Results of the 2006 U.S. Department of Justice review of conditions and practices at the Salem and Portland campuses of the Oregon State Hospital

Overview

The U.S. Department of Justice (USDOJ) Civil Rights Division is responsible under the 1997 Civil Rights of Institutionalized Persons Act (CRIPA) for investigating conditions and practices at public psychiatric institutions. USDOJ regularly conducts reviews of such institutions throughout the United States to ensure protection of the constitutional and federal statutory rights of patients with mental illness who are being treated in public institutions.

During November 2006 USDOJ investigated conditions and care practices at the Salem and Portland campuses of the Oregon State Hospital (OSH). The inquiry included on-site interviews of administrative staff, mental health care providers and patients. Investigators also examined the physical living conditions at the two facilities and reviewed hundreds of documents including policies and procedures, incident reports, and medical and mental health records.

Following that review, USDOJ provided a report in January 2008 to the Oregon Department of Human Services (DHS) advising DHS of USDOJ’s findings. The report, per CRIPA requirements, includes recommended remedial steps for OSH to take to correct any reported deficiencies.

USDOJ stated in its report that “It is apparent that many OSH staff genuinely are concerned for the well-being of the persons in their care. These staff members display admirable dedication and undertake significant efforts to provide appropriate treatment and improve the lives of OSH patients.”

However, USDOJ found deficiencies in five general areas:

• Adequately protecting patients from harm,
• Providing appropriate psychiatric and psychological care and treatment,
• Use of seclusion and restraints in a manner consistent with generally accepted professional standards,
• Providing adequate nursing care,
• Providing discharge planning to ensure placement in the most integrated settings.

The next section provides more details about these findings and OSH’s actions to remedy the identified deficiencies.

Findings and responses

Inadequate protection of patients from harm

Findings

• There is widespread patient-against patient assault, unchecked self-injurious behavior, and a high rate of falls.
• The housing units contain environmental hazards, some of which pose risks of serious injury, illness and death.
• OSH’s ability to address patient safety is hampered by inadequate incident management and quality assurance systems.

Actions

Thus far, OSH has taken the following actions to better protect patients from harm:

• Received approval and $458.1 million in funding from the 2007 Oregon Legislature to replace OSH with two new, state-of-the-art psychiatric hospitals. The hospitals will be located in Salem (opening in 2011) and Junction City (opening in 2013). Many of the recommendations in the USDOJ report will be addressed with the opening of these new facilities.
• Received $9.3 million from the January 2006 Legislative Emergency Board to boost hospital staffing and speed patient discharges. The money was earmarked to hire 30 new staff members, move 71 patients into community-based programs, and renovate the Portland OSH campus to create bed space for patients who had been living in the most-dilapidated building on the Salem campus.
• Implemented a Continuous Improvement Plan process that includes actions to address patient safety.
• Implemented The Joint Commission (for the accreditation of health care organizations) 2008 National Patient Safety Goals.
• Educated all staff on Professional Assault Crisis Training (ProACT).
• Created an electronic critical incident and medication error reporting system.
• Improved critical incident review and response/improvements follow-up.
• Expanded a falls reduction program hospital-wide.
• Supported mandatory pain reduction training for all licensed staff.
• Revised and implemented dangerousness risk assessments hospital-wide.
• Continued seclusion/restraint reduction efforts.
• Promoted a non-violence campaign hospital-wide.
• Trained all management leadership in Trauma-Informed Care.
• Completed fire drills and extinguisher checks as scheduled.
• Trained all staff in asbestos awareness, safe equipment operations, and use of personal protective equipment.
• Cataloged all asbestos in the facility and certified staff in asbestos abatement.
• Met all Occupational Safety and Health Administration requirements.

Lack of appropriate psychiatric and psychological care and treatment

Findings

• Psychiatric practices at both campuses lack adequate assessments and diagnoses, behavioral management services, and medication management.
• Patients do not receive comprehensive treatment planning that integrates assessment and input from mental health professionals representing a variety of disciplines.

