Mental Health Association of Portland

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Suit alleges Oregon State Hospital overmedicated, mistreated man

Posted by admin2 on 3rd November 2011

From the Salem Statesman Journal, November 2, 2011

A lawsuit filed against the Oregon State Hospital on behalf of a 32-year-old mental patient alleges he was mistreated and overmedicated by hospital clinicians, leading to two heart attacks in November 2009.

The civil suit accuses hospital doctors and caregivers of negligence, including:

    -Failing to obtain informed consent for treating the patient, Joshua Jaschke, with the drug Adderall.

    -Failing to provide him with a full explanation of the drug treatment regimen, its risks and possible alternatives.

    -Failing to consult product safety warnings for the drug before prescribing and administering it.

    -Administering doses that exceeded amounts recommended by the drug manufacturer and the hospital.

    -Failing to recognize and treat the patient’s chest pain and other medical complaints and symptoms before to his heart attacks.

    -Continuing to treat Jaschke with Adderall after he had heart attacks, on Nov. 1, 2009, and Nov. 8, 2009.

A $10 million lawsuit filed against the Oregon State Hospital claims that a mental patient suffered two heart attacks because he was overmedicated and mistreated at the Salem psychiatric facility.

The Marion County civil suit alleges that OSH patient Joshua Jaschke, now 32, was prescribed doses of the drug Adderall, along with other medications, which caused him “to feel sick and suffer pain and heart attacks and permanent damage to his heart.”

Jaschke suffered two heart attacks during a one-week period in November 2009 because of negligent care, according to the suit.

It also claims that hospital doctors failed to obtain the patient’s “informed consent” for treatment with the drug and failed to fully explain to him potential side effects or possible alternative treatments.

Adderall is a stimulant composed of mixed amphetamine salts. It is commonly used to treat attention deficit hyperactivity disorder, obesity and narcolepsy.

The lawsuit asserts that Jaschke was treated with the drug “unnecessarily or without a legitimate medical purpose.” It also claims that he was given excessive doses of the drug.

Furthermore, it says hospital doctors prescribed the drug “without due regard of his thromboembolic history,” referring to blood clots that break loose in the bloodstream.

As a result of his two heart attacks, Jaschke faces “future medical expenses for necessary care and treatment and repair of his heart, and/or a heart transplant,” according to the suit.

Named defendants are the state Department of Human Services, the state hospital, and nine doctors and therapists employed by the hospital at the time of the alleged negligence: James Ronald Brylski; Ulista Jean Brooks; Satyanarayana Chandragiri; Frederick Elliot Fried; Steven Edward Fritz; Richard Joseph Mead; John Edward Meyer; William Lee Newton; and Michael Edwin Robinson.

Hospital spokeswoman Rebeka Gipson-King declined to comment on the lawsuit Wednesday.

Portland lawyer Michael Van Hoomissen, who represents Jaschke, said Wednesday that his client is housed in the hospital’s transitional cottage program.

He said Jaschke is on track to be discharged back into the community.

Although Jaschke has made significant progress during his mental health treatment at the psychiatric facility, his physical health remains precarious, Van Hoomissen said.

“Physically, he has a severely damaged heart,” he said.

The lawsuit asserts that Jaschke has suffered “a shortened life expectancy and loss of enjoyment of his life.”

The suit asks for a jury trial.

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Oregon State Hospital doctor who quit is back at job

Posted by admin2 on 2nd October 2010

From the Salem Statesman Journal, September 28, 2010

Deal saves lawsuit costs; mental-health advocates critical

A doctor at the Oregon State Hospital who claimed he was forced to resign after an investigation into a patient death returned to work Monday at the Salem psychiatric facility.

Dr. Michael Robinson has resumed patient care duties under terms of a negotiated settlement agreement between himself and the hospital.

Hospital Superintendent Greg Roberts said Monday in an e-mail to the hospital advisory board that the settlement agreement “gives us the certainty that a costly legal battle would be avoided.”

But mental health advocates criticized the hospital for cutting the deal with Robinson.

