From the Salem Statesman Journal, September 24, 2010
Oregon State Hospital
An Oregon State Hospital doctor failed to examine a mental patient whose “excessive bleeding” later required surgery at Salem Hospital, according to a state investigation report released Thursday.
READ – Offices of Investigations and Training report on Dr. Alexander Horwitz, issued July 28, 2010
Dr. Alexander Horwitz neglected the female patient’s care during his duty as evening on-call physician at the Salem psychiatric facility on May 26, concludes the report by the state Office of Investigations and Training.
Horwitz, while serving as Officer of the Day on the OSH campus, reportedly failed to examine the patient, even though nurses notified him about the patient’s profuse bleeding. Inexplicably, he neglected to check on the patient even though he visited her treatment ward that same evening.
Horwitz also failed to expedite the patient’s transport to Salem Hospital’s emergency room, “which should have been a high priority for him,” the report says.
Investigators determined that hospital nurses may have saved the patient’s life by arranging for her ambulance transport.
Horwitz, who has worked at OSH since 1995, has been removed from on-call duties and is currently under “strict supervision,” new hospital Superintendent Greg Roberts said Thursday.
The human resources department at OSH is conducting a separate investigation into the case. Additional actions may be taken against Horwitz, pending the outcome of the HR inquiry, officials said.
Roberts, who took the reins of the troubled psychiatric facility on Monday, described the confirmed case of neglect as unacceptable.
“What’s described in the OIT report is not acceptable,” he said. “It doesn’t represent an acceptable level of care.”
Roberts credited nursing staff on the patient’s treatment unit for doing an “outstanding job” on the night of the crisis.
“They worked very hard to make sure the patient was treated, and kudos to them,” he said. “We certainly have issues with the doctor’s performance here, and that’s why it’s going to be investigated.”
In a message sent Thursday to members of the state hospital advisory board, Roberts said: “While this report showed neglect by one person, the nursing staff on duty stepped up and made sure this patient got the care needed.
“We have made significant progress in the improvement of patient care at OSH. Clearly we have further to go and I believe we will get there.”
The patient neglect case involving Horwitz comes in the wake of a high-profile investigation that found lapses in hospital care for a patient who died last fall.
Moises Perez, 42, was found dead in his hospital bed Oct. 17. Witness accounts indicated that his death was not noticed by anyone for several hours. An autopsy determined that he died of coronary artery disease.
An OIT investigation concluded that the hospital neglected Perez by failing to provide him with adequate medical care. Investigators reported that Perez’s caregivers failed to properly treat his chronic medical conditions and failed to develop a proper treatment plan for him.
Former hospital superintendent Roy Orr was forced to resign April 2— the same day the state released the critical report examining the lapses in Perez’s care.
Dr. Michael Robinson, the OSH psychiatrist in charge of Perez’s care, subsequently resigned and five other veteran employees received letters of reprimand for their shortcomings involving Perez.
Unlike the Perez case, the latest patient neglect case centers on allegations against one hospital employee — Horwitz, Roberts said Thursday.
“It comes across to me pretty clearly as an individual performance issue,” he said. “Although he came to the ward, he didn’t actually examine the patient, which certainly raises some serious questions. That’s part of what the (HR) investigation will be focusing on: Why didn’t he examine the patient?”
Horwitz reportedly told investigators that May 26 was a “busy evening” at the hospital.
The report says Horwitz said “his usual practice is to let the RN complete an assessment first. He said he will see a patient if a nurse asks him to see the patient.”
In this case, “Horwitz said the nurse did not ask him to see the patient.”
The doctor denied neglecting the patient.
“Horwitz said no one asked him to do more at the time,” the report says. “He said no one told him there was a need for faster action. He said if they wanted him to be on the ward they could have said so.”
Details about the patient’s medical issues were deleted from the OIT report prior to it being released on Thursday. Hospital officials said the information was edited out to protect the patient’s privacy and to conform with confidentiality provisions of federal law.
The report says that witnesses on the ward described seeing “a steady stream of blood” from the patient on the evening of May 26. One staffer said the blood was “coming like a faucet” and other witnesses reported seeing “a lot of bright red blood in a toilet.”
Some witnesses described “a very foul odor.”
The patient reportedly was hysterical.
Certain details about the patient’s medical treatment at Salem Hospital also were deleted from the OIT report.
The patient arrived at the emergency room at 11:24 p.m. on May 26, the report says. She had been bleeding for almost three hours.
At Salem Hospital, her treatment included removing “foreign items” from an unspecified area of her body, the report says. After the procedure, a doctor could see a “significant injury” with “blood spurting,” it says.
Surgery was performed to stop the bleeding, the report says. The patient reportedly received IV fluids and two units of blood via a transfusion that came after her blood pressure dropped to a dangerous level.