Health & Safety Risk Review – Pacific Gateway Hospital

Health & Safety Risk Review Pacific Gateway Hospital

Written by Larry Marx, M.D. and Heeseung Kang, M.S.

April 19, 2001


Opening Statement

The Multnomah County Department of Community and Family Services, Behavioral Health Division, designated a Health and Safety Risk Review team, consisting of the following members: Larry Marx, M.D. (lead); Bill Toomey, M.Ed.; Paul DuCommun, R.N., M.P.H.; Dave Helgeson, Ph.D.; Rosemary Celaya-Allston, M.S.; and Heeseung Kang, M.S. The purpose of this team was to conduct a review in order to determine whether County-sponsored clients were receiving safe, appropriate, acute inpatient care at Pacific Gateway Hospital.


On 04/12/01 and 04/13/01, the team analyzed the following data sets: administrative/clinical policies and procedures; administrative structure; staffing criteria; restraint polices/seclusion & restraint logs; chart audit of county-sponsored clients; tour of physical plant; and staff interviews.

Larry Marx, Paul DuCommun, and Heeseung Kang reviewed the following areas: administrative/clinical policies and procedures; administrative structure; staffing criteria/acuity system; and county-sponsored client charts.

The other half of the team—Bill Toomey, Dave Helgeson, and Rosemary Celaya-Allston—reviewed the seclusion and restraint policies/procedures, cultural competency plan/procedures, charts, and logs; toured the physical plant; and interviewed staff members.


Administrative/Clinical Policies & Procedures


Overall, the policies and procedures of Pacific Gateway Hospital (PGH) were found to address the necessary and appropriate areas for care in an inpatient psychiatric facility. Given that PGH is accredited by the Joint Commission on Accreditation of Hospital Organizations (JCAHO), this level of policy documentation would be expected.


Several concerns emerged during the review on policies and procedures, as well. These concerns are outlined as follows:

  • Based on review of Critical Incident policy and procedure, description of what constitutes a Code 5 (5-point seclusion and restraint), is confusing and incomplete; unclear who should be the organizer of clinical response during Code 5, particularly where seclusion and restraint have to be used; unclear as to what specific path should be followed in carrying out Code 5 procedures
  • Policy which permits police officers to enter a locked psychiatric facility with firearms
  • Lack of clear policy regarding police involvement in containing dangerous or out-of-control situations
  • Policy and training regarding cultural competency inadequate to address needs of community of color; lack of forms in other languages (patient rights, informed consent, release of information, etc.); unclear how interpretive services for non-English-speaking patients readily available on timely basis


Short-Term Corrective Action

The following plan correspond with the concerns identified above:

  • A Code 5 policy needs to be explicit in definition, scope, and explanation of procedure; a licensed RN and/or physician should be the clear organizer in initiating and leading Code 5 procedures.
  • The current policy of permitting police to enter patient care areas with firearms should be discontinued immediately.
  • Clear policy addressing when and how to involve police in clinical matters, needs to be developed. PGH should secure and employ their own security personnel to support clinical staff in addressing physically dangerous behaviors.
  • All patient-oriented materials should be available in languages other than English. Interpretive services should be offered in non-English languages in a timely manner.


Administrative Structure


In general, the administrative structure was found to be intact. There was one identified area of concern:

  • Current need to fill three Unit Manager positions, one for each unit


Short-Term Corrective Action

The following plan corresponds with the concern identified above:

  • Active recruitment of three Unit Managers should be continued until all positions are filled.
  • Active recruitment of all open clinical positions should be continued until filled and staffing is adequate to meet the treatment and safety needs of patients.


Staffing Criteria


A specific staffing plan does exist in policy. However, an area of concern was the following:

  • No documentation demonstrating how this plan is actually operationalized, and how acuity was used as a key factor in determining shift-by-shift staffing patterns.


Short-Term Corrective Action

The following plan corresponds with the concern identified above:

  • Develop a system that ensures ongoing documentation of how staffing plans are operationalized, and of how acuity is used to determine shift-by-shift staffing patterns.


