Records: MeadowWood delayed CPR for 9 minutes before death

On an early summer morning in 2023, staff at one of Delaware’s largest psychiatric hospitals and addiction detox centers found a patient unconscious, according to a state inspection report obtained by Spotlight Delaware.

After the discovery, nine minutes passed before staff began to perform CPR on the patient who was not named in the state records. 

“‘Code Blue’ incident revealed a nine-minute delay between discovery of Patient 5 unconscious and the initiation of CPR by staff,” the report stated about the emergency at the MeadowWood Behavioral Health Hospital.

Code Blue is a medical term indicating that someone is “in danger of dying,” usually because their heart has stopped or they have stopped breathing, according to the Cleveland Clinic. Chances of survival in situations of cardiac arrest decrease by 10% for every minute without CPR, according to the American Red Cross.

The emergency occurred during the same narrow window of time that a Delaware lawsuit asserts that staff at the same hospital found 33-year-old David Tymitz unresponsive.

Shortly after, they called police to report that the man had died, according to the lawsuit brought in Delaware Superior Court by Tymitz’s mother in February.

Spotlight Delaware published a report on the lawsuit on Tuesday. That same day, the Delaware Department of Health and Social Services responded to an open records request from Spotlight Delaware with more than 400 pages of reports based on its inspections of the MeadowWood hospital.

Despite the time, date and situational similarities, a spokesperson for the state health department would not confirm whether the patient described in their report is Tymitz.

Lawyers for Tymitz’s mother, Donna Seldomridge, declined to comment, when asked whether the inspection report referencing the nine-minute “delay” was about Tymitz.

A lawyer for MeadowWood did not respond.

A spokesperson for MeadowWood’s parent company, Acadia Healthcare, also did not respond. 

Report claims violation of federal regulation

The bundle of documents turned over to Spotlight Delaware included a dozen inspection reports as well as several corrective actions plans. 

The incident on July 22, 2023, is one of several described in the documents claiming that MeadowWood hospital violated various federal regulations.

One report from August 2023 claimed that an employee sent an email weeks after the incident with a list of eight staffers who were working on expired CPR certificates. That email included the names of four registered nurses and four behavioral health associates, the report said.

The report also noted CPR certifications are required for those positions.

The state report also said that between December 2022 and August 2023, an incident log revealed three patient deaths.

A corrective action plan signed by MeadowWood CEO Jennifer Shalk in October 2024 said nursing managers were not “regularly receiving” updated lists with employees who were CPR compliant.

The plan also directed the hospital’s human resources director to give weekly CPR compliance lists to nursing managers.

“If an employee does not have an active CPR certificate, the employee may not work on the units,” the plan said. “Additionally, MeadowWood Administration will ensure that CPR training is accessible to employees.”

The plan said these policies should be completed in December 2024.

Asked Thursday whether the hospital has implemented the plan’s directives, a spokesman for the Delaware Department of Health and Social Services said a “revisit survey” was conducted to ensure the implementation.

The previous day, the spokesman Tim Mastro said in an email that the state’s inspections of MeadowWood were conducted on behalf of the U.S. Centers for Medicare and Medicaid Services.

Mastro said the reports investigated whether the hospital is compliant with federal regulations, and that unannounced visits can be triggered when the state or federal government receives a complaint.

“Facilities that are found to be non-compliant with the regulations are cited and required to submit a plan of correction,” Mastro said.

Records parallel to lawsuit

Seldomridge, Tymitz’s mother, sued MeadowWood in February, claiming its staff acted negligently when her son died at the facility with methadone and another synthetic opioid in his system.

Tymitz died five days after he had been admitted to the New Castle-area facility to treat an addiction to alcohol and benzodiazepines, a non-opioid drug commonly referred to as benzos.

A subsequent autopsy and toxicology report found that Tymitz died with methadone and another synthetic opioid in his system – substances the lawsuit claims were not a part of his treatment.

It is unclear whether Tymitz was prescribed opioids by staff while he was a patient, or somehow accessed them on his own. The lawsuit — filed in Delaware Superior Court — does not mention either possibility.

MeadowWood and its Tennessee-based parent company, Acadia Healthcare, are named as defendants in the lawsuit, which adds to a string of medical malpractice claims filed against the Delaware hospital over the past decade.

It also adds to a wave of criticism lobbed in recent months against Acadia following a New York Times investigation concluded last summer that the company “lured patients” into its psychiatric facilities and “held them against their will.”

In Spotlight Delaware’s first report, an Acadia spokesperson declined to comment on the substance of the lawsuit, but said the hospital’s highest priorities are “the care, well-being, and privacy of our patients.”

“Our deepest sympathies go out to David Tymitz’s family,” the spokesperson said.