From Knight Ridder Tribune Business News, September 13 2003
Oregon mental health officials have suspended indefinitely Woodland Park Hospital’s license to admit patients to its psychiatric ward, the second time in three months that the facility has come under state scrutiny.
The move came after a patient escaped by crashing through a locked door on the 30-bed unit. Woodland Park staff didn’t know about the escape until the patient’s family alerted hospital officials.
A day after being returned to the ward, the 300-pound patient escaped a second time, again by barreling through the locked door.
Regulators who visited the Northeast Portland hospital Monday to investigate the incident found that hospital workers had written in charts that the patient was present on the ward when he or she was actually missing. The patient’s gender was not disclosed because of federal privacy laws.
State officials have not determined whether the erroneous information reflected an effort to cover up the escape or a failure to monitor the ward.
“This is a serious set of circumstances and events, and we need some immediate and substantive changes at that hospital,” James C. MacLeod said Thursday. He is the manager of quality assurance and certification for the Department of Human Services’ Office of Mental Health and Addiction Services.
Department investigators not only found irregularities in the patient’s records but also discovered that staff had given medications to several others to control their behavior rather than to treat their symptoms, in violation of hospital policy.
“It was done as a control thing,” MacLeod said. “And that is not allowed.”
No new patients will be admitted to the ward, including people with private insurance as well as those referred by county mental health agencies across the state. Because of the serious nature of the findings, the department gave the hospital until the end of today to prove that the deficiencies have been corrected.
Hospital officials said Thursday that they would correct the problems by the end of today.
In the meantime, about a dozen patients will remain in the unit because there is nowhere else to put them due to a statewide shortage of psychiatric beds, MacLeod said.
State officials also are concerned about Woodland Park using a “high ratio” of nurses from temporary agencies without giving them “adequate orientation to hospital policies and procedures or training,” according to a department letter sent to the hospital Tuesday.
During their visit Monday, regulators also found that the nurses station on the psychiatric ward was unattended for several minutes at a time, allowing patients access “to objects that could potentially be used for self harm or to harm others.”
The suspension comes three months after state investigators threatened to revoke the hospital’s license to operate its inpatient psychiatric ward after finding 16 problems they said threatened the health and safety of patients, including using police officers to deal with disruptive psychiatric patients.
That investigation was sparked in May after a man staff member grabbed a woman patient from behind to forcibly move her to a secure room. The patient fell during the struggle and broke her nose on a bed frame.
Investigators visited the hospital in June and found that the staff member had failed to properly document his actions and that staff often failed to follow written hospital policies relating to physical interventions with patients, failed to complete seclusion and restraint logs, and kept inconsistent records on patient injuries.
Investigators also noted that the hospital had failed to fix several safety problems identified in a September 2001 inspection triggered by two former employees’ complaints.
Reached Thursday, hospital officials said they have corrected the problems identified in June and are working quickly to correct those identified this week.
“We have no disagreement with the state,” said Jack Julius, the interim chief executive of the hospital, which is owned by Symphony Healthcare of Nashville, Tenn. “In fact, we wish to cooperate and assist the department any time there’s a question. We want to be most responsive.”