“As an attorney, I understand why disputes are compromised, but this one carries the lingering odor of an institutional culture that puts patient care down the list after the needs of other interest groups,” said Bob Joondeph, executive director of Disability Rights Oregon.

Joondeph criticized the settlement in an e-mail he sent to three top officials in the state Department of Human Services — Bruce Goldberg, human services director; Richard Harris, director of the Addictions and Mental Health Division; and Roberts, who took the reins of OSH on Sept. 20.

“This settlement does not line up with the OSH culture we are hoping to build,” Joondeph wrote.

The settlement agreement, dated Sept. 24 and obtained by the Statesman Journal on Monday, dictates that Robinson’s reinstatement to the psychiatric hospital will be short lived.

It says that he will “tender an irrevocable resignation” by Jan. 15, or earlier should he take another job prior to that date.

Other terms of the deal specify that Robinson won’t seek reemployment at OSH and that the hospital will provide him with a “neutral reference” consisting of positions held, job duties and salary.

The agreement also says that the hospital union representing Robinson will withdraw all pending grievances filed on his behalf.

Robinson, who formerly worked in the hospital’s forensic psychiatric program, now is assigned to the hospital’s geriatric treatment program.

Earlier this year, Robinson became the subject of a hospital investigation for his treatment of a forensic patient who died last year.

Moises Perez, 42, was found dead in his hospital bed Oct. 17. Witnesses said his death was not noticed by anyone for several hours. An autopsy showed that Perez died of heart disease.

An investigation by the State Office of Investigations and Training concluded that the hospital neglected Perez by failing to provide him with adequate medical care. Investigators reported that Perez’s caregivers on hospital Ward 50F 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 lapses in Perez’s care.

Five hospital employees subsequently received letters of reprimand for their shortcomings involving Perez.

Robinson, the Ward 50F psychiatrist in charge of Perez’s care, was relieved of direct patient care duties in April pending results of a separate hospital inquiry into his treatment of Perez.

Amid the internal inquiry, Robinson informed the hospital that he would resign, effective July 31.

Robinson subsequently attempted to withdraw his resignation but it was rejected by hospital officials, who ordered him to turn in his identification and pick up his final paycheck at the end of July.

In seeking to withdraw his resignation, Robinson asserted in a July 9 letter to the hospital’s chief medical officer that his “resignation offer was made while I was under great duress from threats of adverse employment actions.”

The letter also said that it was Robinson’s understanding that “if I resigned, the hospital would cease their baseless and misguided efforts to damage my reputation as a medical professional.”

The settlement agreement between Robinson and the hospital came after months of negotiation.

Settlement terms are “binding on the parties,” the document says.

The hospital’s employment deal with Robinson comes as another OSH doctor is the subject of an internal investigation into his reported neglect of a patient.

Dr. Alexander Horwitz failed to examine a mental patient whose “excessive bleeding” later required surgery and a blood transfusion, according to a report by the state Office of Investigations and Training.

Investigators determined that Horwitz neglected the female patient’s care during his duty as on-call OSH physician on the night of May 26.

Horwitz reportedly failed to examine the patient, even though nurses notified him about the patient’s profuse bleeding.

Investigators concluded that hospital nurses may have saved the patient’s life by arranging for her ambulance transport to Salem Hospital.

Horwitz told investigators that no one told him there “was a need for faster action.”

Horwitz, who has worked at the state hospital since 1995, has been removed from on-call duties and is under “strict supervision,” Roberts said last week.

The hospital’s human resources department is conducting a separate investigation into the case. Additional actions may be taken against Horwitz, pending the outcome of the inquiry, officials said.

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Oregon State Hospital doctor resigns after patient death

Posted by admin2 on 9th July 2010

From the Salem Statesman Journal, July 9, 2010

An Oregon State Hospital physician who was in charge of medical care on the ward where a patient died in October has resigned, the hospital’s interim superintendent Nena Strickland said Friday in an e-mail.

The e-mail was sent to the hospital’s advisory board.

Dr. Michael Robinson’s resignation is effective July 31, Strickland said.

The patient, Moises Perez, was found dead in his hospital bed Oct. 17.

