After an internal human resources investigation uncovered lapses in care that led to the death of a patient, Oregon State Hospital (OSH) sent five longtime employees letters of reprimand, a punishment that some are calling too light, according to the Statesman Journal.
On Oct. 17, 2009, an aide found Moises Perez, 42, a patient who had been diagnosed with chronic paranoid schizophrenia, dead in his hospital bed. He died of coronary artery disease and his body wasn't discovered for hours, although his room was across from the nurses station, according to later reports.
The letters of reprimand--which represent a disciplinary measure short of suspending pay or firing--went out to three nurses and two aides.
The internal hospital probe into the job performance of employees involved in Perez's care followed a five-month investigation by the State Office of Investigations and Training (OIT) that concluded that the hospital to failed to give Perez adequate care.
One of the most egregious problems was a four-month gap in documentation. HR investigators found no nursing summaries from June 1, 2009, through Oct. 17, 2009, the day the patient died. The investigative reports obtained by the Statesman Journal also revealed:
- Nursing leaders Sue Johnson and Mesme Romason failed to adequately supervise and oversee a mental health supervising nurse on the ward.
- Michelle Giblin, a mental health supervising nurse on the ward, did not receive enough training to do her job.
- Joe Thurman, a registered nurse who serves as a non-voting member on the state hospital advisory board , failed to chart the Perez's care.
- Scott Finnegan, a 15-year veteran at OSH, failed to tell nursing staff that Perez had refused to take his meds and failed to follow hospital policy for dealing with such patients.
- Mental health therapist Henry Laughrey, who has worked at OSH for 14 years, did not write weekly case monitor notes in Perez's chart.
So far, hospital superintendent Roy Orr has been the only person forced to resign due to the medical neglect. He was axed in April, when the state released a critical report by the OIT that concluded that the hospital neglected Perez when it failed to give him adequate medical care.
Dr. Michael Robinson, the OSH psychiatrist who oversaw Perez's care, has been taken off of patient-related duties. His medical practices are under review by the hospital.
Beckie Child, a member of the state hospital advisory board and president of the advocacy group Mental Health America of Oregon, told the Statesman Journal that she found the reprimands woefully inadequate. "I still hope somebody besides Roy gets fired over this," she said.
To learn more:
- read this article in the Statesman Journal (also check out the investigative reports in the blue box to the right)
- check out this Oregon Live blog