Medical Director overprescribes dangerous medications
As a follow up to recent posts regarding the kickback scheme involving OmniCare and Murray Forman and Leonard Grunstein, today I am going to post a well written article from the Chicago Breaking News about a doctor prescribing dangerous medications to nursing home residents.
Inside Chicago's Maxwell Manor nursing home, Dr. Michael Reinstein's patients suffered from side effects so severe that they trembled, hallucinated or lost control of their bladders. Staffers told state investigators that so many patients were clamoring to complain to Reinstein about their medications that a security guard was assigned to accompany him on his visits. In addition, staffers said Reinstein had induced patients to take powerful antipsychotic drugs with the promise of passes to leave the home.
Today he is one of the most prolific providers of psychiatric care in Chicago-area nursing homes and mental health facilities, even as he is trailed by lawsuits and complaints like the ones at Maxwell Manor. An investigation by ProPublica and the Tribune found that Reinstein has compiled a worrisome record, providing assembly-line care with a highly risky drug. Reinstein has been accused of overmedicating his mentally ill patients. His unusually heavy reliance on the drug clozapine -- a potent psychotropic medication that carries five "black box" warnings -- has been linked to at least three deaths.
In 2007 he prescribed various medications to 4,141 Medicaid patients, including more prescriptions for clozapine than were written by all the doctors in Texas put together. Records also show he is getting government reimbursement for seeing an improbably large number of patients. Documents filled out by Reinstein suggest that if each of his patient visits lasts 10 minutes, he would have to work 21 hours a day, seven days a week. Reinstein sees 60 patients each day, he wrote in an audit report in 2007.
Working from a strip-mall office in Uptown, Reinstein says he is psychiatric medical director at 13 nursing facilities, seeing patients with chronic mental illness. Those include people with schizophrenia.
Autopsy and court records show that three patients under Reinstein's care died of clozapine intoxication. Alvin Essary died at age 50 at the Somerset Place nursing home on the North Side in 1999. Medical records show that when he died his blood contained five times the toxic level of clozapine.
The "black box" warnings -- the FDA's strongest -- on clozapine's label detail serious potential side effects, from enlargement of the heart to rapid drops in blood pressure to increased seizure risk. Doctors also are required to take regular blood samples to ensure patients' immune systems aren't shutting down.
The FDA approved the drug two decades ago for only a sliver of the population: the actively suicidal or the quarter of schizophrenic patients who do not improve on medications with lesser side effects. Yet Reinstein last year said under oath that his practice once had more than 300 patients among 415 in one Chicago nursing home on clozapine.
His use of clozapine is at the heart of separate lawsuits filed after the deaths of two patients he treated: Odell Spruell and Wendy Cureton. Spruell's autopsy showed that he died of clozapine intoxication. Cureton had grown increasingly aggressive after two of her family members died in a house fire. Reinstein, her supervising psychiatrist, repeatedly boosted Cureton's clozapine dose -- two times faster than the recommended pace, according to her medical records and guidelines published by the drug's maker. On the 10th day in the psychiatric ward, Cureton had trouble breathing and was taken to the emergency room. The drug's label explicitly warns of that adverse reaction and says doctors should not mix clozapine and certain sedatives, as the team under Reinstein's supervision had done. Reinstein saw her after she returned from the emergency room and increased her dose of another antipsychotic. Within days, Cureton collapsed next to her bed and could not be revived.
One nurse who worked with Reinstein said she worried that he was too busy to give his patients the time they needed. Former Riveredge Hospital nurse Eileen "Cookie" Kempe said in an interview that when Reinstein visited, he went into a room and furiously wrote on stacks of medical records as his patients lined up in the hall. "He wouldn't talk to them," according to Kempe, who said she worked with Reinstein for a year until 2004. "I never saw him go in a patient room, ever. They got no therapeutic interaction with a doctor."
Riveredge is where Reinstein treated a 27-year-old pregnant patient, Tameka Williams, in 2007 after she had an acute schizophrenic episode. She never signed a required form agreeing to take clozapine; nor was her immediate family consulted. Even though it has not been proved safe for use during pregnancy, Reinstein prescribed clozapine. At some point, Williams had developed a blood clot -- a condition particularly threatening for a patient on clozapine. She died days after being admitted when the clot lodged in her heart.
Reinstein's troubles were perhaps most dramatic at Maxwell Manor, a South Side nursing home. The Illinois State Police and the U.S. Postal Service began investigating Reinstein in 2000 amid accusations of billing fraud. Maxwell Manor worker, Engoyama Fela, told investigators that Reinstein "would not spend more than one minute" with a patient during his rounds. "Many patients became agitated and rebellious because they knew they needed care and they wanted to talk to Reinstein but were not allowed to," he said.
Fela said Maxwell Manor security staffers were assigned to guard Reinstein when he came to update medical records. Several years after regulators shut the home in 2000, the U.S. Justice Department, in a separate civil fraud case, alleged that residents had been routinely abused and medicated as punishment.
The agency responsible for investigating physician conduct, the Illinois Department of Financial and Professional Regulation, does not reveal to the public the number of complaints filed against doctors, only findings where there was formal disciplinary action. In 1997 the agency cited Reinstein for improperly admitting a patient for psychiatric care and ordered him to complete 50 hours of education.
Since then, the agency has received at least one other complaint about Reinstein.
In 2003, Chicago psychiatrist Dr. Mark Amdur, of the Thresholds mental health organization, became so concerned about Reinstein's work at area nursing homes that he asked his staff to find out how many patients came under Reinstein's care. The number -- 2,300 -- surprised him.
"I believe that the apparent concentration of care under a single practitioner should be a matter of concern," Amdur wrote state regulators.
When asked what happened to his complaint, the Illinois Department of Public Health said it was unable to find it, and the professional regulation agency could produce no evidence of follow-up.
Amdur said he never got a response. "There ought to be some outside review for the benefit of the people residing in these nursing homes," he said.
