State hospital psychiatrist reassigned to "non-patient" duties following investigation of patient's death; superintendent forced to resign

April 9, 2010

A shakeup is continuing at the Oregon State Hospital in the wake of a state investigation that found the hospital neglected a patient who died at the Salem psychiatric facility last fall.

Dr. Michael Robinson, a psychiatrist who oversaw the treatment of Moises Perez on hospital Ward 50F, has been reassigned to nonpatient duties, Patty Wentz, a spokeswoman for the state Department of Human Services, said Thursday.

Robinson, who has worked at OSH since September 2001, was given new duties Wednesday, pending the outcome of a follow-up investigation by the hospital's human-resources department, Wentz said.

Interim hospital superintendent Nena Strickland said the HR investigation would scrutinize the job-related performance of "all of the staff and managers who had an impact on the care of Mr. Perez on 50F."

After the HR review is finished, potential personnel actions could range from disciplinary action to additional training, education or coaching, Strickland said.

Perez was found dead in his hospital bed Oct. 17.

A five-month investigation by the State Office of Investigations and Training determined the hospital neglected Perez by failing to provide him with adequate medical care.

Investigators reported that Perez's caregivers on Ward 50F failed to properly treat his chronic medical conditions, failed to develop a "meaningful" treatment plan for him, failed to update his medical chart with notes about his condition and failed to return calls from his family in the last weeks of his life.

Perez reportedly was shunned by other patients because he had poor hygiene. He ate meals by himself, rarely left the ward or took part in activities, refused his medications because he thought they were killing him, and spent much of his time sleeping, according to the report.

An autopsy determined that Perez, 42, died of coronary artery disease.

Hospital Superintendent Roy Orr was forced to resign last Friday, the same day the state released the report documenting flaws and failings in Perez's care.

State Human Services Director Bruce Goldberg told the hospital's advisory board Wednesday that new leadership was needed to bring "a greater sense of urgency" to the state's push for better patient care.

A national search will be launched to seek Orr's replacement, Goldberg said.

Meanwhile, hospital officials plan to assign another psychiatrist to assume Robinson's patient-care duties on Ward 50F.

Robinson's new duties consist of reviewing patient medical charts.

"One of the issues brought up by the OIT report is making sure we have the progress notes in the charts and that people are charting the medical information correctly," Wentz said. "So he's going to be looking at that."

Source: Alan Gustafson, "Doctor associated with patient's death reassigned," Statesman-Journal, April 9, 2010.