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Oregon Health Authority finds major problems at Unity Center, the Legacy-run mental health facility

The Oregon Health Authority has given Legacy Health's Unity Center for Behavioral Health in Northeast Portland until Sept. 11 to fix problems that have jeopardized patient safety.

OHA issued its first public statement late Friday after a scathing investigation report found "several issues that jeopardized patient safety."

Unity Center began operations in January 2017, a joint venture of local hospitals and health systems. Local doctors and advocates for the mentally ill had pushed Portland to emulate a specialized emergency ward in Alameda County, California, for people in need of psychiatric care — including those who are homeless. Many psychiatric beds at hospitals in the region were shut down as a result of Unity's creation.

Safety was listed as a top priority in Legacy's presentations about plans for the facility before it opened.

But early this year, two employees complained to OHA of understaffing and patient safety concerns, with one calling it a "hell hole," as the Portland Tribune first reported.

On Friday evening, Legacy released a statement saying it is "working vigorously" to address the safety concerns at Unity.

Launching its investigation in April, the state found a wide array of problems ranging from poor or nonexistent training, poor medical care, inadequate policies, blind spots and lack of supervision allowing patients to harm themselves and other patients.

In May, the state informed Unity that it had created an "immediate jeopardy" situation for patients based on "numerous hazards in the physical environment, a lack of patient supervision, and lack of clear protocols for response to medical emergencies."

According to the report, "Documentation reviewed reflected hazards observed during the survey had resulted in actual harm, patient attempts at self-harm, and suicide attempts."

While the state at first retracted its more serious "immediate jeopardy" warning, investigators found numerous problems that violate patient care standards and legal requirements. A follow-up visit last week caused state investigators to put the facility back into "immediate jeopardy" status on July 27.

The findings contained in the OHA report included that some patients had escaped. One patient on a supervised garden visit was able to escape by following a vendor outside.

Others were not properly supervised, and were allowed to hurt themselves. For instance, a patient "with a history of cutting was provided a shaving razor to use while 'supervised' in the shower and during the shower cut him/herself numerous times."

One patient was able to hoard 24 pills by concealing them under their tongue rather than take them. They included Prozac, trazodone. Patient admitted they intended to overdose on them, and the matter was labeled a "suicide attempt."

One patient died following an apparent failure to provide medical care, despite having reported difficulty in swallowing liquids.

The report noted that despite Legacy's attempts to respond to the state's concerns, "the findings from this survey reflect its limited capacity to provide safe and adequate care."

The deficiencies noted included a lack of an "effective governing body," a failure to investigate incidents of self-harm and alleged abuse, a failure to properly supervise patients, a failure to properly treat patients with medical conditions, and a failure to inform patients of their right to be free of abuse.

"It was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital."

The OHA report was prepared for release in response to an Oregon Public Records Law request by the Portland Tribune. It was then released to the Tribune and The Oregonian late Friday, and first published by The Oregonian.

A statement released by OHA noted that Legacy is addressing the deficiencies — a process that caused Unity to close its doors to most new patients for a few days earlier in the week.

Click to read OHA Unity report

Here's the full OHA statement:

The Oregon Health Authority identified a list of deficiencies uncovered during an ongoing investigation of Unity Center for Behavioral Health. These deficiencies require the center to take corrective action. State officials uncovered several issues that jeopardized patient safety. Unity Center and its parent Legacy Emanuel Medical Center must fix these deficiencies to maintain federal certification.

Surveyors from the Health Facility Survey & Certification Program in the Health Care Regulation and Quality Improvement Section, based at the OHA Public Health Division, have investigated Unity Center since it received a complaint in late February. Unity Center is Legacy Emanuel Medical Center's off-campus behavioral health inpatient and outpatient satellite.

Unity Center was working to formulate an acceptable corrective action plan when new allegations surfaced in late July. These allegations, along with the standard revisit timeline, prompted state health officials to return to the facility. Unity Center's staff is working to develop the corrective actions the psychiatric center must take to maintain certification while continuing to serve vulnerable patients with severe mental illness.

"Our job is to ensure effective treatment of patients and safety of patients and staff members, which is why we initiate these investigations," said Andre Ourso, administrator of the OHA Public Health Division's Center for Health Protection, which oversees the Health Care Regulation and Quality Improvement Section. "We will monitor this situation closely to ensure compliance with state and federal requirements to address all the issues we identified."

Timeline

This timeline summarizes the sequence of events surrounding the complaint investigation survey initiated onsite at Unity Center and the status of the investigation:

• February 19, 2018: Health Care Regulation and Quality Improvement Section (HCRQI), Public Health Division, Oregon Health Authority (OHA) received complaints regarding patient and staff safety at Unity Center.

• March 14, 2018: OHA contacts CMS regional office to recommend investigation of Unity Center after gathering information in response to February 19 complaint and conducting interviews with complainants.

• April 26, 2018: Surveyors from HCRQI, initiated unannounced complaint investigation at Unity Center.

• April 27, 2018: Survey discontinued following provider's refusal to permit surveyors to remove requested photocopied documents from the premises.

• May 15, 2018: Surveyors returned to Unity Center to continue survey, incorporating additional concerns related to patients' rights found during the interim period.

• May 18, 2018, 5:25 p.m.: Surveyors informed the hospital that an immediate jeopardy situation existed after observations, interviews, review of medical records and incident/event investigation documents in staff personnel records, and review of policies and procedures, revealed numerous hazards in the physical environment, a lack of patient supervision and lack of clear protocols for response to medical emergencies. Hazards observed during the survey and documentation reflected actual harm to patients, patient attempts at self-harm, and suicide attempts.

• May 21, 2018, 10 a.m.: Hospital submitted a written plan to abate immediate jeopardy to OHA outlining actions taken to remove the immediate jeopardy situation.

• May 21, 2018, 4:55 p.m.: Plan to abate immediate jeopardy resubmitted with additional information.

• May 22, 2018, 9:45 a.m.: Plan to abate immediate jeopardy resubmitted with final clarifications.

• May 22, 2018, 4 p.m.: Surveyors informed hospital during exit conference that immediate jeopardy was removed.

• May 22, 2018: Unity placed on 90-day termination track (90th day set to occur on Sept. 11, 2018). A termination track is the number of days until CMS terminates a facility's certification, which would end Medicare and Medicaid reimbursement for services.

• July 23, 2018: OHA surveyors initiated a revisit to Unity to review the hospital's efforts to return to compliance and review additional patient health and safety concerns.

• July 27, 2018, 5:15 p.m.: During revisit survey, OHA surveyors informed the hospital that a second immediate jeopardy situation existed. This followed observations, interviews, review of medical records and incident/event investigation documents, and review of policies and procedures, which revealed continued hazards in the physical environment, continued lack of assessment and observation of patients at risk of harm. Surveyors remained at the hospital until an acceptable, written immediate jeopardy mitigation plan was developed and submitted on July 28, 2018, at 12:30 a.m.

Surveyors will draft a report to reflect the results of their revisit. Unity Center will have 10 days to submit a plan of correction, which will be reviewed by OHA. Once approved, OHA will complete an additional on-site revisit to ensure implementation of the plan and return to full compliance.

• July 31, 2018: Unity submitted a written amended immediate jeopardy mitigation plan to OHA.

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