Susan Bauer remembers the last weekend she spent with her brother as pleasantly uneventful. Being home was a rare treat for Joseph Bauer, something his sister recalled only happening four or five times during the last several years of his treatment at Springfield Hospital Center in Sykesville.
Joe, as friends and family called the 61-year-old, was being treated for schizophrenia as a long-term inpatient at the state-run psychiatric hospital. His father and sister often visited him and took him out on two-hour day passes a few times a month.
Bauer recalls her brother being calmer than usual that summer weekend — he wasn't as anxious or as talkative as usual — "cool as a cucumber," she said.
"If you didn't know he was home from the hospital," she recalled, "you would never have known he was sick."
She now wonders if her brother's uncharacteristic calm may have been a sign something was wrong. Minutes after their father, Dick Bauer, got back to their Thurmont home from returning Joe to the hospital on August 2, 2015, he got a call from the hospital staff that his son was having a seizure. Bauer remembers her father yelling, "Save him! Save him!" into the phone.
But it was too late. Rushed to an acute care hospital, Joe Bauer died within a few hours from acute hyponatremia, a condition caused by drinking too much fluids. A federal report later faulted Springfield for failing to ensure he was stable enough to receive an overnight pass, prompting the state to change its rules for issuing passes.
Joe Bauer struggled with psychogenic polydipsia, the uncontrollable impulse to drink liquid which is often associated with schizophrenia, and had been having trouble following the staff's instructions to refrain from drinking.
While doctors recommend that people drink water each day, drinking too much can be harmful and even deadly. Consuming an excess amount of water dilutes sodium levels, which makes cells swell and allows water to enter the brain. The condition can result in respiratory arrest and fluid build-up in the lungs, which are often fatal.
In the days before Springfield staff gave Joe Bauer the overnight pass, several care providers noted he wasn't following instructions to avoid over-drinking and frequently needed to be directed away from the water fountain, according to an inspection report written after his death by the Centers for Medicare and Medicaid Services, which paid for his treatment.
The report did not name Bauer as the patient, in accordance with privacy laws, but both Susan Bauer and the coroner's office in Maryland confirmed the patient described in the inspection report was Joe Bauer.
The use of day and overnight passes, sometimes called home passes, trial passes, leave of absence or convalescent leave, by psychiatric hospitals is part of a patient's recovery process, even in cases where the patient is in long-term care, said Vaile Wright, a psychologist and director of research at the American Psychological Association. Spending time outside the hospital can prepare patients for returning to independent life.
"Day passes are an opportunity to practice skills [learned in treatment] in the real world," said Wright.
But such passes are not without risk. On occasion, patients out on a pass either seriously harmed or killed themselves or others, or committed violent assaults and other crimes. Other patients used the passes to escape the treatment facilities and evade being returned.
In 2012, for example, a young Louisiana patient on a 10-day pass was on his way back to Northlake Behavioral Health System in Mandeville when he overpowered the hospital psychologist traveling with him, jumped out of the van and ran through seven lanes of traffic before being fatally hit by a tow truck. A subsequent government report revealed that there was no documentation of a recent risk assessment for the minor who was mildly mentally retarded, diagnosed with ADHD and being assessed for bipolar disorder.
In 2014, a Staten Island man who admitted to bludgeoning his mother to death with an iron several years earlier was given a day pass and failed to return. The patient, diagnosed with paranoid schizophrenia, previously made a violent escape attempt in 2006, but a judge granted him day pass privileges after his doctors said he had made progress in his mental health treatment. He was arrested three months later on train-hopping charges in North Carolina.
While day passes can be an important part of treatment and recovery for patients, it's crucial to ensure patients do not pose a risk to themselves or others, Wright said.
"You're always assessing and reassessing," said Wright, who noted that patients should be evaluated thoroughly before being allowed to leave the hospital for any period of time.
The Maryland Department of Health and Mental Hygiene, which operates Springfield, declined to comment on Bauer's death, citing patient confidentiality, but said the hospital subsequently changed its day pass policy after conducting an analysis of what happened. The new policy, approved by the Centers for Medicare and Medicaid Services, was implemented during 2016 and went into effect formally in January.
