Sales pitch for Portland’s mental health ER omitted numerous red flags

From the Oregonian, February 5, 2020

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Safety violations and patient overcrowding have long plagued a California psychiatric hospital that served as an inspiration for Portland’s Unity Center for Behavioral Health, suggesting that some of the trouble local hospital leaders continue to face should have been foreseeable.

In 2014, Oregon hospital officials began eagerly promoting the California endeavor, dubbed the “Alameda Model,” as a humane, compassionate alternative that could be adopted in Portland to better treat mentally ill people.

What apparently went unspoken during their sales pitch to local leaders: Numerous red flags at the California center, culminating in a high-profile safety battle between nurses and hospital administrators only a few months before Unity opened its doors in early 2017.

The troubles in California are coming into sharper focus only now, as Unity struggles to remain financially solvent and complains of crowding so intense that it is always at capacity in its ER. The latest problems at Unity follow state and federal investigations in 2018 that revealed incidents of sexual assaults, neglect and even two preventable deaths. Unity is now asking the state for more money to help address its staggering operating losses.

Mentally ill patients wait days for room at Portland psychiatric ER, as leaders say it’s in ‘crisis’

Unity Center for Behavioral Health is now in “crisis,” according to the psychiatric facility’s top medical official, intensifying concerns about a troubled facility that claims it is hemorrhaging money.

The ongoing challenges at Unity echo several issues in California, raising important questions about the underlying premise behind the Unity Center and how it was supposed to benefit vulnerable patients.

Alameda Health System, which operates the California facility, declined to say if its officials told Portland hospital leaders about their challenges during on-site visits to the facility around 2014 or 2015. Because of staffing turnover, tracking down an answer would be difficult, an Alameda Health spokeswoman said.

Officials for Legacy Health, which spearheaded the Portland project, declined to say if they knew about problems in California or shared them with key decision-makers and dignitaries locally.

A former nursing supervisor at the California psychiatric facility told The Oregonian/OregonLive this week that he remembered pulling aside a Portland hospital official during their tour, hoping to temper excitement about the Alameda model.

“I pulled her into a room and I told her, ‘Look, this is bulls—, this is dangerous,’” said Fred Tatum, who worked as a nurse manager at the facility for four years, until 2018. Tatum said he was fired by the hospital in retaliation for raising safety concerns.

Officials and advocates in Portland say concerns about the California model never made it to them.

“I would’ve liked to have known,” said Multnomah County Commissioner Sharon Meieran, who advocated for Unity before she was elected to the county board.

“I don’t know if they knew or not,” Meieran said of Legacy officials, “but they absolutely should have known and they should have done something.”

To be sure, the problems at the Unity Center and the California facility are similar but not identical, and psychiatric facilities often treat volatile patients. Both have extensive reports of patient and staff assaults. But the Unity Center’s recent issues with constant crowding have been blamed on an inability to move patients to the Oregon State Hospital for longer-term care. Many of the challenges in California have been linked to overcrowding in the facility’s psychiatric emergency room, which sometimes admits twice as many patients each day as Portland.

Legacy officials who operate the Unity Center said a planning team not only researched best practices but visited and “looked closely at several facilities,” including the California hospital.

“Ultimately the model implemented at Unity Center was based upon local expertise and the knowledge of our unique community needs,” Legacy spokesman Brian Terrett said in a statement. “The safety of Unity Center’s patients and staff is our highest priority.”

Alameda Health System said steps have been taken to reduce overcrowding by increasing the number of psychiatrists, working with community agencies and restricting some psychiatric patient transfers from regional emergency rooms. However, the health system did not directly address patient safety issues in its comment to The Oregonian/OregonLive.

“Alameda County has embraced a ‘culture of care’ when dealing with individuals who are experiencing a behavioral health emergency,” spokeswoman Jeanne Herrera said in a statement. “John George Psychiatric Hospital is proud to be a part of that culture, of getting individuals who may do themselves or others harm into appropriate care as opposed to being held in medical emergency rooms, county jails, or left on the streets.”

California hospital example was convincing

The John George Psychiatric Hospital opened in 1992 and became a regional clearinghouse for people in Alameda County in need of acute psychiatric care. The facility includes a specialized psychiatric emergency room for up to 24-hour care, with recliners and benches, plus an in-patient branch with 69 beds for patients needing longer-term treatment of up to about a week.

The project began receiving national attention in response to a 2013 study co-authored by Scott Zeller, who at the time was Alameda’s chief of psychiatric emergency services. The study argued that it would be cheaper and faster for hospitals to treat psychiatric patients in a single specialized facility, like John George, than in hospital emergency rooms across the region.

In Oregon, Legacy officials took notice.

Officials proposed consolidating psychiatric services under one roof for Legacy, OHSU Hospital, Adventist Health Portland and Kaiser Permanente. The facility in Northeast Portland, near the Moda Center, now features a psychiatric emergency room with about 40 recliners for up to 24-hour stays and an in-patient branch with 107 beds for longer-term needs – a near replica of John George’s set up.

As part of their pitch, local hospital officials created presentations highlighting John George as a success. They noted that three-quarters of patients at John George were discharged from the specialized emergency room and avoided “unnecessary hospitalization.”

“We feel this is a new model that will address the needs of individuals,” Chris Farentinos, the former Legacy behavioral health director and first head of Unity, said in a presentation to a community board on policing reforms in 2015.

Legacy officials even organized a trip to California to help sell the concept.

