Mental Health Association of Portland

From the Salem Statesman Journal, February 27, 2011

State officials refuse to answer questions about two mental-health consultants who have been paid $1 million to help the Oregon State Hospital respond to an ongoing U.S. Department of Justice investigation of the Salem psychiatric facility.

The taxpayer-subsidized tab for the consulting duo has nearly doubled since the Statesman Journal first reported on their pay in July 2009.

Despite this escalating expense, officials say the consultants work is off-limits to the public because it is part of the state’s response to the four-year federal investigation.

The hospital initially agreed to answer a set of written questions posed by the newspaper about the consultants work. Officials reversed course last week, opting not to respond.

In addition, officials canceled the newspaper’s prearranged Friday interview with OSH Superintendent Greg Roberts. The interview was set up to get the hospital leader’s take on the consulting work performed by Dr. Jeffrey Geller, a professor of psychiatry at the University of Massachusetts Medical School, and Kris McLoughlin, a mental-health consultant based in California.

Among the written questions submitted by the newspaper that were left unanswered:

• Who do the two consultants report to at OSH?
• Do they issue written reports, oral reports, or both?
• How does their expertise benefit the hospital? What are some concrete examples?
• In what specific ways have they assisted OSH in responding to the federal investigation?
• How does their consulting role differ from the legal assistance provided to OSH by the state Attorney General’s Office?
• How long will the two consultants continue to work at OSH?

On Friday, hospital spokeswoman Rebeka Gipson-King described the unwillingness to answer questions about the consultants as a mutual decision reached by the hospital and the state Attorney General’s Office.

“Everything that has to do with U.S. DOJ is going to go through the Attorney General’s Office,” she said.

Tony Green, a spokesman for Attorney General John Kroger, said the consultants work is confidential because the recommendations they make on how to improve patient care are connected to the federal investigation.

“The underlying issue is very much the subject of the investigation and potential legal action,” he said. “It’s not something that you can simply separate out and say there’s not a connection between that and the U.S. DOJ investigation. It’s a difficult situation because of the ongoing investigation. We’re doing our best to protect the state while addressing the concerns that are being raised.”

State officials enlisted help from Geller and McLoughlin in August 2006, shortly after the U.S. Department of Justice launched a civil-rights investigation into Oregon’s main mental hospital in June 2006.

Both consultants were highly regarded for their previous work in other states, which often focused on helping troubled psychiatric facilities deal with federal Justice Department investigations.

Terms of Oregon’s initial contracts with Geller and McLoughlin called for each to be paid $75,000, with the contracts to expire Dec. 31, 2006. However, the consultants have been kept on board through contract amendments.

The current veil of confidentiality on the consultants work is a departure from past practice at OSH.

In 2009, then-hospital Superintendent Roy Orr answered various questions that the newspaper posed to him about the work performed by Geller and McLoughlin.

Orr said the consultants typically visited the hospital each month, normally staying for several days and engaging in wide-ranging discussions with hospital officials and staffers.

“Every time they arrive, it’s like a one-week survey,” he said. “They start the week by asking, ‘What progress have you made on the major initiatives and the assignments we handed out last month?’ ”

Orr credited the consultants with playing key roles in helping the hospital launch reform-minded measures, such as sharply reducing the use of seclusion and restraints to control patients — one of many problems spotlighted by federal investigators.

Last week, Geller and McLoughlin separately declined Statesman Journal requests for interviews about their state hospital work, as they previously did in 2009.

In 2009, the newspaper reported that combined pay and expenses for Geller and McLoughlin totaled $517,859 from the start of their consulting work in September 2006 through July 3, 2009.

Since then, the state has paid out $498,384 to them in combined fees and travel expenses, raising the grand total to $1,016,243, according to pay and expense data obtained by the newspaper.

Geller and McLoughlin were the first in a series of outside consultants who have been brought in to help the hospital improve patient care and analyze operations during the prolonged federal investigation.

Among the former and current OSH advisers:

• Former Lane County Circuit Judge James Hargreaves received $252,465 in state pay for the year he served as governor-appointed “special master” of the hospital. His 14-page report, issued in early 2009, rapped hospital management for poor planning, undefined goals and a lack of urgency.
• Liberty Healthcare, a Pennsylvania-based consulting firm, was paid $175,000 to study the hospital last year. In September, the consultants concluded the hospital has “invested great energy and vigor in striving to improve, but the results to date have been disappointing.”
• Kaufman Global, an Indiana-based consulting firm, is getting paid $2 million to spur culture change at the hospital and help it run more efficiently and effectively. The firm’s contract ends on June 30.

