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Oregon Mental Patient Dead for Hours Feet from Nurse’s Station; Investigations Reveal Deficient Care and Superintendent Forced Out

In 2008, the United States Department of Justice (DOJ) threatened to sue Oregon over abysmal conditions and patient care at the Oregon State Hospital (OSH), where the classic “One Flew Over the Cuckoo’s Nest” was filmed. State officials responded by breaking ground on a new $250 million hospital, appropriating over $60 million to hire more than 500 additional employees, and appointing Roy Orr as the new OSH Superintendent in February 2008, with an annual salary of $231,984.

On April 2, 2010, however, Orr was forced to resign and mental health advocates are calling for federal court intervention in response to the October 17, 2009 death of 42-year old Moises Perez. Although his bed was just a few feet from the nurse’s station, in a room he shared with four other patients, Perez missed meals and medication and his death was not discovered for nearly 12 hours. Three ensuing investigations reveal that serious problems persist at OSH.

Perez was born in Cuba and immigrated to America with his family in 1982 when he was 15 years old. In his late teen years, Perez began to suffer from severe mental illness, resulting in numerous hospitalizations.

One of those hospitalizations ended just before Christmas, 1994, and soon thereafter, the 27-year old Moises attacked his mother during a violent psychotic episode. He punched her, cut her and bit off four of her fingers. He asked a policeman to “shoot him” and tell the other officers that he tried to get away.” His mother told police that she thought he was hallucinating. “He’d never done something like that before,” she said in a police report. “He looked anxious and nervous and scared.”

Perez was found guilty but insane of attempted murder and assault, and sentenced to the jurisdiction of Oregon’s Psychiatric Security Review Board (PSRB), for a maximum of 40 years.

Diagnosed with chronic paranoid schizophrenia, Perez developed serious physical problems associated with the powerful psychiatric drugs he was taking. Only 5 foot, 8 inches tall, Perez weighed 300 pounds, developed high blood pressure and was identified as being at risk of diabetes.

By all accounts, Perez was a “difficult” and “stubborn” patient who was picked on by other patients, refused his medication, and frequently refused to bathe unless staff bribed him with a soda. He was banned from the dining room because of his disgusting eating habits. So nobody missed him when he stayed in bed all day.

On October 17, 2009, Perez was last seen at breakfast at 7:15 a.m. He returned to bed and wasn’t seen alive again. Perez didn’t get up for lunch of dinner. A staff member claims to have shaken Perez’s leg before both meals, but did not check to see why he did not move. At 4 p.m., Perez did not show up at the medication window for his medication. An aide told police that he called out to remind patients to come for their pills. When Perez still did not show up—which staff later said was “odd”—the aide noted in his chart that he refused his medication. When Perez again failed to show up for his 7:30 p.m. pills someone attempted to wake him, finally discovering at 7:35 p.m., that Perez was dead. Staff called his family, then police. The state medical examiner concluded that Perez died of coronary artery disease hours before he was found.

The investigations that followed paint a damning picture of patient care at OSH. An internal review, entitled a “Sentinel Event” report, blames staffing issues for Perez’s death. While the ward had an “appropriate number of staff” on duty, the report suggested that some staff were not regularly assigned to the ward, so they did not know the patients’ habits. Others were working mandatory overtime to cover staff that was on unpaid furloughs.

Orr’s resignation was prompted by a 27-page April 2, 2010 report of the state Office of Investigations and Training, which is far more critical of the care Perez and other patients received. Although investigators found that the evidence was inconclusive as to whether Perez was neglected in his final days, serious problems were noted.

Perez had complained of chest pains and other physical ailments, according to some of the 29 witnesses who were interviewed. However, the last progress note in his chart was August 5, 2009—73 days before he died. Hospital policy requires that progress notes be made at least weekly. “One nurse described hearing staff joking about not having written a progress note in two years and thought this was a problem not unique to this unit,” investigators reported.

The DOJ issued the sharpest response of all. Shanetta Cutlar, head of the DOJ’s special litigation section, sent state officials a “warning letter,” finding that Perez had received care that “consistently fell well below constitutional and statutory standards.” Cutlar criticized system wide deficiencies that could cause serious harm or death in other situations.”

Between April 30, 2009 and his October 17, 2009 death, Perez’s medical file contained just two blood pressure readings. Despite being identified as at risk for diabetes, doctors did not regularly monitor Perez for the disease. Perez saw a psychiatrist just twice—once in July and once in September—in the months before his death. Federal officials also questioned whether Perez actually refused his psychiatric medication as staff claimed, or he simply failed to show up for pill line. The DOJ joined state officials in criticizing the lack of nursing notes, in violation of hospital policy.

Orr expressed surprise that DOJ found that OSH conditions had not improved. He noted that those officials toured the hospital in July 2009 and “they all said it was clear to them that we’d made progress.” Still, “Mr. Perez’s death was a real opportunity for us to zero in on changes,” conceded Orr.

And zero in they did, calling for Orr’s resignation. “It was time for a change,” said Richard Harris, head of Oregon’s Addictions and Mental Health Division. “We just got to a place where the pace of necessary change to make the culture of that hospital patient-oriented just got bogged down.” Dr. Bruce Goldberg, director of the Oregon Department of Human Services agrees, acknowledging that improvements had been made during Orr’s short tenure. Still, “we need to speed up the pace of change,” said Goldberg.

In response to Perez’s death, OSH implemented a policy requiring staff to “confirm patient viability” through observation, touch or the sound of breathing. Additionally, since severely mentally ill people die on average of 25 years earlier than the general population, OSH doctors will be required to pay closer attention to the physical well-being of patients. OSH is also rethinking its policy concerning how it responds to patient medication refusals. Given the findings of staff policy violations, a compliance officer will be hired, according to Goldberg.

Mental health advocates think much more needs to be done, and soon. “Reading that (April 2, 2010) report was one of the more discouraging things I’ve ever done,” said Chris Bouneff, executive director of the Oregon chapter of the National Alliance on Mental Illness. “He essentially was there and rotting away in the Oregon State Hospital.” Bouneff and other advocates are calling for federal court oversight and enforcement of improvements at OSH.

“Court involvement would be helpful, because it would create greater incentives for there to be speedy changes at the hospital,” agreed Bob Joondeph, executive director for Disability Rights Oregon.

Of course, state officials don’t want oversight. “I don’t think this is about oversight. I think this is about a long-term problem that we’ve been making changes on,” said Goldberg. “We’ve made changes. We just need to make changes faster.” Joondeph contends, however, that while the state has pledged to do what federal officials have asked, it has resisted putting those promises into any kind of official legal agreement.

Oregon Governor Ted Kulongoski backs Goldberg’s resistance to greater oversight. “A court-enforced agreement only adds another layer and hurdle to our efforts to improve patient care” at OSH, said Kulongoski spokeswoman Anna Richter Taylor. “It would result in ongoing litigation, very expensive legal fees. The governor would rather see our resources directed to improve patient care than lawyers and litigation.

A court-ordered agreement would be expensive only if the state refused to fulfill its promises, notes Beckie Child, president of Mental Health America of Oregon. “They’ve had time to do things on their own,” said Child. “And we feel that there are still bad results.”

“We know the physical building was falling down,” said Oregon Senate President Peter Courtney, D-Salem, who has pushed hard for changes at OSH. He said he is discouraged to learn that “it’s so much worse than we thought.

“I just hope,” he said, “I just hope now we truly understand it.” We do too, Senator.

Source: The Oregonian

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