Inadequate staffing leaves mental patients unsafe

Mind Games: Oregon’s Mental Health System

First of a five part series on the Oregon State Hospital

From The Oregonian – October 25, 1987. Not available elsewhere online.

Asylum: A place where one is safe and secure.” — Webster’s New World Dictionary.

When George Lewis Archer, 60, collapsed dead in a pool of blood by a nursing station in Oregon State Hospital’s general psychiatric ward last Nov. 6, staff employees took it in stride.

According to hospital records, no one at the time pressed to determine the cause of Archer’s bleeding or even suspected foul play. Two doctors at the hospital called it a natural death, from esophageal bleeding.

The Oregon State Police, which routinely looks into institutional deaths, asked for an autopsy. Four days later a pathologist discovered the true cause of Archer’s demise — he had been stabbed in the face with a butter knife.

A state police investigation would find that Archer had been stabbed by another patient in the ward’s visiting room while five staff members were on duty — none of whom noticed what happened.

Good gumshoe work solved one of the hospital’s secrets. Not all the secrets of Oregon’s mental institutions reveal themselves so completely.

The stabbing death is just one extreme example of what can happen in Oregon’s mental institutions. According to hospital records, Archer’s homicide was the second on hospital grounds in 16 years. One patient was killed in the hospital’s forensic unit for the criminally insane in 1985, and at least one other murder attempt has taken place there.

At least one other patient’s death, listed as from natural causes, should have been classified as homicide, according to Dr. Peter J. Batten, the Marion County medical examiner. Batten, who formerly served as a psychiatrist at the Oregon State Hospital, said a 68-year-old patient’s death of a heart attack in 1983 was sparked by another patient’s assault.

In contrast, the Oregon State Penitentiary, the state’s maximum-security prison, has had but one homicide in the last 15 years, although it houses nearly three times as many inmates as the hospital has residents.

Patient advocates and current and former staff members at the Oregon and Dammasch state hospitals for the mentally ill say patients are threatened by inadequate supervision. Similar problems also plagued the Fairview Training Center for the mentally handicapped until the state began a massive, $25 million plan of correction last spring — prompted by a federal lawsuit and termination of federal Medicaid and Medicare funding.

Injuries, rapes and, on occasion, even deaths continue to occur in the state’s mental institutions when patients hurt themselves or prey upon others, both patients and staff members. Sometimes the cause is determined, sometimes not — no one sees them, or no one will or can tell what he saw.

Consider the following:

  • In addition to Archer’s homicide at Oregon State Hospital, bizarre accidental and unexplained deaths have occurred. Two middle-age women patients at Dammasch have died of heat exposure after wandering onto the grounds in the last four years. Two older women died — one from complications arising from a broken hip — after one fell from a bed and the other from a chair at Oregon State Hospital last winter.A 24-year-old woman wandered off Fairview’s grounds in March and was found dead three days later, drowned in a creek nearby.
  • So ineffective is normal supervision that stopgap solutions must be devised. For example, Dammasch officials, frustrated by their inability to protect a middle-age woman from rapes, have put her in a thick plastic coverall secured by locks — a 1980s version of the medieval chastity belt. The ratio of staff members to patients is far below what the state says are federal standards.
  • Injuries to staff members, often caused by combative patients, have been so common in the state’s three largest mental institutions that they cause staff shortages and millions of dollars in workers’ compensation claims.
  • Federal certification has been yanked for almost all of the state’s institutions, at least temporarily, costing the state millions in lost federal aid.

Proud record tarnished

Oregon’s mental institutions once ranked among the best and most progressive in America. The state burnished its reputation for progressive thinking in matters of the mind 12 years ago when it permitted the filming in Oregon State Hospital of the movie “One Flew Over the Cuckoo’s Nest,” an indictment of inhumanity in mental hospitals; state officials believed that Oregon had nothing to hide.

But as the 1990s approach, the state has not fulfilled the promise of its progressivism, and the reputation of its institutions is tottering.

Oregon’s two main state hospitals for the mentally ill operate on the very edge of respectability. Fairview Training Center, the state’s largest institution for the mentally handicapped, also has had a history of safety problems.

Since the spring of 1986, Dammasch, Oregon State Hospital and Fairview Training Center all have been at least temporarily denied federal Medicaid and Medicare payments for substandard conditions.

The state last week announced new superintendents for all three of the state’s large mental institutions. Linda K. Gustafson, director of a mental health hospital in Lincoln, Ill., will become Fairview’s new superintendent Dec. 1. Stanley F. Mazur-Hart, the acting superintendent of Oregon State Hospital, will replace Dr. Victor M. Holm as superintendent of Dammasch on Nov. 23. Holm announced his retirement last week. George Bachik, director of the Idaho State Hospital South, will take over as superintendent of the Oregon State Hospital on Dec. 7, it was announced Friday.