Actions
Thus far, OSH has taken the following actions to improve mental health care and treatment:

• Entered into a two-year agreement with Oregon Health & Science University (OHSU) to add a chief psychiatrist, six additional psychiatrists/physicians and one research assistant to the Salem OSH campus to improve patient care.
• Implemented a Continuous Improvement Plan process that includes actions to address mental health care and treatment.
• Increased active, centralized treatment services at the Portland OSH facility and completed plans to implement this at the Salem OSH campus in August 2008.
• Established a consumer-run Empowerment Center.
• Implemented evidence-based practice of Relapse Prevention hospital-wide.
• Implemented evidence-based practice individual and group therapies.
• Supported Certified Alcohol and Drug Counselor (CADC) training for mental health credentialed staff.
• Provided Dual Diagnosis Anonymous (mental health and addictions) groups.
• Created Community Reintegration Program for addictions, which supports community transitions, employment and education.
• Established best-practice, self-help coping skills training, Recovery International, hospital-wide.
• Expanded vocational and educational services hospital-wide.
• Implemented a medication accuracy and interaction verification system.
• Created involuntary medication procedures to protect patients’ rights.
• Enhanced physician peer review for completeness and quality of assessments and diagnosis, and evidence-based prescribing.
• Improved behavior support plans.
• Improved physician recruitment.
• Renewed all hospital and residential licenses with the State of Oregon.
• Addressed The Joint Commission findings and received continued conditional accreditation.
• Received continued certification by Centers for Medicaid and Medicare Services (CMS).

Inappropriate use of seclusion and restraints

Findings

Inappropriate use of seclusion and restraints
Findings

Inappropriate use of seclusion and restraints
Findings

VISIT – the Sir J Millage Autistic Drop-In Center, in Portland, Oregon
LIKE – the Sir J Millage Autistic Drop-In Center Facebook page
READ – Excessive Force In Portland, Oregon (mentions Sir Millage)
LISTEN – Sir Millage Vigil for Justice (5:25M), KBOO.org
LISTEN – Special on Police Brutality: Sir Millage (16:50M), KBOO.org
READ – Vigil Ups the Ante – Crowd Prays for Police Accountability, Portland Mercury, January 25, 2007

Force used to subdue ‘threatening’ person questioned

from The Oregonian, December 19, 2006

When Portland police encountered Sir J. Millage walking barefoot and shirtless in the chill December dawn, carrying what appeared to be a stick or metal rod, they thought he “might be unstable and possibly violent.”

Witnesses who had spotted Millage walking amid traffic across the Broadway Bridge told police they thought the 5-foot-10 inch, 260-pound person was around 25. An officer later was struck by his “fixed gaze,” as if he was looking “right through” him. He did not respond to shouted orders to drop his stick, and, according to the officer, waved it in a threatening manner.

One officer fired four Taser shots at Millage, and then another struck him six times with his baton because he wouldn’t stay on the ground. They thought Millage was high on drugs.

Millage’s great-grandmother and legal guardian, Pastor Mary Overstreet Smith, said Millage didn’t respond to police because he’s autistic.

He’s also 15 years old and can hardly talk. She said she can’t understand what led to the use of physical force that Dec. 5 morning and is sickened by what occurred.

“He can’t speak for himself. It tears me up when I read this,” she said, flipping through the police report. “I just feel like what they did was unwarranted.”

The episode illustrates the challenge police increasingly face as they are called to deal with people either putting themselves in danger or acting oddly. Sometimes they display characteristics similar to people on drugs but are actually mentally ill or disabled.

Police spokesman Sgt. Brian Schmautz and Robert King, president of the Portland Police Association, said the officers did what they’re trained to do, based on the information they had.

Portland police say the person they encountered looked much older than his age because of his size. He didn’t respond to their commands or the Taser shots, and appeared to be under the influence of drugs or alcohol.

“Officers will use what force is appropriate depending on the circumstance,” Schmautz said. “You can’t know what’s going on with someone until they’re in a controlled situation.”

King said police don’t have the “option of leaving or of not engaging.”

“We have to take steps to stop or protect. You recognize that other people looking in on your actions later will have a different perspective because they have more information available to them than you did,” King said. “In a case like this, we’re grateful that we have tools like the Taser to control the person safely and reduce the amount of injury to the person and the officers involved.”

Stephen Edelson, president of the Autism Society of Oregon that has provided training to Portland police on autism, said the big question that occurred to him was: “What did he do that was threatening because autistic individuals typically don’t do that.”

“Since there is an epidemic of autism now, there’s going to be many situations like this,” he said. “Maybe this will wake them (police) up to realize they really need to be much more aware of the characteristics of these individuals.”

Overstreet Smith, who has raised her great-grandson since he was 41/2, said the teenager climbed out of the dining room window in the middle of the night. Awakened by a chill in the room, Overstreet Smith noticed the window open and thought a burglar had entered her house. Shortly afterwards, she realized the boy was gone.