Restraint Policies/Seclusion & Restraint Logs


Review of the Hold and Restraint charts and logs revealed that holds and restraints identified in the charts were inconsistently documented in the logs. Also, the charts did not meet “Substantial OAR Compliance” in accordance with OAR 309-033-0730 in the following areas:

  • Type and quality of documentation regarding specific behavior which led to use of seclusion and restraint
  • Type and quality of documentation regarding methods used and patient’s response to intervention
  • Lack of documentation regarding reason seclusion and restraint was used over other less restrictive options
  • Lack of documentation of seclusion and restraint events being reported to Health Care Supervisor on daily basis
  • Lack of documentation of Quarterly Seclusion and Restraint Committee reviewing appropriateness of all seclusion and restraint episodes and of reporting findings to Health Care Supervisor
  • Seclusion and restraint orders written for duration of time rather than around specific observable behaviors; lack of documentation of patients being released from seclusion and restraint “as soon as it [was] reasonable to assume that the behavior that caused the use of restraint [would] not immediately resume if the person [was] released”


Short-Term Corrective Action

The following plan corresponds with the concerns identified above:

  • Clinical records should demonstrate 100% compliance with documentation of holds and restraints in hold and restraint logs.
  • Clinical records should meet all criteria for “Substantial OAR Compliance.”
  • Clinical records should demonstrate 100% compliance with HCFA rules, particularly as it relates to face-to-face assessment for seclusion and restraint.
  • Evidence of seclusion and restraint training provided to all clinical personnel should be clearly documented. Yearly re-training of staff on seclusion and restraint protocols should also be documented.


Chart Audit of County-Sponsored Clients


Chart audit revealed that clinical documentation was grossly intact. Progress notes appeared adequate and seemed to correlate with initial assessment and treatment plans. Doctors’ orders appeared to be accurately transcribed in a timely fashion. Medication logs seemed to be in order, and Quality Assurance reports addressed medication errors and proposed strategies for remedying these errors.


However, a few areas of concern were also identified, as follows:

  • Short- and long-term goals sometimes missing from master treatment plans
  • Appropriate credentials sometimes lacking in handwritten progress notes
  • Documentation demonstrating patients seen by physician daily, intermittent
  • Patient signatures often absent from treatment plans


Short-Term Corrective Action

The following plan corresponds with the concerns identified above:

  • Short- and long-term goals should consistently be documented in master treatment plans.
  • Appropriate credentials should consistently be affixed to progress notes.
  • Patients should be seen by a physician daily.
  • Patient signatures should consistently be attained on all treatment plans.



Staff Interviews


A total of three PGH charge nurses and one mental health therapist were interviewed, in the presence of a clinical supervisor. The concerns identified by the interviewees are the following:

  • All three charge nurses expressed inconsistent adequate staffing to ensure patient and staff safety
  • At least one interviewee informed a supervisor and Administration of inadequate staffing patterns through a Quality Management form, and still did not see improvement in staffing patterns
  • One charge nurse described situation in which s/he was unable to address a patient’s medical issues during entire shift, due to understaffing problems


Short-Term Corrective Action

The following plan corresponds with the concerns identified above:

  • Staffing patterns should be based on census and acuity, such that individual needs of patients are met within appropriate and medically necessary timeframes.
  • Analysis of staffing patterns should be a continuous quality improvement activity.


Summary Statement

Based on the findings contained in this report, the Multnomah County Department of Community and Family Services, Behavioral Health Division, expects a plan from Pacific Gateway Hospital, to address the corrective actions recommended herein, within five (5) working days of receipt of this report. This plan should detail specific implementation steps to be used in achieving the corrective actions. It should also include short-term timelines within which the corrective actions will be completed.


Until receipt of the corrective action plan and successful implementation of said plan occurs, the following will ensue:

  • DCFS will suspend admission of County-sponsored patients.
  • DCFS has implemented an acuity review and planful transfer of any current County-sponsored patients.
  • DCFS is conferring with the State Health Division, and the State Mental Health and Developmental Disabilities Services Division.
  • DCFS will provide technical assistance, as appropriate.