A five-month investigation by the State Office of Investigations and Training determined that the hospital neglected Perez by failing to provide him with adequate medical care.

Investigators found that Perez’s caregivers on Ward 50F failed to properly treat his chronic medical conditions, failed to develop a “meaningful” treatment plan for him, failed to update his medical chart with notes about his condition and failed to return calls from his family in the last weeks of his life.

Five Oregon State Hospital employees received letters of reprimand in June in connection with inadequate care for Perez.

All failed to perform their duties, according to an investigation by the hospital’s human resources department.

Also in the wake of Perez’s death, a committee of OSH clinicians began a separate review of Robinson’s medical practices, and Robinson was assigned to nonpatient duties pending the outcome of the review, officials said.

Robinson also treated David Morse, 56, who hanged himself at the hospital on the same ward a year earlier. A subsequent investigation found Robinson had provided an “appropriate standard of care.”

That investigation continues, Strickland said Friday in the e-mail.

READ – Oregon State Hospital psychiatrist put on desk duty pending outcome of investigation, Oregonian July 9, 2010

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Oregon State Hospital reprimands five in patient’s death

Posted by admin2 on 18th June 2010

From the Salem Statesman Journal, June 19, 2010

Oregon State Hospital reprimands five in patient’s death – tougher sanctions were ruled out in medical-neglect case

Oregon State Hospital

Oregon State Hospital

Five Oregon State Hospital employees have received letters of reprimand in connection with inadequate care for a patient who died at the Salem psychiatric facility in October, documents released Thursday show.

All failed to perform their duties, according to an investigation by the hospital’s human resources department.

Two of the sanctioned employees, Sue Johnson and Mesme Tomason, are nursing leaders in the hospital’s forensic program. Also reprimanded were three veteran staffers in the forensic program: Joe Thurman, a nurse who also serves as a non-voting member on the state hospital advisory board, and Scott Finnegan and Henry Laughrey, two front-line staffers.

A committee composed of OSH clinicians is conducting a separate review of the medical practices of Dr. Michael Robinson, the hospital psychiatrist who oversaw the care of Moises Perez, the patient died on hospital Ward 50F. Robinson is performing non-patient duties pending the outcome of the review, officials said.

Perez, 42, was found dead in his hospital bed Oct. 17. An autopsy found that he died of coronary artery disease.

A five-month investigation by the State Office of Investigations and Training determined that the hospital neglected Perez by failing to provide him with adequate medical care.

The OIT investigation spurred a shakeup in hospital leadership in early April, and a spinoff hospital investigation into the job performance of seven employees involved in Perez’s care.

Richard Harris, director of the state Addictions and Mental Health Division, said Thursday that reprimands for five employees were deemed appropriate sanctions by himself and hospital leaders, including interim superintendent Nena Strickland, chief medical officer Mark Diamond and human resources officials.

Tougher sanctions, including termination and docked pay, were ruled out, he said.

“It’s a pretty serious disciplinary action within the hospital,” Harris said about reprimands. “It’s something that stays within a person’s record for three years.”

Disappointed by the disciplinary action was Beckie Child, a member of the state hospital advisory board and president of Mental Health America of Oregon, an advocacy group.

Child noted that hospital Superintendent Roy Orr was forced to resign on April 2, the same day the state released the critical OIT report documenting flaws and failings in Perez’s care.

“Considering that they fired Roy, no,” she said. “I’m sorry, Roy had nothing to do with what happened to Mr. Perez. He was a scapegoat. I think reprimands are woefully inadequate … I still hope somebody besides Roy gets fired over this.”

Strickland informed hospital workers and the advisory board about the disciplinary action Thursday morning via an e-mail message.

“There were seven employees investigated,” she stated. “While one investigation is ongoing, six are complete. Five employees were given disciplinary actions.”

Strickland’s message did not identify the sanctioned employees or specify the type of discipline they received.

However, HR investigative documents released Thursday to the Statesman Journal identified the five disciplined employees and spelled out how they allegedly failed to perform their duties.