Meieran tagged along. An ER doctor and budding mental health advocate, she jumped at the chance to visit John George as part of a tour with Legacy and OHSU officials.

Not yet elected to the county board, Meieran said she paid her own way for one day of a two-day tour in 2014.

What Meieran saw and heard was convincing. She remembers an Alameda Health official telling the group that they used no restraints on patients and had no violence.

The Alameda officials admitted to bumps in the road at the beginning — use of restraints had gone up initially, for instance. But Meieran and the others were assured that those problems had been figured out.

“It was so inspiring and hopeful,” Meieran said. “Going from this horrible system we have where we’re torturing people essentially to going to this model where we can help people heal.”

After the tour, Meieran became an enthusiast and adviser to the project even though she never held a decision-making role. She spoke at public meetings independently and backed up Legacy officials’ presentation, saying that she had seen the model and believed in it.

Meieran said she didn’t learn about issues at John George until approached by The Oregonian/OregonLive this week.

Problems made headlines

John George’s regulatory troubles stretch back at least until 1998, according to media reports. Documented problems were still mounting in 2004, when a patient beat a doctor to death at the facility.

Regulators documented more workplace safety violations in 2009 and 2010, federal records show. Then, in late 2015 — about a year before Unity opened in Portland — problems exploded publicly.

Staff wrote an open letter in November 2015 saying the psychiatric emergency room was in a “crisis of its own.”

“The lack of transparency and dishonesty about the feasibility and practical repercussions of the

Alameda Model has disallowed a larger, necessary conversation about what happens to Alameda

County’s neediest patients,” the letter read.

News reports soon described mass overcrowding in the psychiatric emergency room that led to dangerous situations, including assaults.

A TV news crew separately obtained undercover videos showing what was described as “appalling conditions” with patients sometimes sleeping on the floor in the psychiatric emergency room.

County leaders acknowledged overcrowding issues and worked publicly to find solutions.

But problems remain to this day.

Investigators for the California Department of Public Health have cited the facility about 15 time for continued patient safety issues since 2015, records show. In 2018, John George administrators had to send a letter to hospital employees reminding them that they are required to investigate and report allegations of sexual assault among patients.

State investigators found several patients in the past few years had made credible claims about being groped or penetrated without their consent that were not properly examined by staff, according to documents obtained by the newsroom through a public records request.

Media reports continued into 2019, highlighting more than six dozen instances of violence against staff over the past year.

One high-profile incident led to a $11,250 fine in 2018 for failing to protect employees. In that case, a patient with a documented history of violence at John George, admitted under an alias, punched an employee in the face and slammed the employee’s head into the ground, according to public records obtained by The Oregonian/OregonLive.

The employee was knocked unconscious and suffered a seizure, records show.

State workplace safety inspectors issued another proposed fine, of $19,125, at the end of 2019. The facility lacked a written policy for communicating important patient information between staff, according to records obtained by The Oregonian/OregonLive. Staff didn’t communicate a patient’s mental status to one another, and the patient didn’t receive anti-psychotic medication as scheduled. The patient, who had a history of violence toward staff, pounded a nurse in the head and elbowed another staffer in the mouth in June 2019.

Hospital officials are contesting the fine.

In all, California’s Division of Occupational Safety and Health has conducted 19 on-site inspections and issued 20 citations tied to John George since 1993, a spokesman said. Since 2000, related fines actually paid by the hospital have totaled more than $50,000.

Cal/OSHA spokesman Frank Polizzi said that the psychiatric hospital industry is considered high-hazard in California because of the injury rate.

Rachel Odes, a nurse at John George who works in both the emergency room and the in-patient wing, told The Oregonian/OregonLive that problems continue, even after steps were taken to restrict emergency room admissions from as many as 80 patients to 50.

Odes said she has personally witnessed many assaults, including patients punching other patients in the face and attacking older staff members. Odes is listed in state records as a witness in to the June 2019 assault.

Rather than a therapeutic environment, she said, patients awaiting admission from the emergency center to the in-patient facility are left with others in mental health crisis inside an open living-room concept, sometimes for longer than a day.

“It’s 36 hours where they don’t have a bed, can’t close the door, they can’t turn the lights off,” Odes said of John George. “That’s the big lie of it. What do those hours actually look like?”

Ann Kasper has first-hand experience with John George and Unity Center.

The Portland mental health advocate said she visited John George a few months after Legacy’s tour, as part of her research to make suggestions about how Unity should be designed. Kasper has been in and out of mental health facilities and was part of several committees that helped guide Unity decisions before it opened.

She was so disturbed by her visit, she had trouble getting out of bed the next day.

Kasper said she saw patients share plates of food because there wasn’t enough for everyone. There were too many people packed into one room and the recliners were too close together. Everyone was on top of each other and the room wasn’t inviting.

Kasper said she later told a Legacy official about her concerns with the Alameda Model, but nothing ever came of that conversation.

Later, she told a state committee that created rules to allow Unity to open about her concerns at John George. She pushed for Unity to admit fewer people in the emergency room and build more space in between recliners.

Kasper said she has been treated at Unity a few times, most recently Jan. 15. She still sees problems with the way Unity is designed, but said she doesn’t feel as bad there as she felt at John George.

“Being put in a room without barriers,” she said of Unity, “with 40 other people, and you’re in the most sensitive time in your life doesn’t work for everybody.”

— Molly Harbarger and Brad Schmidt