Testimony to the OSH Committee
Testimony to the Joint Legislative Committee On Oregon State Hospital Patient Care given by MHAO board member Meghan Caughey on February 20, 2008 to the Co-Chair Senator Courtney and Co-Chair Representative Rosenbaum, Members of the Committee:
My name is Meghan Caughey and I am the Peer Wellness Coordinator of Benton County Health Services. I also serve on the Board of Directors of Mental Health America of Oregon; previously known as the Mental Health Association of Oregon.
I thank you for this opportunity to come before you and speak on behalf of Mental Health America of Oregon, and more succinctly, to try to give voice to the persons whose voices are not being heard on account of their being hospitalized at our state hospital. These issues have a very immediate and profound meaning for me because I know first hand what it is like to be locked up in an institution. Before I entered into the time of my life that I will call my recovery, I was hospitalized over one hundred times, sometimes for months at a time, and I must say that I know firsthand what it is like to be in seclusion and four point restraint, as I have known that condition many times in the past.
There are several areas of the Dept. of Justice CRIPA report that I am going to focus on in my testimony. They are the need for quality and quantity of adequate assessments, the need for adequate treatment, and the necessity for discharge planning that ensures that patients have a timely discharge into an Testimony Submitted to the Joint Legislative Committee integrated setting and that they are provided with the skills and treatments needed so that they will succeed when they return to our communities.
I am speaking on behalf of Mental Health America of Oregon and I need to say that while we on the Board all agree that action must be immediate and substantial in correcting the problems at the State Hospital, there is not total consensus as to whether it is possible to actually effect the level of systemic change we see as being necessary for the problems to be solved in any truly meaningful, non-cosmetic way.
I am personally of a hopeful attitude. I say I am hopeful because I think that we are dealing with, in essence a problem that has a great deal to do with the perception of hope. We currently have to take an environment at the state hospital where some persons are ascribing to a “Culture of Despair “and replace it with a “Culture of Hope”. Giving persons appropriate assessments in a timely manner including the form of person –centered treatment plans is a start, if the clinicians believe that the patients that they are assessing are capable of recovery from their mental illness. Simply stated, recovery might be defined as the person’s ability to live a life which that person finds meaningful and gratifying, which he or she determines themselves, and which is characterized by an inclusive social role in a community of the person’s choosing. The expectation of “recovery” is a profound concept which is communicated from mental health providers to patients through language, nonverbal cues, as well as through therapeutic interventions. This belief and expectation conveys hope and also respect and it is a powerful ally for the patient’s own will and incentive to heal.
Some clinicians and mental health technicians understand this innate sacred quality about their patients and they skillfully nurture it. To them, we all owe our respect and gratitude. For some workers, however, the patients are alien, and hopeless, and the only way they know to relate is to control them. The atmosphere of fear and violence breeds more of the same and a “culture of despair” is the norm.
It is my understanding that in 2006, seclusion or restraint hours for patients were approximately 16,000 hours and in 2007 the number was still an alarming 13,000 patient hours. This says to me that there is still a coercive quality in too many of the staff to patient interactions. Violence is still an acceptable alternative in too many situations. Because of this, I am not convinced that simply adding more staff will solve the problems that still exist at the hospital. It is essential that there be a shift from a culture of fear to a culture of hope. Otherwise, the same maladaptive patterns will just be repeated on a broader scale, with new staff adopting the tone and culture of the old form.
It is important to note that the Dept. of Justice report notes significant concerns with use of seclusion and restraint. Yet, the hospital’s “Crosswalk” document notes that current policies on seclusion and restraint already address these issues and many Projected Results/Targets boxes are, as a result, marked “not applicable.” The Committee should insist that policies, in the absence of demonstrated adherence, are not an acceptable answer. We must see outcomes that demonstrate a culture of dignity, respect, and recovery for patients and elimination of coercive modes of control.
We would like to applaud the “Crosswalk” document, though, for the many thoughtful and deliberate steps that are being taken to address the shocking problems uncovered by the Department of Justice. However, the DOJ report notes that seclusion and restraint and inappropriate use of medications—among other problems—is likely a result of the lack of an appropriate clinical formulations and a consistent and effective standard of care that integrates behavioral plans, discharge planning, medications, and clinical interventions.