According to the reports:

Johnson and Tomason failed to provide adequate supervision and oversight of Michelle Giblin, a mental health supervising nurse on Ward 50F.

Giblin was responsible for supervising 22 staff on the unit, but investigators concluded she did not receive adequate training to perform her duties.

Johnson is nurse manager in the forensic program and Tomason is assistant director of forensic nursing services. Both supervisors have worked at OSH for four years.

Thurman, a registered nurse assigned to Ward 50F, failed to chart the care provided to Perez.

Investigators reportedly found no nursing summaries from June 1, 2009, to Oct. 17, 2009, when Perez died. An HR investigation report says, “Mr. Thurman states that he did interact with the patient but on review after the patient’s death, stated he felt embarrassment for the lack of charting.” Thurman has worked at OSH for 14 years.

Finnegan, a mental health therapist responsible for passing out medications to Perez, failed to notify nursing staff that the patient refused to take his medication and failed to follow hospital policy for dealing with such patients. Finnegan has worked at OSH for 15 years.

Laughrey, a mental health therapist, failed to write weekly case monitor notes in Perez’s chart. Laughrey has worked at OSH for 14 years.

HR reports released Thursday spotlighted some of the flaws in Perez’s care that were previously documented by the OIT investigation.

For example, Giblin reportedly told investigators that lax medical charting was a “systemic problem” on treatment wards at OSH.

“Michelle stated that three month gaps without documentation is excessive but we may see similar patterns with other patients and the staff is working hard to make permanent improvements on the ward to prevent this from occurring,” states one report. “Giblin reported that she has heard stories that staff on other units have bragged about not doing any charting in months and even years. She met with her staff after hearing this story and reminded them all that this was unacceptable and her expectation was that staff document as required.”

Harris said an outside consulting firm has been hired to conduct a review of the hospital’s medical charting process and provide recommendations to improve it.

“We have a quality-improvement unit in the hospital,” he said. “They review the process, the charts and various medical procedures, but I don’t believe it’s operating to the level of depth and detail that we need in terms of making sure these kinds of charting errors and communication problems are identified.”

In her message to OSH staff Thursday, Strickland said the hospital has been “diligent in our efforts” to improve patient care on Ward 50F and throughout the hospital.

“I know reading this news will be very difficult but we are all in this together,” she said, referring to the results of the HR investigation. “We must rely on each other for strength and support in difficult times. Please be kind to one another and inspire your fellow co-workers to do the same.

“If you have special concerns bring them to your supervisor, contact a Human Resource representative or send me a message. We must continue to move forward with our mission to improve patient care and make OSH a safe place for all of us to work.”

READ – OSH Investigation Report – Joe Thurman
READ – Oregon State Hospital Investigation Summary
READ – OSH Investigation Report – Michelle Giblin
READ – OSH Investigation Report – Sue Johnson
READ – OSH Investigation Report – Mesme Tomason
READ – OSH Investigation Report – Henry Laughrey

READ – Five Oregon State Hospital employees reprimanded for care to patient Moises Perez, who died last fall, The Oregonian, June 19, 2010

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Doctor associated with patient’s death reassigned: state hospital psychiatrist given ‘nonpatient’ duties

Posted by admin2 on 9th April 2010

From the Salem Statesman Journal, April 9, 2010

A shakeup is continuing at the Oregon State Hospital in the wake of a state investigation that found the hospital neglected a patient who died at the Salem psychiatric facility last fall.

Dr. Michael Robinson, a psychiatrist who oversaw the treatment of Moises Perez on hospital Ward 50F, has been reassigned to non-patient duties, Patty Wentz, a spokeswoman for the state Department of Human Services, said Thursday.

Robinson, who has worked at OSH since September 2001, was given new duties Wednesday, pending the outcome of a follow-up investigation by the hospital’s human-resources department, Wentz said.

Interim hospital superintendent Nena Strickland said the HR investigation would scrutinize the job-related performance of “all of the staff and managers who had an impact on the care of Mr. Perez on 50F.”

After the HR review is finished, potential personnel actions could range from disciplinary action to additional training, education or coaching, Strickland said.

