Oregon State Hospital failures ‘alarming,’ feds say

From the Salem Statesman Journal, February 24, 2010

Federal investigators have slammed Oregon State Hospital again, citing “alarming” failures in care for a patient who died at the Salem psychiatric facility in October.

The U.S. Department of Justice found numerous flaws and failings in hospital care provided to Moises Perez during the year before his death, documents obtained by the Statesman Journal show.

Writing last month to the Oregon Department of Justice, a U.S. DOJ official said the case has triggered concerns about the overall health and safety of patients at Oregon’s main mental hospital.

Breakdowns in Perez’s care mirrored hospital problems that federal investigators reported to the state two years ago, wrote Shanetta Cutlar, chief of the Special Litigation Section of the U.S. DOJ’s Civil Rights Division.

“Given the amount of time that OSH has had to remedy these deficiencies, we are particularly alarmed by the failures that appeared to have occurred in this case,” she wrote. “We urge OSH to take immediate measures to address these deficiencies in order to prevent similar harm to other patients and to comply with OSH’s obligations under the U.S. Constitution, the Americans with Disabilities Act, and other applicable federal laws.”

On Oct. 17, Perez, 42, was found dead in his bed in a secure treatment unit in the hospital’s forensic psychiatric program. His death was discovered about 7:35 p.m. by a staffer delivering his evening medication.

Perez’s death sparked complaints from other patients and mental health advocates who alleged that staffers neglected Perez and that he was dead for hours before anybody noticed.

A state police investigation found no criminal wrongdoing. An autopsy determined that Perez died from coronary artery disease.

The U.S. Department of Justice reviewed Perez’s care as part of its ongoing investigation into patient care and hospital conditions.

OSH therapists, nurses and staffers consistently failed to provide Perez with adequate supervision, nursing, medication, medical care and psychiatric treatment during the last year of his life, Cutlar wrote. His care “failed to meet generally accepted professional standards” and “consistently fell well below constitutional and statutory standards,” she reported.

The federal agency has concerns that similar defects in care may “likewise violate patients’ rights and foreseeably could give rise to serious harm or death in other situations,” states the letter.

The Statesman Journal obtained Cutlar’s letter, along with a state lawyer’s response to it, through a public records request filed with the state Department of Justice.

The federal review of the case stopped short of concluding that any treatment flaws or failings directly contributed to the patient’s death.

“We understand OSH is conducting its own review, and we respect that process and await those findings,” Cutlar wrote. “We received a limited amount of information, which did not include autopsy reports. We therefore refrain from making any determination as to whether the failures that occurred contributed to the patient’s death.”

Feds uncover familiar problems

The U.S. DOJ’s latest criticism of OSH comes as the state is building a new psychiatric hospital on the Salem campus. The $280 million complex, billed as a world-class facility by state officials, is scheduled to partially open in the fall and become fully operational in 2011.

Cutlar’s letter demonstrates that federal investigators are far from satisfied about reform-minded efforts at the existing 127-year-old mental institution. It also indicates that tough federal monitoring of the hospital won’t end anytime soon.

The U.S. DOJ’s investigation of the hospital began in June 2006.

In January 2008, the agency issued a scathing report that criticized nearly every aspect of patient care and hospital conditions. The report shocked state officials and spurred sweeping reform-minded efforts.

State officials have touted improved patient care. But federal reviewers reportedly found all-too-familiar problems during their review of Perez’s care.

“Specifically, our review revealed inadequate nursing, medical, mental health, and psychiatric care, including a failure to provide individualized treatment,” Cutlar wrote.

Additional shortcomings included deficiencies in the patient’s medication management, supervision and planned interventions for his risky behavior.

“Unfortunately, these are all issues that we have identified as system-wide issues in our findings letter issued January 9, 2008, and that we largely continued to observe during our latest tour of the facility in July 2009,” Cutlar wrote. “We therefore believe that a pattern or practice of violations of patients’ rights continues to exist at OSH.”

Barring an out-of-court settlement with the feds on terms for hospital reforms, the state continues to face the threat of a federal lawsuit that could place the state-run facility under federal court control.

State lawyer defends OSH

Responding to Cutlar’s letter, an Oregon lawyer acknowledged that Perez’s death stirred concerns, but she defended the state’s push to provide patients with better care.

“Like USDOJ, OSH was and is very concerned about this death,” Micky Logan, a senior state assistant attorney general, wrote in a letter to Cutlar dated Feb. 12.

There’s “no doubt” that Perez’s death brought added momentum to the hospital’s drive for reforms, prompting the facility “to redouble its improvement efforts generally and to focus specifically on several issues that you and OSH each identified,” Logan stated.

Her letter outlined 25 “significant changes” made at the hospital since Perez died, including enhanced patient monitoring, increased medical and nursing staffing levels and new standards for dispensing medication.

Logan, the state’s lead attorney in dealing with the feds, denied the U.S. DOJ’s assertion that systemic hospital deficiencies jeopardize patients’ safety and constitute sweeping violations of their civil rights.

“As serious as this event was,” she wrote, “Oregon does not agree that it demonstrates a pattern or practice of violations of patients’ rights.”

Logan emphasized various hospital reforms adopted in recent years, and she said that members of a federal team who made a weeklong visit to OSH last summer appeared to be favorably impressed with the progress. Logan said she was taken aback by Cutlar’s assertion that the federal team observed lingering problems at OSH.

“This statement comes as a surprise to us, as our interactions with the US DOJ experts throughout their July 2009 visit suggested to us that they were favorably impressed by the significant improvements they observed,” she wrote.

The state attorney complained about Oregon officials being kept in the dark about key federal findings during the prolonged investigation.

“We note that we have requested on multiple occasions that US DOJ provide us with the reports of all its experts,” she wrote. “While such reports (especially the most recent) would be of particular assistance to OSH in its ongoing efforts, we have not received copies of any of these reports.”

Letter from Special Litigation Chief, U.S Department of Justice Civil Rights Division Shanetta Cutler to Oregon Assistant Attorney General Mickey Logan, 2 12 2010

Letter from Oregon Assistant Attorney General Mickey Logan to Special Litigation Chief, U.S Department of Justice Civil Rights Division Shanetta Cutler, 2 12 2010

READ – Letter lists oversights in patient’s death, Salem Statesman-Journal, February 24 2010