Oregon State Hospital reprimands five in patient’s death

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

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