The “Crosswalk” notes that for remedial measures B.1.e., f, and g, which refer to assessments, diagnoses and appropriate clinical formulations, and medication regimens, there are no current measures. This is unacceptable—particularly given that these deficits have surely been known for years, if not decades. In other problem areas, proposed targets have no timelines for reaching the goals—or indication of remedial action if goals are not met.
We, along with our partner advocates, propose that this Committee demand quality of clinical care. It is our deeply held belief that a clear and enforceable standard of care is desperately needed to ensure quality care for consumers—and will do much to address problems with inappropriate use of medications and seclusion and restraint.
But we also need to look beyond the walls of the hospital. And we need a new look at what we do with persons who have major mental illnesses. I am curious why Oregon, unlike most states or provinces of other countries around the world that is not only building an institution to replace its existing institution, but also building a new institution in addition to the first one.
Doesn’t it seem that perhaps the institutional setting is problematic in and of itself?
For me personally, the day that I gave up my identity of being a “mental patient” and replaced it with a new identity of who I was as a person, with an identity that was competent, strong, and beautiful, it was a huge day on my personal journey of recovery.
Let us become more creative, and look at the models from around the world where communities such as in Toronto, Ontario, Canada, are finding innovative ways to treat serious and persistent mental illness without building huge institutions.
The CRIPA Report states that we are in violation of Olmstead if we do not accomplish the timely discharge of patients to the most integrated, appropriate setting consistent with that patient’s needs. It also says that we should identify what factors will foster viable discharge and use these factors to drive treatment.
I have to ask: isn’t it possible that being in an institution in the first place is antithetical to what people really need—the institutionalization of persons is very costly fiscally, but it has an enormous cost to a person’s self image and psychological well being and we need to bravely be willing to explore the question of if putting persons in a huge hospital is in their best interest, or if their might not be some options that are viable, if we only are willing to ask the right questions.
Are we willing to ask the really hard questions and just how innovative and bravely do we dare to act?
The CRIPA Report also recommends that the Oregon State Hospital contract with community providers to provide placement on a “non –rejection” basis or implement a state operated system of community operated residential services to help with discharge placements into communities. This would help counter the “not in my back yard” resistance problem, but also what is really needed here is massive anti-stigma, anti-discrimination efforts that we all must work at to bring about change, hope, and greater understanding.
This work is the work of all of us.
The work of making hope thrive is the work of all of us.
The work of creating hopeful environments where people can heal, as is all of our birthright, is a challenge but it is possible.
We must not settle for hundreds of hours of seclusion and/or restraint.
We must not settle for persons being locked up when by law they deserve to be free.
We must act on the side of hope and health; so that all of our fellow citizens and peers can have the environment that they need in order to heal.
They are not here tonight. They are locked up. But we are here. It is up to us.
Because we are free.
Let us act with hope.
Thank you.
Letter to Governor Kulongoski
January 28, 2008
The Honorable Theodore Kulongoski
900 Court St NE
Salem OR 97301
Dear Governor Kulongoski:
On behalf of Mental Health America, the country’s oldest and largest mental health advocacy organization and its affiliate chapter, Mental Health America of Oregon, we are writing to express our deep concerns about the findings of the November 2006 U.S. Department of Justice investigation of conditions and care practices at the Salem and Portland campuses of the Oregon State Hospital (OSH). We are appalled by the report findings and the unconscionable conditions that mental health consumers in these facilities must endure.
As you know, the U.S. Department of Justice (DOJ) cited the OSH campuses for violating the civil rights of these individuals by failing to ensure their safety and provide appropriate mental health treatment. We urge you to address the concerns raised in the DOJ report including the deficiencies found in the five general areas:
1. Adequately protecting patients from harm,
2. Providing appropriate psychiatric and psychological care and treatment,
3. Use of seclusion and restraints in a manner consistent with generally accepted professional standards,
4. Providing adequate nursing care, and
5. Providing discharge planning to ensure placement in the most integrated settings.
These current conditions are unacceptable and we call on the state of Oregon to address these problems immediately. Mental Health America and Mental Health America of Oregon offer the following recommendations:
Persons who use or have used mental health services should be involved in addressing the problems identified in the DOJ report. Specifically, persons who currently/formerly received mental health service participants should be considered as consultants in moving the OSH campuses towards recovery and trauma-informed systems
Funding for community-based mental health services should not be cut or scaled-back because concentrated effort and focus is on the state hospitals.