It requires that specific questions about a patient's condition be answered "satisfactorily" by staff members before a day pass is granted. The department didn't elaborate on how that is measured. A sign-out form documenting behavior expectations and instructions for caring for a patient while on the pass is also a new requirement.
"If they are a risk to themselves or others, that's a reason that you would not give a day pass," Wright said. "That is the criteria for commitment to a hospital."
Five days before Bauer's death, a physician assistant who treated the unnamed patient wrote that he was "especially" non-compliant during his weekly two-hour day pass, according to the federal inspection report dated October 7, 2015.
The next day, his social worker wrote that the patient thought he could go home to live with family, but noted that it was "not a realistic option because his family cannot control his fluid intake while on a two-hour weekly pass," according to the report.
Still, on July 30, 2015, a psychiatrist decided the patient could try an overnight pass to see if it would help with controlling his fluid intake, while simultaneously noting that the patient was still drinking water and arguing with the nurses. The report noted that the patient's psychiatrist failed to document why he would be safe without staff supervision for over 30 hours when he didn't listen to instructions from the nursing staff.
Dick Bauer picked up his son on the morning of August 1 and was scheduled to return him about 30 hours later. Neither Dick Bauer nor Susan Bauer recall Joe drinking excessive amounts of water that weekend, but both said it would have been difficult for them to monitor him during the entire 30 hours.
The decision to give a night pass to a patient like Bauer, who had documented difficulty following the treatment requirement for the life-threatening condition, was questionable, said Dr. Thomas Penders, medical director of the department of psychiatric medicine at East Carolina University. Penders, who has written a case study on polydipsia, can only recall giving one patient a two-hour pass for a funeral in the past 20 years.
"First of all, it's not normal to give passes, but secondly to delegate to family members when nurses are having trouble in the hospital seems unusual," he said.
Overnight passes used to be common 30 years ago, when patients would stay for several weeks for psychiatric evaluations, Penders said, but insurance companies have made them a rarity.
"Generally, insurance companies will say that if a patient can handle a pass, they don't need to be in a hospital," he said.
Typically, a patient with a severe case of polydipsia would have supervised access to water and would be checked every 15 minutes, Penders said. A family member, he added, would not have more success controlling a patient than hospital workers.
The hospital told Bauer's family that his polydipsia was so severe that he sometimes drank out of the hospital's restroom toilet, Susan Bauer said. But the federal report found the discharge nurse didn't document telling the family what to do if he drank too much water or started slurring his speech or walking off-kilter during his overnight stay — signs that his water intake was causing his sodium levels to plummet to a fatal level.
Since Bauer's death, Springfield Hospital Center recently came under fresh scrutiny after a riot by patients on Thanksgiving Day last year. Staff members were under siege for five hours, locked in offices while patients tore down security cameras, dumped cooking oil on the floors and poured spices from the kitchen through the suspended ceilings of the offices where staff were hiding, making it difficult to breathe. Workers subsequently complained that understaffing and a lack of training in dealing with mentally ill patients referred by the criminal justice system contributed to losing control of their patients.
Though dying from drinking too much fluid might sound like a freak accident, polydipsia is not uncommon in psychiatric hospitals like Springfield.
"I'd say five percent of people who are seriously mentally ill are doing it," Penders said.
A study reviewing the epidemiological literature on water intoxication in psychiatric patients and published in Biological Psychiatry estimated that anywhere from 6 to 17 percent of mentally ill patients in the U.S. consume dangerous amounts of fluid.
Among patients with schizophrenia, those with severe polydipsia have a 75 percent chance of dying before patients without the compulsion to drink water, according to another study published in 2009 in Schizophrenia Research. That study, found that the median age of death for severely polydipsic patients was 57; for non-polydipsic patients it was 68.
Bauer's father and sister were aware of his polydipsia and did try to discourage Bauer from drinking too much liquid whenever they were with him. They weren't briefed on any new developments or given any new instructions when they took Bauer home, they said.
"We do what we can, but we can't tie him up," Susan Bauer said.
Bauer, whose father will be 90 this year, is devastated by the loss of her brother.
"I always thought, 'It'll be me and Joe,'" said Bauer, her voice breaking. "Now he's gone."