported that he was not injured.
The RPD officer threatened to tase Byers several times if he did not comply with being handcuffed.
“Stop resisting or I’m going to f***** tase you. Put your hands behind your back. Do it now," the RPD officer said.
The RPD officer then announced Byers was under arrest for kicking a medical worker.
“Right now, you’re probably going to jail instead of staying here for treatment," the RPD officer told Byers.
The CMS investigation report noted that before the hallway encounter, Byers' behavior was recorded as "agitated/reckless," "irritable" and he was "responding to internal stimuli."
Investigators said that medical staff never told the RPD officer that Byers was under a TDO, never presented the officer with TDO paperwork, did not advocate for Byers' continued treatment and never told the officer about Byers' "dire mental health treatment needs."
However, in its corrective action plan, Chippenham shifted blame to RPD, saying it could not "continue patient care due to the arrest and removal of the patient by law enforcement."
Medical staff told CMS investigators they "never requested" Byers "to be arrested," despite body camera footage showing a nurse asking the officer to handcuff him and "take him."
“At this point, I would just request that you guys take him," the nurse told the RPD officer shortly before Byers was arrested.
The findings also revealed that the hospital discharged Byers without filling out the proper discharge paperwork. The hospital stated Byers was discharged "against medical advice" (AMA) but did not complete an AMA form.
And despite Byers being assessed as incapable of making medical decisions, investigators noted the hospital did not notify Byers' family about his involuntary removal from the facility.
During his time at the hospital, the report showed Byers was never seen by a psychiatrist.
“It's outrageous that he was ordered to a mental health facility upon a finding that he lacked the capacity to care for himself, to protect himself from harm, and never saw a doctor," Curley said.
Once Byers was the jail, he was released by a Richmond magistrate.
36 hours later, he was shot and killed by Chesterfield Police officers after they said Byers attempted to break into homes and refused to comply with orders to drop a hatchet.
“Had Charles Byers received the proper care at HCA Chippenham, where his patient rights were protected and advocated for, do you believe that he would be alive today?” reporter Tyler Layne asked Curley.
“There is no question he would be alive. No question at all," Curley said.
Moving forward, Chippenham said it would improve how it interacts with law enforcement through education planning, training, and ongoing audits.
Another investigation into Chippenham Hospital by the Virginia Department of Behavioral Health and Developmental Services, the agency that licenses psychiatric facilities, cited the hospital with 17 violations of state standards.
HCA Healthcare and Richmond Police, in response to the lawsuit filed by the Byers family, maintained they were not responsible for Byers' death. Attorneys for both entities have asked a federal judge to dismiss the lawsuit.
A judge's decision on whether the lawsuit can move forward is pending.
Eight months after the shooting, the Office of Chesterfield Commonwealth's Attorney Erin Barr indicated a prosecutorial decision regarding the officer who shot and killed Byers may be coming soon.
"We are still evaluating the information that has been provided and expect to have a decision in the near future," said spokesperson Brittany Lilly.
Depend on CBS 6 News and WTVR.com for in-depth coverage of this important local story. Anyone with more information can email newstips@wtvr.com to send a tip.
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