Unity Center confirms 2 deaths, wants to be free of investigation in September

Unity Behavioral Health on Northeast 2nd Avenue in Portland.  (Beth Nakamura)

The president of Unity Center for Behavioral Health said Wednesday he expects the metro area’s troubled mental health hospital to remain open and fix serious safety problems this month.

“The Unity Center is critical to the community and I can assure you on behalf of our leadership team, our staff at the four organizations, we are 100 percent committed to its success,” Trent Green said in an interview Wednesday.

The center, a 24-7 clinic for people in mental health crisis, opened at the end of January 2017 as a collective answer to long waits at regular hospital ERs. It’s supported by four major health groups – Legacy Health, Oregon Health & Science University, Adventist Health and Kaiser Permanente — and run by Legacy.

The center has been under investigation since March by state and federal authorities. Inspectors found medical neglect led to at least one death and Unity officials have confirmed a second death.

In the state report, a patient died after struggling to swallow fluids for days. Five days before the death, the patient was supposed to undergo an evaluation for the problem, but medical records don’t show if that every happened.

Unity did not explain the circumstances of the second death, but documents obtained by The Oregonian/OregonLive show that a county employee reported that a woman hanged herself on a door at the facility. Unity officials said previously that they had replaced modified doors to curtains as a harm reduction measure.

Investigators also found patient assaults of other patients, patient assaults on staff, unsafe building conditions, lack of staff training and other problems, records show.

Those problems appear to have still existed halfway through the investigation, which led to an Oregon Health Authority announcement that indicated Unity might have significant work left to do to get state and federal approval.

Green said many improvements are done or underway. Unity staff have moved cameras so all areas of all rooms can be seen on monitors at nurse stations.

Staff members also will check every new patient every 15 minutes for the first 24 hours after admission to the hospital, he said. Then, doctors and nurses will come up with a treatment plan that includes how often the patient should be checked.

Patients will be assessed for their likelihood of suicide each day. Nurses will use a barcode scanner to administer medication that Green said will ensure each patient gets the correct medication.

Unity also has posted openings for 20 staff positions and has started to cross-train nurses throughout Legacy so they can help at the mental health center if needed, he said.

“We’ve been working on things and we think this process has reinvigorated the work and the improvements we’re making,” Green said.

Unity hopes to meet an earlier Sept. 11 deadline, he said, to satisfy investigators and avoid losing its certification from the U.S. Centers for Medicare and Medicaid Services — a step that could jeopardize its ability to stay in business.

State regulators, representing the federal agency, said this week that they had extended the deadline to make fixes until Oct. 31 after finding more problems at Unity, but Green said his staff didn’t ask for the extension and hopes not to need it.

The latest findings from the state aren’t public yet, but a summary from Unity officials said that investigators cited many of the same issues that started the investigation: patients were able to hurt themselves and attempt suicide, staff weren’t properly trained in restraint and seclusion procedures, nurses gave out wrong medications at wrong doses to the wrong patients, among other things.

Legacy Health has started a website, unityfacts.org, to post answers to frequently asked questions and documents related to the investigation.

Meanwhile, Multnomah County is continuing its own investigation into why complaints made to the county about the Unity Centerappear to have gone largely ignored.

The county is reviewing nearly 1,200 health reports made to its Office of Quality Management since January 2017. The reports cover not only Unity but hospitals and other health care facilities in the county.

Documents released to The Oregonian/OregonLive show that some of the complaints to the county revealed problems at Unity as early as February 2017.

Joan Rice, the quality manager, and her boss, the head of Mental Health and Addiction Services, David Hidalgo, are both on paid administrative leave pending the results of the review.

Multnomah County has asked that anyone who reported an incident of abuse of an adult with mental illness since January 2017 and is concerned about what happened to the report to call 503-988-8170.

All new reports are now being reviewed by a manager, according to county statement Wednesday.


Posted Sep 5, 2018/Updated Sep 6, 2018
By Molly Harbarger
The Oregonian

https://www.oregonlive.com/health/index.ssf/2018/09/unity_center_confirms_2_deaths.html