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Culture of Abuse Continues at Oregon Mental Hospital Despite Ongoing DOJ Investigation
As we've previously reported, in October 2009, patient Moises Perez died in his bed across the hall from a nurse's station, but was not discovered for several hours. An investigation led to the resignation of the OSH superintendent and the reprimand of five other employees, for neglect and inadequate medical care.
In another case, a female patient bled profusely for nearly three hours before she was taken to an emergency room. As a result she needed emergency surgery, IV fluids and two units of blood, according to a June 28, 2010 investigative report.
Dr. Alexander Horowitz, the on-call physician was called at 8:45 p.m. about a female patient whose "excessive bleeding" was soaking through towels. At 9 p.m., Horowitz visited the patient's ward to see a different patient, but did not bother to examine her.
Horowitz claims that he spoke with nurses about the woman's condition and vital signs. He later defended his inaction by claiming that the "situation did not appear to be critical." Witnesses told investigators, however, that the woman was "hysterical, pale, ashen or gray." At least two nurses who witnessed the blood flow said they thought Horowitz would have sent her to the emergency room immediately if he would have examined her.
After several hours, hospital staff finally called Horowitz to tell him that they were sending the woman to a hospital and to ask him to fill out the necessary paperwork, investigators found. Rather than return to the ward, however, Horowitz requested that OSH staff deliver the paperwork to him.
"Doctors at the state hospital do the best we can given the difficult situation we are in," Horowitz claimed. "We work with a very troubled group of patients in a facility that is largely antiquated and is constantly understaffed. We are not perfect, and I am no exception, but I did not abuse or neglect this or any other patient." Investigators concluded otherwise.
On December 27, 2010, another female patient, Elisabeth Sellars, was found dead in her room, the victim of an apparent suicide. Little information has been released about the circumstances surrounding her death.
On October 20, 2008, Richard Gonzalez was hired by OSH to work as a "mental health security technician." Just two years later, however, two separate 2010 investigations substantiated patient abuse allegations against Gonzalez. Even so, he was issued a single letter of reprimand and was not disciplined for his conduct.
The first investigation stemmed from an April 2010 incident in which Gonzalez and tw other security staff were called to move a patient to a different room.
Gonzalez used unnecessary or excessive physical force against the patient, according to an investigation by the state Office of Investigations and Training (OIT). Gonzalez and his two co-workers "put hands" on the patient to escort him out of the room, even though the patient "presented no threat" to himself or others, wrote OIT investigators. When the patient resisted, he was "pushed or dragged" down the hallway and held against a wall. Gonzalez then grabbed his arm and yanked it up behind his back. The patient alleged that Gonzalez was attempting to "dish out punishment" which "hurt like hell," according to the OIT report.
The OIT found Gonzalez guilty of patient abuse, concluding that he "used pain to force (the patient) to comply with a directive." Even so, no sanctions were imposed against Gonzalez.
In August, 2010, Gonzalez abused another OSH patient, according to a second OIT investigation. The patient was receiving one-on-one staff monitoring when staff directed him to shut his door, in violation of OSH policy, the OIT report found.
The patient refused to close his door and became upset, so security was called. Gonzalez responded, confronted the patient and began steering him to a side room.
A struggle ensued, and Gonzalez and another guard took the patient to the floor. The OIT investigation determined that Gonzalez committed physical abuse by "unnecessarily restraining" the patient. Investigators also found that Gonzalez exceeded his authority in responding to the situation.
OSH officials believed the second act of patient abuse warranted a pay cut. Given that he was already at the bottom rung of the pay scale, however, OSH settled on merely issuing a letter of reprimand, in lieu of a pay reduction.
The March 28, 2011 reprimand letter concluded that Gonzalez had demonstrated poor judgment and "failed to meet performance expectations."
If not for an April 4, 2011 domestic violence arrest, unrelated to his OSH employment, Gonzalez would have remained on the ward. Fortunately for OSH patients, however, Gonzalez was charged with recklessly endangering another person, reckless driving, criminal mischief and eluding police, forcing him to resign his OSH position on April 15, 2011.
Two separate 2010 audits criticize OSH management, finding a culture of blame and irresponsibility as the root of the endless tide of patient abuse.
In September, 2010, Liberty Healthcare, an Indiana-based consulting firm, issued a report identifying conflicts and blame between OSH management and Human Resource (HR) personnel. "There is a prevalent thinking that managers can do little to discipline or remove problem employees," Liberty found. "Clinical managers have looked to HR to handle personnel issues, while HR declines such responsibility because it is a management issue."
"Reluctant to act, managers retreat into helplessness and tolerate continued poor performance from problem employees whose behavior hurts team cohesion and morale," Liberty concluded.
Another Indiana-based consulting firm, Kaufman Global, was hired to examine OSH's "culture." Its January 2011 report echoes the Liberty report, describing a "lack of accountability at all levels of OSH as "an enabler for problematic employees."
"There seems to be a disconnect between what OSH managers expect in the way of HR support and that for which Human Resources actually feels responsible," Kaufman found in its January 2011 report. "One manager noted, ‘HR is a barrier, not a help. I'm not abdicating my responsibility to train and supervise, but HR isn't helping to get rid of the bad apples, not taking a stand.’"
Meanwhile, as we have reported time and again, the mighty DOJ appears to be all bark and no bite. Patients continue to suffer needless abuse, and die, while DOJ officials look on, threatening litigation but neglecting to take concrete action.
Sources: The Statesman Journal; The Oregonian
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