Above, Oregon State Senate President Peter Courtney criticizes Oregon State Hospital construction and opening delay in an interview with the editorial board of the Salem Statesman Journal in January 2011.

From the Salem Statesman Journal, December 29, 2010

An Oregon State Hospital patient apparently committed suicide Monday night in a single-person bedroom in the hospital’s forensic psychiatric program, officials said Tuesday.

The female patient died on Ward 50I, a medium-security forensic unit that houses more than two-dozen men and women.

A staffer reportedly found the patient near death in her room at 9:28 p.m. Monday.

Oregon State Hospital Replacement Project (OSHRP) is expected to cost approximately $458 million.

“It appears the patient committed suicide. As is standard procedure in these situations, we notified state police, and they are conducting an investigation. The family has been notified, and our thoughts and prayers are with them in their time of loss. We will make sure they, as well as patients and staff, have the support they need.”

Roberts said the hospital will conduct “a full review” of the death “to ensure all hospital policies and procedures were followed surrounding the incident.”

Oregon State Police identified the deceased patient as Anne Elizabeth Sellers, 32.

An autopsy was performed Tuesday by the state medical examiner, but the results “are not going to be released at this time pending the ongoing investigation,” said state police Lt. Gregg Hastings.

Other patients on Ward 50I told the Statesman Journal that Sellers hanged herself.

Sellers had a history of suicide attempts and often received around-the-clock staff supervision, patients said.

Several months ago, she was placed on intensive supervision — known as a constant watch in hospital parlance — after she tried to cut her throat with a kitchen knife while attending a cooking class, they said.

Sellers recently was taken off tight supervision and assigned to a private room after going for an extended period of time without any behavioral problems, patients said.

Her death shocked patients and staffers at the troubled mental institution.

“Some patients are really upset. Others are really sad,” said Renee Putnam, a patient on Ward 50I.

Putnam and other patients described Sellers as quiet, shy and a bookworm. They said she worked as the librarian at a centralized treatment mall and was well-known and well-liked by fellow patients and staffers.

“They’re upset, of course,” hospital spokeswoman Rebeka Gipson-King said. “We’re going to be making sure that all the patients’ needs are met so far as support. Some patients are going to need more help than others — those who were closer to that patient.”

Hospital officials said confidentiality laws prevented them from disclosing the patient’s name or specifics about the apparent suicide. Officials also declined to say when or how many times staff checked on the patient Monday, saying that the information also was covered by confidentiality laws.

Sellers was admitted to the state hospital in early 2007 after being found guilty but insane for Lane County charges of assault on a public safety officer, unlawful use of a firearm and resisting arrest, records show. She was to remain under the jurisdiction of the state Psychiatric Security Review Board for 10 years.

The last suicide at OSH occurred about two years ago. On Oct. 29, 2008, patient David Morse hanged himself on Ward 50F by tying a cloth around his neck and attaching it to a metal bed frame tilted up. Morse was still alive when staff cut the cloth from around his neck. Transported to Salem Hospital, he died of medical complications caused by the hanging.

Last year, a patient death prompted inquiries that pointed to lapses in patient care, leading to a shake up in hospital leadership and new bed-check procedures.

Moises Perez, 42, was found dead in his hospital bed on Oct. 17, 2009. Witnesses said his death was not noticed by anyone for several hours. An autopsy showed that Perez died of heart disease.

A state investigation 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.

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 and the doctor in charge of his care resigned.

In the wake of Perez’s death, the hospital instituted new bed-check policies, requiring expanded checks on patients.

Putnam praised staff members on Ward 50I for responding quickly to Monday night’s incident.

“They were just doing their rounds and found her and they immediately went into action,” she said. “They’re pretty good with their rounds up here. I mean, they’re pretty right on with the times.”

But another resident of Ward 50I, who asked to remain anonymous citing concerns about possible retaliation or other repercussions, said many patients have a hard time dealing with boredom, stress and friction caused, in part, by idle time.