She and her son raced outside to look for him.

By 6:20 a.m., she called 9-1-1, police records show.

The dispatcher thought her description of Sir might match that of a man who was reported walking along the Broadway Bridge at 3:55 a.m. and later stopped by police.

According to a police report provided by Overstreet Smith, two city employees in a pickup spotted a man wearing shorts and no shirt, and carrying a stick, walking west along the center line in the middle of the bridge. The two witnesses told police they tried to talk to the man but didn’t get a response. They were concerned because he wasn’t wearing enough clothing and might get hit by a car.

Officer Andrew Griggs, a three-year bureau member, spotted the man on Northwest Fifth Avenue, walking toward Irving. In his report, Griggs describes the man as “very large,” holding a “large tan item” that looked like a large stick, or possibly a large piece of metal.

Griggs wrote that the man passed in front of him, swinging the metal object, as he looked directly at the officer with a “fixed gaze” and picked up his pace. “These indicators led me to believe that the man might be unstable and possibly violent and that distance was going to be important in my contact,” the officer wrote.

Griggs called for cover, pulled up alongside Millage and yelled at him to stop. According to his report, the man hesitated for a moment “but gave no verbal response.” He then continued walking. Griggs pulled up.

“As I got out of my car, I immediately pulled my Taser from its holster,” he wrote. He aimed a laser dot on the man’s chest, and ordered him to drop the weapon or he’d be Tased. He got no response.

Overstreet Smith said the officer didn’t need to confront him. “I would’ve liked the officer to at least have asked him what his name was. . . .”

Griggs said the man came toward him, swinging the object in front of him in a threatening manner. Griggs fired his Taser, saying the man was engaging in “aggressive physical resistance” and “coming at me with the physical actions of attack,” noting his size and presence of a weapon in his report.

Overstreet Smith wants to know what exactly her great-grandson was doing. “What were the ‘physical actions of attack’?”

She said Millage often likes to play with plastic battens that he finds in chain-link fences. “It’s a play thing to him,” she said.

The first Taser shot made Millage drop what he was holding and fall to the ground. The officer yelled at him to get on his stomach, but Millage was screaming. The officer concluded that the man “seemed to be screaming more out of anger than pain.” Because Millage wouldn’t stay on the ground, Griggs fired a second Taser shot.

“In my experience using a Taser, I have yet to see a person not comply, so I believed this person was high on drugs and possessed an extremely high pain tolerance,” Griggs wrote. Every time Millage tried to get up, he was Tased again.

Police later learned that the Taser shots were ineffective because one of the probes fired never attached to the teen’s skin, Schmautz said. The bureau declined to release reports on the incident because Millage is a juvenile was not arrested, and the reports contained medical information.

Overstreet Smith said Millage probably didn’t understand the officers’ commands and was just trying to get up. She is disturbed that police concluded he was on some type of drug and called the police action “excessive physical force.”

After the Taser shots, the backup officer, Michael Chapman, struck Millage six times with his baton on his right leg and right arm, police said.

As Overstreet Smith was talking to the emergency dispatcher, an officer came to her door. He told her that her great-grandson was at Adventist Medical Center. In the emergency room, she found Millage restrained, bleeding from his knees, with bruises to his right side and right leg from the Taser probes and baton strikes.

“He was smiling. He was glad to see us” she said, “but he couldn’t tell us what happened.”

Millage has the comprehension of a 2-year-old, the pastor said. Portland police have a disability identification card on file on the teenager, which Overstreet Smith updates each year. It has his full name, address, phone number and describes his autism, childhood degenerative disease, and his mannerisms, listing “mumbled language, speaks very little, doesn’t answer commands, fearful of angry voices.”

Millage ‘s characteristics –from playing with an object in his hands to not having normal responses to pain or cold weather –fit those of severely autistic people, Edelson said.

From The Oregonian, December 12, 2006

Portland Officer Dan Thompson this summer spent at least 30 minutes on a cell phone trying to coax a man armed with a gun out of a Southeast Portland house. The man was waving the firearm around, threatening his friends and holding it to his head.

Thompson, speaking from the street using a police car for cover, introduced himself, asked the man what was bothering him and assured him he was “here to help.” Thompson reminded the man that police were not going away, “so we’re going to have to find a solution to his problem.”

