Oregon State Hospital chief resigns in wake of negligence report

Oregon State Hospital chief resigns in wake of negligence report

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PORTLAND — The superintendent of the Oregon State Hospital is out of a job after a departmental report described neglect of a patient who died there of heart disease.

In the wake of the report, the state Department of Human Services said Friday that Roy Orr resigned after being superintendent for two years.

The report said an investigation into the death of the longtime patient found negligence in his overall treatment, although it couldn't conclude there was negligence on the day he died last year. His body was not discovered for hours.

The mental hospital in Salem has been the focus of criticism for years and has been under threat of a federal lawsuit.

In response, the state has begun rebuilding and expanding the staff. But the state's director of human services said in explaining Orr's departure that more is needed.

"The pace of change needed to be speeded up," said Dr. Bruce Goldberg. "This wasn't about a single report."

Information Goldberg's department released Friday doesn't identify the man who died but describes him as "AV," a longtime patient, sedentary, with poor English skills, who took several medications.

He was last seen alive after breakfast Oct. 17, but he missed lunch, late-afternoon medications and dinner, said a report from departmental investigators. Staff members did hourly checks and noted he was asleep.

"One person reported shaking AV's leg at lunch but said he/she got no response," the report said. A staff member determined he was dead about 7:30 p.m., it said.

The investigators said the widely varying expectations among staff members about handling medication refusals and sleeping patients made it impossible to pinpoint negligence that day.

"While it is possible a nurse or direct care staff could have discovered AV in distress ... this assumption is by no means conclusive," it said.

But the investigators cited numerous flaws in his care long term, such as failing to follow up on the man's refusal of medications so that nurses could intervene, failing to document progress on his treatment plan, failing to do blood work required by his medications, failing to pursue diet and weight loss strategies, and failing to use an interpreter in assessing his refusal to take medications.

"One of the most distressing aspects of this case was the apparent failure of hospital staff to return calls to AV's family members in the last week of AV's life, to respond to their concerns," it said.

The 126-year-old hospital is well known as the site of the filming of "One Flew Over the Cuckoo's Nest" in 1975. In 2008, federal investigators issued a report highly critical of the facilities and patient care.

A $280 million project designed to replace the facility is under construction, and legislators have appropriated $60 million to expand the staff.

Goldberg said Friday the hospital itself has been neglected for years, but "you don't erase decades of neglect overnight."

In the report Friday, the investigators ordered numerous changes at the hospital, starting with a requirement that staffers who see patients seemingly asleep listen for breathing or watch for chest movement.

The hospital must establish guidelines for doctors to assess whether patients are able to consent to medical treatment and guidelines for seeking the intervention of a guardian or the courts in medical treatment.


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