While constructing new facilities offer some solutions to the physical plant issues raised in the report, we believe that this is a “quick-fix” proposition that does not address the long-term treatment needs of consumers.
According to the 2002 President’s New Freedom Commission Report, effective treatments for mental illness exist including community-based supportive services. In building these new facilities, Oregon should not abandon its financial support of these proven community-based supports.
Oregon should invest more in community-based services instead of constructing new hospitals. While the decision to construct these new facilities can not be reversed, we believe that Oregon should follow the June 1999 United States Supreme Court decision held in Olmstead v. L.C. that the unnecessary segregation of individuals with disabilities in institutions may constitute discrimination based on disability. The court ruled that the Americans with Disabilities Act may require states to provide community-based services rather than institutional placements for individuals with disabilities.
Oregon officials must address the lack of a concrete plan for hospital staffing issues raised by this report. It is imperative that Oregon immediately identify barriers to adequate hospital staffing and develop a concrete, measurable plan for increasing hospital staffing, including any legislation needed to implement plans to attract, train, and retain qualified staff that are committed to recovery-focused state hospital care.
Serious impediments to timely transitions to the community remain a serious problem. Oregon should provide expert assistance to communities to develop community housing for discharging patients. Oregon’s Attorney General should ensure that federal and state laws regarding fair housing are properly enforced to reduce the amount of discrimination that people transitioning from the State Hospital to the Community Face. In addition, Oregon should develop community discharge teams that are engaged in visiting community mental health programs and working collaboratively to ensure successful community placements. Oregon should develop a plan to provide mobile intensive interventions to patients for 90-180 days after their transition to the community in order to support and reduce risk to both patients and community mental health programs.
As stated in Mental Health America’s policy statement, we are firmly convinced that seclusion and restraints have no therapeutic value, contribute to human suffering, and have frequently resulted in severe emotional and physical harm, and even death. Therefore, as a matter of fundamental policy, Mental Health America urges abolition of the use of seclusion and restraints to control symptoms of mental illnesses, and prohibition of the use of sedatives and other medications as chemical restraints. These practices cause trauma, even when used by well-meaning practitioners. To read more about our policy visit: http://www.nmha.org/go/position-statements/24
Mental Health America supports legislation introduced by Senator Margaret Carter for a comprehensive analysis of the mental health service delivery system. As stated earlier, Mental Health America believes that a comprehensive community mental health system is imperative to both minimizing the need for hospitalization and for ensuring successful and timely transitions back to the community.
We urge you to take these recommendations under strong consideration and are willing to be a resource should you have any questions or need additional information.
Thank you for your consideration of these matters.
Sincerely,
David L. Shern, Ph.D., President and CEO
Mental Health America
Beckie Child, Board President
Mental Health America of Oregon
REMONSTRANCES - items from the DOJ investigation of the Oregon State Hospital
Week of February 3rd
Mon, 2/4 Section A. Inadequate Protection From Harm“Patients at OSH have a right to live in reasonable safety. Yet, in our judgment, OSH fails to provide la living environment that complies with this constitutional mandate. Specifically, there is widespread patient-against-patient assault, unchecked self-injurious behavior, and a high rate of falls. In addition, the housing units contain environmental hazards, some of which pose risks of serious injury, illness, and death. The harm OSH patients experience as a result of these deficiencies is multi-faceted, and includes physical injury; psychological harm; excessive and inappropriate use of restraints; inadequate, ineffective, and counterproductive treatment; and excessively long hospitalizations. The facility’s ability to address this harm is hampered by inadequate incident management and quality assurance systems.”
Tue, 2/5 Section A.1. Inadequate Incident Management “The lack of clarity and conformity in OSH’s incident reporting system virtually ensures that adverse events will not be reported or categorized consistently. …As an initial matter, there is no requirement that OSH staff conduct even a cursory investigation of serious incidents. …Even when OSH identifies problematic trends, we found no evidence that adequate or appropriate remedies ensue. …OSH’s failure to take appropriate and timely action to address such trends suggests a pattern of institutional neglect and substantially departs from generally accepted professional standards.”
Wed, 2/6 Section A.2. Inadequate Quality Management “Generally accepted professional standards require that a facility like OSH develop and maintain an integrated system to monitor and ensure quality of care across all aspects of care and treatment. An effective quality management program must incorporate adequate systems for data capture, retrieval, and statistical analysis to identify and track trends. The program also should include a process for developing a corrective action plan and a process for monitoring the effectiveness of corrective measures that are taken. Throughout this letter, we enumerate various failures at OSH to provide adequate care and treatment for its patients. With few exceptions, OSH has failed to identify these problems independently, or formulate and implement remedies to address them. Consequently, actual and potential sources of harm to OSH’s patients are going unaddressed.”