“Right now, we’re on Christmas break, so there’s absolutely nothing to do,” she said. “We sit around in different rooms or our bedrooms and that’s when people can cycle, then the whole ward is basically involved in trauma or drama or violence.”

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.

From the Salem Statesman Journal, July 23, 2010

The three candidates who interviewed this week for the top leadership job at the Oregon State Hospital oversee state-run psychiatric hospitals in New Jersey, Alaska and Arizona, the Statesman Journal learned today.

The candidates are: Gregory Roberts, assistant director for the Office of State Hospital Management in New Jersey; Ron Adler, CEO of the Alaska Psychiatric Institute; and John Cooper, CEO of the Arizona State Hospital.

The names of the three OSH superintendent candidates were provided to the newspaper this morning by a participant in Tuesday’s candidate interviews in Salem.

Richard Harris, director of the state Addictions and Mental Health Division, subsequently confirmed the information this afternoon.

State officials previously had declined the newspaper’s request for release of the candidates names and resumes, citing the need to protect their current employment.

Harris said he contacted all three candidates to inform them that their names had been leaked to the newspaper.

“I wanted them to have a heads up,” he said. “They’re all aware of it now, so the prohibition against not revealing their names is sort of a moot point.”

On Monday, the three candidates toured the hospital campus in central Salem. On Tuesday, they answered questions posed to them by four rotating panels. The interviews occurred at the headquarters of the state Department of Human Services.

The panels were charged with ranking the candidates and evaluating each person’s strengths and weaknesses.

Selection of a top candidate is expected soon. After that choice is made, Harris said, a vetting process will focus on contacting people familiar with the prospect’s track record, including leaders of mental health advocacy groups, key legislators, co-workers and others.

If the inquiries go well, Harris said, contract negotiations will ensue.

A timetable outlined by Harris calls for a negotiated contract to be completed by the end of August and the new superintendent assuming the post by the end of September.

All three candidates made favorable impressions during Tuesday’s interviews, said Robert Joondeph, executive director of Disability Rights Oregon, an advocacy group that monitors patient care at the state hospital.

Joondeph served on the interview panels. He did not leak the names of the candidates to the newspaper.
“I thought they had three very experienced, qualified candidates, and each would bring something a little different to the job,” he said.

Joondeph said one candidate rose above the other two, but he did not specify which person he thought emerged as the front-runner.

“I think in terms of the interviewers, there’s kind of a consensus, but we’ll wait and see,” he said.

The search for a new hospital leader began on the heels of the April 2 forced resignation of superintendent Roy Orr.

Orr was forced out by state human services director Bruce Goldberg and Harris. They said new leadership was necessary to speed up the pace of change at OSH.

The U.S. Department of Justice Civil Rights Division has strongly criticized patient care and hospital conditions during an ongoing, four-year investigation of OSH.

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

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

From the Salem Statesman Journal, June 10, 2010

Richard Harris

A $4.8 million package of proposed budget cuts at the Oregon State Hospital includes a freeze on hiring administrators and a delay in hiring of staff for the second phase of hospital replacement project.

But the understaffed and overcrowded psychiatric facility in Salem is moving forward with fast-track hiring of front-line staffers, Richard Harris, director of the state Addictions and Mental Health Division, said Thursday.

“We’ve exempted them from any of the hiring freeze and any of the reductions,” he said.

The hospital budget cuts were carefully fashioned, he said, to avoid harmful effects on patients and existing front-line staffers.

“We sort of divided this into a freeze on administrative positions, a continued aggressive hiring process for the direct care staff, and a slow down of hiring of the anticipated staff for the Phase 2 start up,” he said.

“For me, the mandatory overtime issue remains the No. 1 priority to be dealt with. It’s absolutely imperative that we bring more people on.”

Harris recently set a goal for the hospital to hire 60 front-line staffers by this summer. The accelerated hiring effort is aimed at reducing the hospital’s growing reliance on forced overtime to run the facility, plus easing the burdens on frustrated and frazzled direct-care staffers who frequently receive marching orders to pull double shifts.

This week, OSH took a big step toward meeting the 60-person hiring goal by extending employment offers to 28 potential front-line staffers, Harris said.

“We’ll end up with a yield that is lower than 28 but my hope is we end up with at least 20 out of this, so we’re about a third of the way there,” he said.