Dammasch continues to operate without federal funding certification. Oregon State Hospital has regained partial funding but has chosen to forgo certification review for three of its five main sections, knowing that conditions in them do not meet federal standards for either adequate treatment or staffing.

In April, federal health-care inspectors concluded that too many Fairview patients were being injured, and they cut off funding. They charged that inadequate staff and poor procedures posed a immediate threat to residents’ health and safety.

The state regained federal funding for Fairview after a 14-week hiatus — and a $7 million loss — by agreeing to spend $25 million over two years to hire 500 new employees and move 300 of Fairview’s more than 1,000 residents into community care.

Health Care Financing Administration officials say that Fairview now meets standards for safety but barely complies with those for treatment. In a pending lawsuit separate from the financing administration’s review, the U.S. Department of Justice alleges that care at Fairview violates patients’ constitutional rights to safety, training, medical treatment and education.

Two smaller state institutions, Eastern Oregon Psychiatric Center and Eastern Oregon Training Center, both in Pendleton, continue to have federal funding certification. The state Department of Human Resources director, Kevin Concannon, said he thought both were doing well and, with a combined population about 150, were examples of his belief that “small is better.”

Violations of federal treatment standards, designed to prevent warehousing of patients, account for the continuing lack of certification of Dammasch and parts of Oregon State Hospital.

According to state officials, one of the key federal benchmarks not met by Oregon’s state hospitals is the ratio of staff members to patients. While the federal officials deny that they use a specific standard, top state administrators say they believe the unwritten expectation for state hospitals is about 1.2 direct-care staff members per patient. The state hospitals have only about 0.6 direct-care staff members per patient — half of what the federal government says is adequate. Only the children’s and geriatric programs at Oregon State Hospital approximate the federal staffing standard and are certified.

The federal expectation for training centers for the mentally handicapped is about 1.5 direct-care staff members per patient, state officials say. At Fairview the ratio is about 0.9.

Concannon, who took office Oct. 12 as director of the state Department of Human Resources after a brief term as mental health chief, said the state planned improvements at both state mental hospitals but not on the same scale as at Fairview, and not enough to regain federal funding soon.

The Legislative Emergency Board earlier this month appropriated $900,000 to relieve staff workload by shifting 50 long-term Dammasch patients into community care. It rejected a request to pay for more Oregon State Hospital employees, saying such a decision should wait for the 1989 Legislature.

The state hopes that a new law, designed to increase civil commitments by providing for closer monitoring of those with two or more commitments in the last three years, won’t increase the pressure on state hospitals. It has set aside $7 million to keep track of such chronic patients more closely and provide community programs for them, and it has made no plans for enlarging the hospitals.

Fewer patients

The overall number of people in institutions has dropped sharply for the last 30 years under the state’s policy of diverting patients into the community, called deinstitutionalization.

Despite that drop, the state’s institutions suffer from insufficient staff, inadequate programs and conditions that critics call not only unhealthy but also dangerous to inmates and staff members alike.

State officials attribute the problems of the three larger state institutions to their size, outdated buildings and a lack of staff.

“Standards have moved a considerable distance in 20 years,” Gov. Neil Goldschmidt said last year. “And our programs didn’t move enough in 20 years to keep up. . . . It’s going to take a little catch-up time.”

The amount of money needed to catch up may be great.

For example, Holm, Dammasch ‘s superintendent, said the hospital “ideally” needed a 50 percent staff increase. “It’s like an airplane: You can guarantee it’s safe, but it’ll never fly,” he said.

In addition, the state says it has had problems recruiting and keeping doctors, nurses and other professionals. Dr. Philip Shapiro, clinical director of Oregon State Hospital, said he had had one to four vacancies for physicians for three years and had a standing help-wanted ad in five psychiatric journals.

One reason given for the shortage, especially for doctors, is the relatively low pay, compared to private practice. The starting state maximum is $63,000 a year, and Shapiro said earnings can be far higher in private practice.

Concannon said he could not predict when or whether Dammasch and the decertified 70-patient general psychiatric section of Oregon State Hospital could regain federal funding. The state has no plans to comply with federal treatment standards for the forensics and correctional treatment programs. Those three decertified programs house 70 percent of Oregon State Hospital’s patients.

Assaults occur daily

Violent assaults by patients are a daily occurrence in the state’s three largest mental institutions.

The most violent and threatening patients in the state end up in the security ward at Dammasch and the forensic unit for the criminally insane at Oregon State Hospital.

But violence inside state institutions is not confined to these units.

For example, according to figures compiled by the state for The Oregonian, 4,469 assaults by patients on other patients and on staff members were recorded during the 20-month period from January 1986 through August 1987 at Oregon State Hospital — an average of more than seven per day.

By far the greatest number occurred in the five wards of the hospital’s 160-patient geriatric program, for mentally ill patients who are 65 and older. The program averages about five patient assaults on other patients or staff members a day.