Thu, 2/7 Section A.3. Failure to Provide a Safe Living Environment “OSH also fails to provide patients at the Salem campus with a safe living environment. Indeed, the Salem facility is rife with serious environmental hazards, many of which pose risks of serious injury, illness, and death. These environmental deficiencies exacerbate the deficiencies in patient care and treatment identified throughout this letter. In a facility serving people at risk of harming themselves or others, the environment should be free of physical risks and environmental hazards. …OSH egregiously departs from this generally accepted professional standard of care. …Additionally, OSH’s consultants acknowledge that the physical layout negatively impacts the ability of OSH staff to administer appropriate treatment programs and accordingly, creates a potentially unsafe environment for the patients and staff.”
Week of February 10th
Mon, 2/11 Section B. Failure To Provide Adequate Mental Health Care “OSH patients have a constitutional right to receive adequate mental health treatment. …Psychiatric practices at both campuses are marked by inadequate assessments and diagnoses, inadequate behavioral management services, and inadequate medication management” “…patients’ actual illnesses are not properly assessed and diagnosed; patients are not receiving appropriate treatment and rehabilitation; patients are at risk of harm from themselves and others; patients are subject to excessive use of restrictive treatment interventions; patients are at increased risk of relapses and repeat hospitalizations; and patients’ options for discharge are seriously limited, resulting in unnecessarily prolonged hospitalization, and, with respect to forensic patients, prolonged involvement in the criminal justice system.”
Tue, 2/12 Section B.1. Inadequate Psychiatric Assessments and Diagnoses “In many cases, OSH simply does not conduct initial assessments. “In the instances when they are performed, they often do not identify or prioritize specific mental health problems and needs.” “Patients receive, or are at risk of receiving, treatment that, at best, is unnecessary and, at worst, may actually exacerbate their mental illnesses. All the while, the actual mental illness is unaddressed, placing patients at risk of prolonged institutionalization and/or repeated admissions to the facility.”
Wed, 2/13 Section B.2. Inadequate Behavioral Management Services “Untrained staff lack the skills necessary to handle the large number of very impaired patients who are dangerous to themselves or others or who have specialized needs. …staff effort is focused primarily on controlling dangerous patients rather than treating them and changing their behavior. …This problem is exacerbated by OSH’s failure to provide a centralized system of oversight, review, feedback, and expert consultation, where necessary, to protect patients and ensure that adequate treatment is provided.”
Thu, 2/14 Section B.3. Inadequate Medication Management and Monitoring “OSH’s inappropriate psycho-pharmacological practices have led to the inappropriate use of PRN (pro re nata or “as needed”) medication. …it appears that clinicians prescribe these medications for their secondary sedating effects and as a substitution for appropriate therapeutic interventions. ...Because OSH’s psychiatrists rarely analyze the use of PRN medications and patients’ reactions to them, they cannot refine patients’ diagnoses and adjust routinely administered medications. Without such monitoring, patients are at risk of being overly and/or improperly medicated. This practice constitutes chemical restraint, which violates federal regulations. ...OSH fails to provide any systematic monitoring to ensure appropriate, safe, and effective medication use in the facility. Furthermore, OSH’s medication guidelines, which are the basis of any effective medication monitoring system, are seriously deficient.”
Week of February 17th
Mon, 2/18 (Holiday) Section C. Inappropriate Use of Seclusion and Restraints “The right to be free from undue bodily restraint is the core of the liberty protected from arbitrary governmental action by the Due Process Clause. Thus, the State may not subject residents of OSH to seclusion and restraint ‘except when and to the extent professional judgment deems this necessary to assure [reasonable] safety [for all residents and personnel within the institution] or to provide needed training.’ …OSH’s use of seclusion and restraints substantially departs from these standards and exposes patients to excessive and unnecessarily restrictive interventions.”
Tue, 2/19 Section C.1. Planned Seclusion and Restraint “In practice, planned seclusion/restraint often is the only component of a patient’s treatment plan. It is an unrefined and unlawful strategy that consists of restricting patients to a bedroom or seclusion room for weeks and sometimes months at a time.” …The fact that OSH condones this unconstitutional practice reveals much about the facility’s permissive attitude towards the use of seclusion and restraints.”