Proposed budget cuts at OSH come in response to Gov. Ted Kulongoski’s order that state agencies slice 9 percent from the final 12 months of their 2009-11 budgets. The cuts are designed to compensate for a big shortfall in tax collections triggered by the recession.

Planned OSH cuts totaling nearly $5 million are well below the 9 percent benchmark established by the governor, Harris said. Spending reductions range from $100,000 per month cutbacks in supplies and services to delayed hiring next year of new hospital employees.

State budget cuts are occurring as the state is building a new $280 million 620-bed hospital to replace the existing 127-year-old institution, which was declared obsolete and unsafe by state-hired consultants five years ago.

The first patient-occupied sections of the new hospital are scheduled to open late this year, and the facility is projected to become fully operational late next year.

Last year, state lawmakers boosted the hospital’s two-year budget for 2009-11 to $324 million, a 31 percent increase that provided funding to hire 527 new employees.

As a cost-containment measure, the massive staffing expansion was set up to occur in waves of hiring, timed to coincide with the phased opening of new facilities.

The looming budget cuts will delay the hiring of workers slated to be hired next year during Phase 2 opening of the new hospital.

To save money, new employees will be hired two months before patients move into Phase 2 portions of the new hospital, around next May. Those workers previously had been slated to come on board four to five months prior to patient occupancy of that part of the facility.

Despite the proposed freeze on administrative hiring, the hospital will proceed with recruitment of a new superintendent, Harris said.

It is “absolutely vital that we fill that position,” he said.

More than 30 applicants have applied for the hospital leadership post. Plans call for filling the position by early August. Former OSH Superintendent Roy Orr, who was ousted by Harris April 2, was paid about $232,000 per year.

Harris said it was hard to say how federal investigators might react to budget cuts at the hospital. The U.S. Department of Justice has been a harsh critic of understaffing, patient care and hospital conditions.

“My own estimate is, I don’t think it changes much of the equation,” he said. “But if we’re blunt about it, everything we do at the hospital is under the scrutiny of the U.S. Department of Justice, and I don’t know what there reaction is going to be when they see we’re making budget reductions at the hospital.”

From OPB.org, April 12, 2010

The Oregon State Hospital was in the news again recently. Hospital superintendent Roy Orr‘s resignation April 2 coincided with the release of a report (pdf) on the investigation into the death of a patient at the mental hospital last October. Richard Harris, head of the Addiction and Mental Health Division at DHS, asked for Orr’s resignation. He told the [Salem] Statesman Journal, “it was time to make a change in leadership.”

The Oregon State Hospital has been under scrutiny in the past and an ongoing federal investigation has resulted in harsh criticisms of the facility. The hospital has demonstrated a reduction in violent incidents and is currently expanding to create more space for patients, but advocacy organizations say they want to see more improvements on a faster timeline.

Do you have experience at the Oregon State Hospital as an employee or as a patient? What would you like to see new leadership bring to the facility? Have you experienced mental health care in another state’s mental hospital? What was that experience like?

GUESTS:

* Richard Harris: Head of the Addictions and Mental Health division of the Oregon Department of Human Services
* Nena Strickland: Acting superintendent of the Oregon State Hospital
* Chris Bouneff: Executive director of NAMI Oregon

DOWNLOAD – The State of the Oregon State Hospital (22.4 MB)

From the Salem Statesman Journal, April 9, 2010

Anna Richter Taylor is wrong – mental health services are NOT a priority for Governor Ted Kulongoski. Under his watch and with his approval, state legislators mis-directed the future of funding for desperately needed outpatient services to unneeded and unwanted hospitals. This misdirection satisfies public employee unions and is promoted by the state as a jobs program. Further, it misinforms by indicating the problems at the Oregon State Hospital can be resolved with bricks and mortar. This is utterly false.

Our impression is it’s the state and it’s employees recalcitrance which causes “prolonged monitoring, expensive legal bills and sluggish reforms.”

Gov. Ted Kulongoski doesn’t intend to heed calls from mental-health advocacy groups, all urging him to enter into a court-enforceable agreement with the U.S. Department of Justice for terms of better patient care at the Oregon State Hospital.