Indeed, hospital employees say some of the most dangerous conditions exist on the 12 general psychiatric wards for both large state hospitals. None of the wards meets federal treatment and staffing standards.

Oregon State Hospital continues to accept patients who voluntarily check into its 70-bed general psychiatric program, but Dammasch has reserved nearly all its 345 beds for patients who have been committed by the courts.

Diane Neubert, the Dammasch nursing chief, said the hospital’s patients over the last five years had become much more difficult to handle, particularly since voluntary patients were shut out.

“We’ve condensed down. We have a totally different population. . . . People are sicker. Patients get injured more,” she said.

“We have a very poorly staffed facility. It needs more staff to be truly safe,” she said.

During the state employees’ strike in September, hospital workers complained loudly about patient-caused injuries to them and wore buttons portraying black-eyed employees.

About 340 injury claims were filed by employees of Dammasch and Oregon state hospitals last year — nearly one a day. At Fairview, 920 similar workers’ compensation claims were filed in 1986.

The cost to the state in workers’ compensation: nearly $6 million last year.

Jan Curry, Fairview’s former acting superintendent, said the addition of 500 employees in recent months had helped reduce the severity of injuries caused by accidents or patients, but not their number.

Curry and a spokeswoman for the Fairview workers’ union said they believed the new workers had improved the overall safety at the institution.

Even so, “We have enough to watch (patients), but not enough to provide active treatment,” said Colleen Moen, of the American Federation of State, County and Municipal Employees.

Archer’s stabbing death on one of the program’s two wards was just an example of conditions inside it, said Chuck Forward, a psychiatric aide who is president of the hospital’s Oregon Public Employees Union unit.

“It’s not a safe place,” Forward said of the general psychiatric program where he works. “When you got four (psychiatric) aides, it’s hard to cover 30 to 40 patients on all parts of the ward.”

The aides and two nurses typically cover each ward, a long corridor of single and double rooms that stretches roughly two-thirds the length of a football field and includes a large day room, porch, two bathrooms and a shower.

State police concluded that Archer was fatally stabbed while in the visiting room.

Batten, the Marion County medical examiner, said that the assailant, Daniel Edison Miller, 30, had time to stab Archer with a butter knife, hide the weapon and wash the blood from his hands, all without the staff’s knowledge. Miller later confessed and was found guilty except for insanity.

The inability of staff members to prevent such assaults also was demonstrated by the 1983 death of George Nosen, 68, who in 1947 mistook cockroach poison for powdered milk while helping prepare a dish of scrambled eggs and accidentally killed 47 fellow Oregon State Hospital patients.

Nosen died of an apparent heart attack that occurred after he had been in a scuffle with another patient in the hospital’s geriatric ward. The fight occurred while about seven ward employees were in a 7 a.m. staff meeting.

At the time, Batten said, he listed Nosen’s cause of death as natural — arteriosclerotic heart disease. He listed a “non-fatal assault” by another inmate as a possible contributing cause. Batten said he had since changed his mind, and that the death was actually an “inadvertent” homicide — a heart attack caused by an assault by another patient.

In addition to the three homicides at Oregon State Hospital, four accidental deaths have occurred there in the last two years, two in falls and two from choking on food.

One person, Wanda Jackson, 50, died of “complications” two days after surgery for repair of a hip that was broken in a fall from her bed in a general psychiatric ward at Oregon State Hospital in January. Batten said the hospital initially wanted to have an autopsy done but the woman’s family refused to give permission. He said the hospital then concluded it was “probably a routine death that should be handled in a routine manner” and did not advise his office of it until after the woman was buried.

Delores Perez, 77, died of serious head injuries after she fell off a chair onto the floor of the geriatric unit on Dec. 25.

Two other patients died after choking on food. Byron Jacobs, another geriatric patient, who had a history of swallowing non-edible objects, choked to death after gorging himself on a magazine page and breakfast on Dec. 9. 1986.

LeRoy Lancaster, 60, died after choking on food in the hospital’s forensic unit on April 12. 1987.

In the last 10 years, there have been at least two other bizarre deaths at the hospital. Joshua Goodman, 21, choked to death on a rope in July 1981 while climbing on a painter’s rigging. Hospital officials and state police concluded he had been practicing rappelling for a planned rock-climbing expedition.

In the other case, Mark Radke, 25, died in June 1979 of “undetermined natural causes” eight days after being arrested for failing to pay for a meal in a Marion County restaurant. Batten said Radke possibly died from a drug overdose, but that an autopsy could not confirm that or any other specific cause.

Assaults by patients and unusual deaths offer two examples of what employees of both state hospitals say are products of inadequate staffing. Patient advocates say staffing not only creates safety problems but also results in inadequate treatment for patients.

“State institutions are abominations,” said Steven H. Gorham, a Salem attorney, who represents mentally ill and handicapped clients. “The object now is to get patients out as fast as you can. What they are concerned about is doing it the cheapest way possible.”