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Report: Oregon mental health hospital failed to stop suicide

September 12, 2018

PORTLAND, Ore. (AP) — A patient died by suicide at a troubled Portland mental health hospital two months after investigators told the facility that it was failing to protect patients, according to an inspection report.

The state Health Authority inspected the Unity Center for Behavioral Health in late July on behalf of the federal government, finding many of the same deficiencies identified in an initial inspection in March, The Oregonian/OregonLive reported this week.

Investigators in the report focused on one example of when the facility’s policies failed to stop a patient from killing herself.

A patient admitted to the facility in early July was assessed as being at high risk of suicide, according to the report released Monday. Staff recommended that the patient be checked every 15 minutes and that her bathroom door should stay locked. Only paper scrubs and an anti-suicide blanket were instructed to be given to her.

A housekeeper found the patient dead in the bathroom on July 11. Video footage showed the patient carrying linens and clothing in and out of the bathroom multiple times that morning.

Investigators determined the patient’s bathroom door had never been locked, according to the report. The facility’s internal review into the death was started but never completed.

Another patient attempted suicide with clothing and bedsheets 12 days later. Investigators attributed the matter to similar inconsistent or incomplete directions on the patient’s medical forms.

“Our job is to ensure effective treatment of patients and safety of patients and staff members, which is why we initiative these investigations,” said Andre Ourso, administrator of the state Public Health Division’s Center for Health Protection. “We will monitor this situation closely to ensure compliance with state and federal requirements to address all the issues we identified.”

The facility intends to have an improvement plan in place this week to satisfy investigators, Unity President Trent Green said.

“We are trying to deinstitutionalize psychiatric care in this community and treat every patient with the respect and dignity they deserve,” Green said.

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Information from: The Oregonian/OregonLive, http://www.oregonlive.com

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