Legacy releases detailed action plan to address deficiencies, boost patient safety at Unity Center

Portland Business Journal – August 6, 2018

Legacy Health has publicly released its action plan to correct deficiencies at the Unity Center for Behavioral Health, which came under fire by state regulators for safety problems, including harm to patients and suicide attempts.

Legacy initially deferred answering questions about how the 18-month-old psychiatric facility had responded to a state investigation. After the Oregon Health Authority on Friday released more details about the center’s deficiencies and a timeline of events, Legacy shared its 76-page Plan of Correction.

“The plan documents the amount of work that has been done to ensure Unity Center is safe for patients and staff,” Legacy spokesman Brian Terrett said in an email. “Our number one priority has always been, and will always be, the safety and well-being of our patients and our staff. We take OHA’s investigation very seriously and are working vigorously to address every area of concern and to ensure the safety our patients and employees.”

He cited, as an example, bathroom doors, which were modified twice, then replaced with Velcro-hung privacy curtains to prevent patients from harming themselves. Unity also removed safety suite door closures and plastic utensil dispensers.

Unity, which is run by Legacy in collaboration with three other area hospital systems, is in danger of losing its federal certification if the problems aren’t addressed by Sept. 11. The U.S. Centers for Medicare and Medicaid Services placed Unity on a “90-day termination track” on May 22 that would end government reimbursement for services.

Unity briefly closed to new admissions from hospitals and ambulances last week, but continued to take walk-in patients, while it worked to put new safety protocols in place.

Unity’s corrective action plan includes reeducation of nursing staff and addressing issues in the physical environment. Some examples:

  • All patient care areas will be assessed for blind spots when looked at via camera and addressed.
  • Patients observed using the physical environment to inflict self-harm will be continuously observed while in seclusion.
  • Documentation of patient safety with potentially unsafe items will be entered daily into the electronic health record.
  • Staffers must conduct at least hourly in-person checks and monitor location and status of patients every 30 minutes. Checks now include visualization of patient breathing.
  • Open nurses’ stations must be supervised by staff at all times.
  • Abuse investigations will be widened to include patient-on-patient incidents and guidelines will be developed for investigating abuse allegations and actual cases involving patient-on-patient harm.

Legacy’s policy on Patient Rights and Responsibilities will be updated to include: “The patient has the right to be free from all forms of abuse and harassment.”

Fifty charts will be audited per month for three months to assess compliance with restraint and seclusion requirements.

Safety event reports related to patients “cheeking” medications will be investigated.

Department education records will be reviewed annually for every staff member as part of their annual review process.

Legacy released a statement on Friday night that reads, in part:

“During our first year of operation, like any new entity, we have identified opportunities for improvement and the Oregon Health Authority has added to our own efforts in their investigation into claims of an unsafe environment of care, we welcomed their review and have cooperated fully with the agency. We have worked diligently to specifically address all of the issues raised in their Statement of Deficiencies. We have made significant progress and will continue to make changes in both our physical environment and our practices.

“As the investigation continues, Unity Center will be dedicated to transparency about the work we have undertaken. We look forward to having the community see the work we’ve done and how it will continue to improve as we care for those in such critical need.”