The man stepped out, only to see a flank of police cars surrounding his home and retreated inside.

“I go, ‘Darn it,’ ” Thompson recalled.

But the veteran cop didn’t give up, connecting once again by phone with the armed man, trying to regain his trust. “I do remember walking back and forth between the police cars, totally focused on this guy,” Thompson recalled.

The man eventually surrendered that June 6 evening and was unharmed. For his effective communication skills, Thompson on Monday was awarded the Chief’s Forum’s highest honor: the Nathan Thomas Memorial Award.

“It was Officer Thompson’s maturity, patience and keen de-escalation skills that made sure this call had a positive outcome,” said Louise Grant, the forum’s co-chairwoman.

Thompson, 56, a 31-year bureau member, doesn’t have special hostage negotiation training, but finds from his experience on the streets that “it seems like everybody hands me the phone.” He was shocked by the recognition, calling it probably the highlight of his career, which he says he’ll continue until he stops “having fun.”

“This award is extremely special to every member of the bureau because we all carry with us the day Nathan Thomas was killed,” Thompson said. “I’m humbled by it.”

The award is named for a 12-year-old boy who was accidentally shot and killed by police in January 1992 while being held hostage in his home by a burglar. Nathan’s mom, Martha McMurry, presented the award, noting that January will mark the 15th anniversary of Nathan’s death; he would have turned 27 on Dec. 19.

“I no longer know what he might have been doing or what he might have looked like,” McMurry said.

McMurry and Nathan’s father, Gregory Thomas, chose not to sue the Police Bureau. Instead, they pressed the bureau to enhance officers’ communication skills to de-escalate tense encounters and have the bureau recognize officers who exhibit this skill. Often, she said, she’s asked whether she and her husband took the right path, if their efforts have helped.

“Well” she said, “it’s very hard to answer that question.”

She said she’s pleased there has been the introduction of less-lethal weapons, such as bean-bag shotguns, and in the wake of James P. Chasse Jr.’s death in police custody, money set aside to ensure all officers complete 40 hours of crisis intervention training. But she said she recognizes that the training is not going to resolve every situation.

“Unfortunately, when things like that happen and people die and families love that person, we’re all sorry this happens and it hurts everybody,” McMurry said.

Nathan’s mom urged the Bureau to continue recognizing officers who use communication as a police tool to connect with people and avoid violent encounters.

“If we’re going to value community policing, we have to recognize communication, treating people with respect,” McMurry said. “It might help keep other families from living the tragedy we live with every day.”

From The Portland Business Journal, December 6, 2006

Trillium Family Services has received a $2 million donation that will jump-start renovations at the Trillium Children’s Farm Home campus in Corvallis.

The donation, from Dave and Penny Lowther of Philomath, is the second-largest gift in the agency’s 130-year history. The donation also serves as the lead gift in a fund-raising campaign to improve facilities on the campus and build a new residential treatment center for teenagers suffering with mental illness who formerly were relegated to the Oregon State Hospital.

READ – Renovation continues at Children’s Farm Home

Trillium Family Services is a nonprofit agency that provides children’s mental health care programs and services. The agency has operations in the Mid-Willamette Valley, Portland metro and Central Oregon regions. The Trillium Children’s Farm Home houses Trillium’s psychiatric residential treatment programs for the Mid-Willamette Valley and for children statewide.

The Old School on the Children’s Farm Home campus, built in 1925, once was a center of life for the campus, which was founded as an orphanage in 1922. The building saw some use through the 1980s, but in recent years it has sat idle and boarded up, a victim of age, modern building codes and a lack of funds to renovate it.

The Lowthers’ donation will allow Trillium to either renovate the Old School or rebuild it to reflect the original Georgian architecture. The building will become badly needed office space, freeing room elsewhere on campus for clinical uses. The new building will be named to honor Dave’s mother, Hazel V. Lowther, an ardent supporter of local children’s causes who died in August.

Trillium’s overall goal is to raise about $10 million to $15 million for improvements at the Corvallis campus. The agency completed work on renovations to two residential cottages, a new school and new playground in 2004-05. Construction could begin as early as this spring on improvements to the cafeteria and gymnasium and a new covered play area.

Another goal of the capital campaign is a new psychiatric treatment center designed specifically for teenagers once served at the decrepit Oregon State Hospital in Salem. The state closed its psychiatric program for adolescents in 2005 and transferred the program to Trillium’s Corvallis campus.