State finds new problems at Unity Center; Legacy vows improvements
Problems continued at the Unity Center for Behavioral Health in Portland weeks after the state investigators issued a scathing report in late May, with a follow-up report saying that continued "failures" resulted in one patient's successful suicide as well as other issues.
The patient who successfully hung themself while in the psychiatric facility on July 11 had been identified as being at high risk of suicide. They had heard voices directing them to kill themself, according to Unity's initial patient evaluation cited by the state report, and had previously unsuccessfully tried hanging, drowning, at least two separate overdose attempts as well as created a "penetrating neck injury requiring surgery" before being admitted to Unity on July 4.
According to the state's report, Unity staff repeatedly failed to recommend upgraded precautions for the patient, known as "Patient 50," including on July 10 when the patient said they were "desperate" to end their life and a psychiatrist wrote "risk of sucide is high."
The patient went long periods without in-person observation, according to the state report, Video later showed the patient spent a half-hour moving clothes into the bathroom before apparently hanging themself.
The patient had been allowed free access to the bathroom despite an initial report by the state that the bathroom door hinges represented a hanging risk, acording to the follow-up state report.
Other issues cited by the state elsewhere in the report include medication errors and failure to provide adequate nursing services.
Legacy Health, which operates the facility, has vowed transparency and to address the many concerns discovered by the state, saying safety is it's "number one priority" on its website set up to address the problems, called unityfacts.org. It has expressed interest in redeploying staff and hiring staff to address complaints of understaffing and lack of safety.
Legacy did not respond to requests for general comment on the state's latest report or Legacy's plan to address it on Aug. 30 and Aug 31, and on Sept. 10 did not immediately respond to a request for comment on the newly disclosed report.
Legacy has posted online a summary of Legacy's plan to respond to the state's findings.
Click here to read the follow-up report
What follows is a press release issued by the state.
September 10, 2018
OHA identifies deficiencies during investigation of Unity Center for Behavioral Health
Portland facility developing solutions to address deficiencies
The Oregon Health Authority (OHA) 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 been investigating Unity Center since it received a complaint in late February 2018. 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."
The following 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 drafted a report reflecting the results of their revisit.
• July 31, 2018: Unity submitted a written amended immediate jeopardy mitigation plan to OHA.
• August 10, 2018: CMS sent Unity the report following the July revisit and informed Unity that the termination date was extended to October 31, 2018. The CMS letter gave Unity Center 10 days to submit a plan of correction, to be reviewed by OHA. Once approved, Unity will implement the plan and OHA will complete an additional on-site revisit to ensure return to full compliance.
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