Wed, 2/20 Section C.2. Use of Seclusion and Restraint as Informal Alternatives to Treatment and as Punishment. “Indeed, between January and June 2006, OSH staff used seclusion and/or restraints 393 times. On 83 of these occasions, patients were placed in prone restraints, which are dangerous and can be deadly, before being moved to a seclusion room. …OSH’s frequent use of seclusion and restraint supports our finding that many OSH patients have erroneous diagnoses and/or inappropriate treatment plans. The facility’s reliance on seclusion and restraint as treatment strategies is inappropriate, ineffective, extraordinarily detrimental, and, at times, life-threatening.”
Thu, 2/21 Section C.3. Use of Ad Hoc Restrictive Measures “Another concern about seclusion and restraint at OSH is the widespread use of ad hoc restrictive measures such as “suicide suits,” “safety status,” “east end restriction,” “the 10 foot rule,” and “security hold.” These unconventional measures are not defined or described in OSH policy. Rather, they appear to be improvised responses to patient behavior that, over time, have been adopted throughout the facility.”
Fri, 2/22 Section C.4. Failure to Assess Patients in Seclusion and Restraint. “OSH also fails to comply with its own policy and generally accepted professional standards which require staff to constantly observe patients who are in restraints. …In D.I.’s case, she could have choked to death while unsupervised.”
Week of February 24th
Mon, 2/25 Section D.1. Staffing “Generally accepted professional standards require facilities like OSH to provide sufficient nursing staff to, at a minimum, protect patients from harm, ensure adequate and appropriate treatment, and prevent unnecessary and prolonged institutionalization. OSH, however, routinely compromises its patients’ care and treatment by failing to satisfy these requirements. …A recurring issue is that OSH has no formal mechanism with which to analyze the specific needs of each unit and determine the number and skill mix of nursing staff that each unit requires. Instead, nursing staff seem to be assigned to particular units based upon their schedules and availability without serious regard to patients’ needs. …In short, OSH’s staffing shortages fall dangerously below the minimum levels required to provide basic levels of nursing services and care. Unless and until OSH hires, trains, and supervises a sufficient number of nursing staff, patients will continue to receive inadequate care.”
Tue, 2/26 Section D.2. Failure to Provide Basic Care “At OSH, however, nursing staff often fail to provide even the most basic care, opting instead for a reactive approach in which patients’ medical needs are addressed only after problems develop.”
Wed, 2/27 Section D.3. Failure to Provide Feedback to Treatment Teams “Unfortunately, the culture and structure at OSH do not facilitate communication between treatment team members. …both nursing staff and treatment teams respond to patient needs, if at all, in a largely reactive way. Consequently, OSH patients are subjected to excessive and inappropriate uses of medication, seclusion and restraints, and inadequate and ineffective therapeutic interventions.”
Thu, 2/28 Section D.4. Medication Administration “We identified many instances in which staff documented that medication had been given when, in fact, the patient had never received it.” …Indeed, there are numerous examples of staff giving medications to the wrong patients or giving incorrect doses. In some cases, these mistakes had serious consequences.”
Fri, 2/29 Section D.5. Infection Control “OSH’s failure to prevent and control infections in the hospital places patients, staff, and visitors at risk of harm, including death. Indeed, of the 28 patient deaths that occurred between January 2005 and August 2006, 15 were from pneumonia, an infection-related condition. …Other documents noted problems with mice inpatients’ rooms, norovirus outbreaks, scabies outbreaks, and failure of staff to clean up “messes” in seclusion rooms”
Week of March 2nd
Mon, 3/3 Section E. Inadequate Discharge Planning and Placement In The Most Integrated Setting “The failure to provide adequate, individualized treatment and discharge planning for these and other patients deviates from generally accepted professional standards and contributes to extended hospitalizations, unsuccessful community placements, and a high likelihood of readmission. … the facility does not provide the follow-up supports and services that are essential for successful transitions to the community. Patient records rarely discuss the provision of transition supports, and when discharged, patients are ill-equipped to succeed in community placement. ...Patients’ despair, anger, and agitation about having been turned down by community providers become a part of their illness. These and other effects of prolonged institutionalization result in harm or a serious risk of harm to OSH patients.”