Perez was found dead in his hospital bed Oct. 17.

A five-month investigation by the State Office of Investigations and Training determined the hospital neglected Perez by failing to provide him with adequate medical care.

Investigators reported that Perez’s caregivers on Ward 50F failed to properly treat his chronic medical conditions, failed to develop a “meaningful” treatment plan for him, failed to update his medical chart with notes about his condition and failed to return calls from his family in the last weeks of his life.

Perez reportedly was shunned by other patients because he had poor hygiene. He ate meals by himself, rarely left the ward or took part in activities, refused his medications because he thought they were killing him, and spent much of his time sleeping, according to the report.

An autopsy determined that Perez, 42, died of coronary artery disease.

Hospital Superintendent Roy Orr was forced to resign last Friday, the same day the state released the report documenting flaws and failings in Perez’s care.

State Human Services Director Bruce Goldberg told the hospital’s advisory board Wednesday that new leadership was needed to bring “a greater sense of urgency” to the state’s push for better patient care.

A national search will be launched to seek Orr’s replacement, Goldberg said.

Meanwhile, hospital officials plan to assign another psychiatrist to assume Robinson’s patient-care duties on Ward 50F.

Robinson’s new duties consist of reviewing patient medical charts.

“One of the issues brought up by the OIT report is making sure we have the progress notes in the charts and that people are charting the medical information correctly,” Wentz said. “So he’s going to be looking at that.”

See also: A year before Moises Perez died at OSH, another patient killed himself on the same ward

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A year before Moises Perez died at OSH, another patient killed himself on the same ward

Posted by admin2 on 8th April 2010

According to The Oregonian, Moises Perez‘ death at Oregon State Hospital in October 2009 was preceded a year earlier by the suicide of another patient, David Morse. Both were on Ward 50F, and both were being treated by the same psychiatrist, Dr. Michael Robinson.

Despite two tragedies only a year apart, a report released to The Oregonian concluded that Robinson treated Morse with an “appropriate standard of care.”

Morse, age 56, hanged himself Oct. 29, 2008. He used a piece of cloth attached to a tilted metal bed frame, setting off a review by the state Office of Investigations and Training to investigate whether Robinson was negligent, overlooking Morse’s worsening condition.

According to the report, Morse had an empty bed in his room, which may have been standing up on end for three days or more.  After hospital personnel noticed Morse’s suicide attempt, they cut the cloth strips from his neck. He was still breathing. Emergency medical responders were called, but they were delayed. One of the building’s elevators was closed for repair, and the other was being used to haul lunch trays.

Morse continued to hang on to life for several days, but died on Nov. 10.

Although the report said Robinson’s care met an appropriate standard, it also listed additional problems on Ward 50F, a medium security ward that housed Perez when he died last year. Perez lay dead in his room for several hours without anyone noticing.

According to The Oregonian, “Fallout from the Perez case led to the forced resignation last week of the Oregon State Hospital superintendent, a sharp warning letter from the U.S. Department of Justice, and calls from patient advocates for greater scrutiny of an institution that has seen decades of troubles.”

Bob Joondeph, executive director of Disability Rights Oregon, told The Oregonian that two deaths, with a year of each other, on the same ward, with the victims under the care of the same doctor, are “disturbing.” But, he went on to say, it is consistent with the ward’s repution. Interim Superintendent Nena Strickland, who has worked at OSH for 15 years, told the newspaper that officials “recognize there are issues on Ward 50F.”

Three weeks ago, the hospital assigned a physician to evaluate the ward’s functioning and develop plans for improvement. Those plans, sadly, will come too late for Perez and Morse.

READ: Oregon State Hospital patient committed suicide on same ward as Moises Perez, by Michelle Cole – The Oregonian, April 7, 2010

READ: Hospital will search nation for leadership, by Alan Gustafson – StatesmanJournal.com, April 7, 2010

READ: Advocates want oversight at Oregon State Hospital (AP) – The Oregonian, April 6, 2010

READ: Films look at chickens, wetlands, state hospital – StatesmanJournal.com, April 8, 2010

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