Ted Kulongoski

Though Kulongoski “agrees with advocates that the hospital has been neglected for too long,” he won’t enter into any agreement with the U.S. DOJ that would result in federal court oversight of the state hospital, Anna Richter Taylor, the governor’s spokeswoman, said Monday.

“The bottom line is the court-enforced agreement adds another layer and hurdle to our efforts to improve patient care at the state hospital,” she said.

Once a state enters into a court-enforceable agreement with the U.S. DOJ, a court-approved monitor keeps tabs on mandated improvements. The process can lead to prolonged monitoring, expensive legal bills and sluggish reforms, Richter Taylor said.

“In looking at other states, like Georgia and Hawaii that have had federal court oversight of their hospitals, their outcomes have actually been slower, not faster, and they’ve been very, very costly because of litigation,” she said.

Mental-health advocates reacted strongly Monday to the governor’s rebuff of their request for federal court oversight of the state hospital and the reasons against it cited by Richter Taylor.

Leaders of Disability Rights Oregon, NAMI Oregon and Mental Health America of Oregon said in a joint statement: “We are disappointed that the governor does not see the need for a new direction. If there is a bottom line to the tragedies at OSH, it is that the change is not coming fast enough.

“The costs of litigation occur only if Oregon fails to obey a court agreement. Georgia and Hawaii didn’t do that but instead chose to fight all the way …We say: make the agreement and stick to it.”

The three advocacy groups went public with their request to Kulongoski in the wake of Friday’s release of a critical report examining the death of a state hospital patient.

Capping a five-month investigation, the state Office of Investigations and Training concluded that the hospital failed to provide Moises Perez, a longtime OSH patient, with adequate medical care.

Perez, 42, was found dead in his hospital bed Oct. 17.

Investigators ruled the evidence was inconclusive about whether Perez was neglected the day of his death. But it found the hospital negligent in failing to provide him with proper care for chronic medical problems that led to his death.

Advocates described the case as all-too-familiar.

“Unfortunately, what happened to him is not outside the ordinary in the hospital in terms of the level of attention and care that people receive,” said Bob Joondeph, executive director of Disability Rights Oregon.

A court-enforceable agreement voluntarily entered into by the state, or a lawsuit brought against Oregon by the U.S. DOJ, are the only ways to hold state officials accountable for real reforms, advocates said.

“At present time, there is no penalty, there is no enforcement mechanism, to make sure goals are met,” Joondeph said.

Chris Bouneff, executive director of NAMI Oregon, a chapter of the National Alliance on Mental Illness, said: “The truth of the matter is, they don’t want to be forced into actually making changes. I think our only hope now is that the Department of Justice files suit and forces them to do it.”

Richter Taylor said Kulongoski supports changes announced Friday by leaders of the state Department of Human Services, including the forced resignation of hospital superintendent Roy Orr. Orr was ousted by Human Services Director Bruce Goldberg and Addictions and Mental Health Division chief Richard Harris.

“The governor does support Dr. Goldberg’s decision to change the superintendent and for additional staff (at OSH), such as hiring a compliance officer and bringing in an objective consulting team to help address the cultural issues within the state hospital,” she said.

Kulongoski “has been and continues to be committed to working closely with the U.S. Department of Justice to address the quality of patient care,” Richter Taylor said.

The U.S. DOJ has been investigating patient care and hospital conditions since mid-2006.

Bouneff blasted Kulongoski for not doing enough to reform the state hospital.

“This governor has had eight years to change this institution,” he said. “Clearly, this is not a priority for him, and the patients in this institution are not a priority for him.”

Richter Taylor defended Kulongoski’s OSH track record.

“I don’t think there’s a question about the governor’s commitment,” she said.

During Kulongoski’s tenure, the state hospital has added hundreds of new employees, and the state now is moving forward with a $458 million plan to build two new psychiatric hospitals to replace the existing facility, which was deemed obsolete and unsafe by state-hired consultants in 2005.

“If you look at his record, it was under his administration that changes really started to be made at the state hospital,” Richter Taylor said. “Today’s hospital is not the same one it was a few years ago. Recognizing that there are still many, many improvements that need to be made, tomorrow’s hospital will be even better.”

READ – Advocates want oversight at Oregon State Hospital, Oregonian, April 6, 2010
READ – Advocates call for increased federal oversight at Oregon State Hospital, Oregonian, April 6, 2010