'Floor-assisted restraint' led to Shipman's death

DHS report shows Glenn Shipman Jr. died after being held face down on hospital floor

By Darryl Swan

The South County Spotlight, Dec 4, 2007, Updated Oct 30, 2009 (8 Reader comments)

Jim Clark / Portland Tribune

A state medical examiner has ruled that Glenn Shipman Jr. (top) died of asphyxiation three days after being admitted to Legacy Emanuel Hospital & Health Center in August. Investigations since then have pinned his death on the unmonitored use of a nontypical form of restraint and identified other areas of concern.

ADVERTISEMENTS

Hospital and security staff with Legacy Emanuel Hospital and Health Center in Portland made several critical errors in their management of Glenn Shipman, and bear significant responsibility for the 50-year-old Scappoose man’s death last August.

A report furnished by the Oregon Department of Human Services on Shipman following a complaint by the federal Center for Medicare and Medicaid Services revealed that Shipman was restrained by hospital staff in a manner counter to procedure: face down, arms crossed under his chest, and with force applied to his back.

There were other causes, follies that include emergency hospital staff responding to a wrong, locked door while trying to reach Shipman after he had stopped breathing, and a failure to supervise Shipman’s life signs during his restraint.

A witness — unnamed in the report — finally noticed that Glenn’s hand was turning blue after he had been restrained for 10 minutes, trigging life-saving measures. When security and hospital staff turned his head to the side, they discovered his tongue hanging out, according to the report. His face had turned blue, he had no pulse and was not breathing.

A responding nurse was untrained in how to retrieve emergency medication for Glenn, who was diagnosed with a schizoaffective disorder, from an automatic dispensing machine.

The hospital denied a witness report finding that it failed to have a “code cart,” or a mobile tray unit that contains life-saving supplies, on the Behavioral Health Unit where Glenn was housed. The report states that one had to be brought up from the hospital’s Burn Unit, a three-minute elevator ride.

A hospital spokesperson did not return a page prior to press time Tuesday, though in earlier discussions the spokesperson said the hospital is restricted from commenting on the ongoing investigation.

Elaine Shipman, Glenn’s mother, said the investigative report, which was obtained by Peter Korn of the Portland Tribune, confirms what she had suspected since receipt of her son’s death certificate.

“As soon as the funeral home dropped off the death certificate, I knew,” Elaine said.

Elaine, 76, had formerly worked as a medical technician for Kaiser Permanente. Part of her job was reading medical reports to determine patient eligibility for various assistance programs.

The hospital reported to Elaine and Jim Morud, a friend of Glenn’s, that Glenn had died from a cardiac arrest, or stoppage of the heart. The death certificate reported “compressed asphyxia,” or asphyxiation.

The Multnomah County District Attorney’s Office had subpoenaed Glenn’s medical records for review, though no charges have been filed. Elaine said she was growing increasingly frustrated with that investigative effort.

“I’m not sure they’re doing anything about it,” Elaine said.

In a Spotlight article published Nov. 14, a detective with the Portland Police Bureau said the records were being held under confidential review.

Morud said the DHS report provides a different characterization of the events leading up to Glenn’s death than what hospital staff had provided at an Oct. 23 meeting. Initially, Morud said he believed the hospital was being forthcoming.

“Now I can see it more clearly,” Morud said. “They were very guarded.”

Since the results of the Sept. 19 complaint probe, Legacy Emanuel Hospital and Health Center has lost its Joint Commission accreditation. The Joint Commission is a nonprofit accreditation agency used by 15,000 hospitals nationwide, and provides a sort of a stamp of approval for healthcare organizations that demonstrate a commitment to certain performance standards.

It is one of the components needed for a hospital to participate in Medicare and Medicaid programs.

After losing Joint Commission coverage in Oregon, immediate hospital oversight falls to DHS.

Restoration of Joint Commission accreditation occurs when the offending hospital installs corrective actions following an investigation, said Ron Prinslow, the DHS manager for the Health Care Licensure and Certification Department that conducted the investigation.

Prinslow said that, while rare, an investigated hospital that does not correct the identified failures could have its license revoked.

“The only authority we have is just a really big hammer,” Prinslow said. In 21 years in his office, Prinslow said he can recall only three instances where smaller hospitals had their license revoked.

The Office of Medicare and Medicaid could also halt Medicare payments to the hospital, or could cease allowing admissions.

Had the actions leading to Glenn’s death occurred even a year earlier, there is a good likelihood the truth about the circumstances leading to his death never would have been brought to light.

Earlier this year, a new federal requirement became effective requiring all Medicare and Medicaid participating hospitals to report restraint-caused deaths to the Office of Medicare and Medicaid Services.

1 | 2 Next Page >>