Patient’s death points to persistent problems at Oregon’s state mental hospital
By Michelle Cole, The Oregonian
March 16, 2010, 9:45PM
The body of Moises Perez, 42, was discovered in this bed located just to the left of the door of a room he shared with four other men. The Oregon State Hospital patient had been dead several hours before he was discovered during evening medication checks.T he last time anybody can be sure that they saw Moises Perez alive was about 7:15 a.m. Oct. 17.
A nurse at the Oregon State Hospital saw Perez lumbering down the hallway in Ward 50 F, a medium-security unit inside the state’s mental hospital.
He seemed, the nurse told police, “just like he always was.”
Diagnosed with chronic paranoid schizophrenia, Perez had been institutionalized for nearly 15 years. In that time, he’d developed physical problems often linked with powerful psychiatric drugs and years spent behind locked doors.
At 5-foot-8, Perez weighed 300 pounds, had high blood pressure and was at risk for diabetes. He was 42 and in terrible shape.
So nobody was shocked that Perez died later that day. The shock came in knowing he died in a room across the hall from the nurses’ station and nobody discovered his body for several hours.
His death, according to public records gathered by The Oregonian, points to serious problems that persist at the Oregon State Hospital despite multiple outside reviews, the threat of a federal lawsuit and millions spent on hiring and other improvements.
Police concluded that no crime had been committed. The state medical examiner ruled Perez died of coronary artery disease. Still, his case prompted a sharp rebuke from the U.S. Department of Justice, which had threatened federal legal action two years ago if the state did not address the abysmal conditions at the same hospital where “One Flew Over the Cuckoo’s Nest” was filmed.
After reviewing Perez’s hospital records, Shanetta Cutlar, head of the department’s special litigation section, sent Oregon a warning letter that said Perez received care that “consistently fell well below constitutional and statutory standards.” What’s more, Cutlar wrote, the hospital has systemwide deficiencies that could cause “serious harm or death in other situations.”
Perez’s family has declined to talk to the reporters. But public records and interviews paint a picture of a closely knit family that stood behind a young man, even in the worst of times.
Born in Cuba, Perez immigrated to the United States with his family in 1982, when he was 15. He was the third of four children and the only son. He had a clubfoot that was corrected surgically but that left his right leg shorter, leading to a life of chronic back and foot pain.
His mental illness surfaced during his late teens. Perez was hospitalized multiple times, returning home to a small apartment on his parents’ property in Woodburn. His mother, Dora Perez, cooked his meals and did his laundry.
Just before Christmas 1994, 27-year-old Perez suffered a violent break. He had been unable to sleep since his release from the hospital two days prior. His mother told police she felt sorry for him: “He looked anxious and nervous and scared.”
She was cooking breakfast when he attacked. Perez punched his mother, cut her and bit off four of her fingers. She thought he was hallucinating. “He’d never done something like that before,” she said in a police report.
Later, Perez asked a Woodburn policeman to “shoot him” and “tell the other officers that he tried to get away.”
He was found guilty except for insanity of attempted murder and assault. Instead of prison, the court placed him under the jurisdiction of Oregon’s Psychiatric Security Review Board for a maximum of 40 years.
Dora Perez filed a federal civil rights lawsuit against the doctor, the private hospital and Marion County. The suit, which ended in a settlement, claimed that Moises Perez had been discharged before his medication took hold.
Dora Perez’s lawyer, Les Swanson, said the 1995 case is among the few he won’t ever forget.
Dora Perez forgave Moises, Swanson said. “This was a mother who had an ill son and who loved him very much. She understood that he did not do this voluntarily but it was a result of his illness.”
Perez’s family routinely visited him at the Oregon State Hospital, where he lived on the third floor of a beige building that from the outside resembles a 1970s college dorm.
On weekdays, Perez spent much of his day watching game shows on the giant-screen TV. “The Price is Right” was among his favorites.
But Oct. 17 was a Saturday, and there were no game shows on. Nurses, staff and patients told investigators they didn’t think it all that unusual when Perez stayed in bed.
He could be a difficult patient. Perez often refused to take a bath unless staff bribed him with a soda. His slovenly eating habits got him barred from the ward’s main dining room. That meant he ate alone from a tray set up elsewhere.
Acknowledging that Perez was difficult, the Department of Justice’s review of his medical records still criticizes the hospital and staff for the care Perez received.
Federal officials note that from April 30 until his death on Oct. 17, Perez’s medical file contained only two recorded blood pressure readings in nurses’ notes.
Doctors had identified his risk for diabetes, but Perez was not regularly monitored for the disease. He also refused his psychiatric medications at times. Federal officials described his contact with his psychiatrist as “infrequent” in the months prior to his death — once in July and once in September.
Federal officials also question whether Perez actively refused medication or simply didn’t show up at the appointed hour to get his pills.
His file contained no nursing notes for the 10 weeks leading up to his death despite the fact that hospital policy requires nursing notes on each patient at least once every four weeks.
On the day he died, Perez didn’t wake up and have lunch. He was scheduled to receive medications at 4 p.m. but did not show up at the medication window near the nursing station. An aide told police that he called out to remind patients to come for their pills. When Perez failed to show, the aide wrote an “R” with a circle around it in his chart to indicate that Perez had refused his meds.
Perez shared room 379 with four other men. His bed was just to the left of the door. Police reports indicate patients and staff were in and out throughout the day.
Staff later noted it was odd that he did not show up for dinner at 4:30. But it wasn’t until 7:35 p.m. that staff tried to wake him up for medications. That’s when they discovered Perez, who lay covered by two thin hospital blankets, had died. They called his family and then the police.
Perez’s death has prompted some advocates and state leaders to ask: Has the hospital changed at all?
On Thursday, a newly formed hospital advisory committee is expected to question hospital Superintendent Roy Orr about the death and the Department of Justice letter.
During a recent interview, Orr said he was surprised by suggestions from federal officials that conditions at the hospital have not improved. Those same officials visited in July and “they all said it was clear to them that we’d made progress,” he said.
Since the federal government issued its scathing report in 2008, Oregon has broken ground on a $250 million hospital. Lawmakers have committed more than $60 million to hire more than 500 new employees. Officials are pushing a “continuous improvement” plan that addresses everything from patient aggression to electronic record-keeping.
Still, Orr concedes, “Mr. Perez’s death was a real opportunity for us to zero in on changes.”
The hospital has revisited its policy on what to do when a patient refuses medications.
Because people with severe mental illnesses die, on average, 25 years earlier than those without mental illness, doctors are paying more attention to a mental patient’s physical well-being.
And since Perez’s death, the hospital has changed its rounds policy. From now on, for each hour a patient is in bed, staff is required to “confirm patient viability” through observation, touch — or the sound of breathing.
— Michelle Cole