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Suicide At Unity Shows Mental Health Center Has Long Way To Go

Two months after state investigators warned officials at Portland's only psychiatric ER they could lose federal certification, a woman who was known to be suicidal killed herself.
Unity Center for Behavioral Health in Portland. | LEGACY HEALTH
September 12, 2018

Hazardous conditions, inadequate patient oversight and negligence at the Unity Center for Behavioral Health enabled the suicide of at least one patient, an inspection report found.

The death came two months after state investigators warned the center that it could lose its federal certification due to unsafe conditions, the report said.

Oregon Health Authority investigators on Monday extended the behavioral health center’s deadline to address patient safety concerns, but the recent suicide of a despondent woman who made it clear at Unity that she was suicidal shows that the mental health crisis center still has a long way to go. The Oregonian/OregonLive first reported the latest findings.

A woman who sought treatment at Unity after feeling suicidal hung herself from a door inside the facility in July.

The patient was transferred to Unity on July 4 due to her risk of suicide. She committed multiple suicide attempts before getting admitted to Unity, including overdosing on acetaminophen, hanging, drowning and a “penetrating neck injury” that required surgery, the report said.

A day after she was admitted, the woman told staff that the pain she experienced was so unbearable that she regretted that she had failed to kill herself.

Two days later, staff discontinued the suicide precautions saying in a note that there were no behavioral problems. The note did not mention her suicide risk.

Notes over the next three days said the patient was preoccupied with suicide, felt hopeless and didn’t want to go home for fear she would kill herself. On July 7, the patient said she considered suicide but felt safe in the hospital.

On July 9, a psychiatrist note said “(Patient) continues to be utterly hopeless.”

Still, the staff did not restart suicide precautions and monitoring, the report said. Nor did they check on her every 15 minutes despite doctors’ orders to do so, the state investigation found.

Staff left the patient unattended in a room with unlocked doors. This was after a federal investigation identified bathroom door hinges as a risk to patients.

The woman hung herself with a bathrobe from a bathroom door on July 11.

The findings related to the suicide are the latest in a long list of patient hazards uncovered by the Oregon Health Authority over the last four months. This week’s report found that hazards discovered as early as May 2018 also caused multiple other suicide attempts and self-harm and the hospitalization of a patient who was given another patient’s medication.  

Unity President Trent Green told The Oregonian/OregonLive that staff at the Legacy, which runs Unity,  is committed to making the behavioral health center succeed.

“We’re in a state of continuous improvement,” Green told The Oregonian.

Unity spokespeople Kristin Whitney and Brian Terrett, director of Legacy communications, declined to comment.

Unity opened in February 2017 as a collaboration of four of Portland’s major health organizations. Adventist Health, Kaiser Permanente, Legacy Health and Oregon Health & Science.

The center uses a unique care model, called the Alameda Model, that places patients in one large room with about 50 recliner chairs and no privacy. Psychiatrists evaluate them and caregivers tend to their needs. Patients can stay there for as many as 23 hours before being released or placed in a private room.

Just three months after the center opened, it started getting complaints about patient care.

Officials at the hospital, affiliated with Legacy Emanuel Medical Center, have taken several steps to address the most glaring problems. They stopped all patient admissions on July 27. They increased suicide screenings, patient observation and searches for unsafe contraband. A second nurse will be required to observe and document medication administration by another nurse.

They agreed to lock more doors to mitigate environmental hazards such as sheets that could be used for hangings.  

Oregon Health Authority investigators on Monday extended Unity’s deadline to correct its problems by seven weeks. The center now has until Oct. 31 to fix the issues or lose its federal certification and reimbursements from the Centers for Medicare & Medicaid Services.

“CMS came to the conclusion that it would be very difficult for the hospital to complete the correction tasks by Sept. 11, but recognized the efforts the hospital made to remedy the immediate jeopardy,” Oregon Health Authority spokesman Jonathan Modie said in a statement.