Patient Suicide at Bay Area Hospital Could Bring Federal Probe of County Facilities

A patient suicide at a troubled psychiatric hospital here Dec. 2 -- the second death at the facility in the last few weeks -- could trigger a federal investigation of the entire county public hospital system, according to a state health official.

Barbara Gagne, district administrator of the licensing and certification division of the state Department of Health Services in Berkeley, said she has recommended that her office send investigators to examine the operation of the Alameda County Medical Center for the federal government.

Currently, state health officials are conducting their own investigations into two recent deaths at John George Psychiatric Pavilion, an 80-bed locked facility, which is part of the medical center. On Nov. 19, Dr. Erlinda Ursua, 60, the hospital’s lead internal medicine physician, was killed, allegedly by a patient she was examining. On Dec. 2, a 38-year-old patient, Mark Oyarzo, hanged himself with a shoelace in his room.

“We notify the federal government if we think things are problematic enough,” Gagne said. “The amount of publicity they’ve gotten, the incidents of deaths happening in the same unit in such a short time, you say, ‘what’s going on?’ ”

And although her office is investigating each death separately, Gagne said, “You also have to stop and think if there’s any correlation.”

If the federal Centers for Medicare and Medicaid Services agrees to Gagne’s request, the state health department would conduct the survey, which would probably include nursing operations along with any other aspects of the facility’s procedures that the federal agency requests.

The California Division of Occupational Safety and Health earlier this year imposed $30,000 in fines against the medical center related to injuries to two nurses by patients at the psychiatric hospital and for inadequate injury-prevention measures there. The medical center is appealing. Cal/OSHA is also investigating the physician’s death.

Between December 2002 and April 2003, 15 assaults at the psychiatric hospital were reported to the state health department. The medical center told the state that 94 “violent gestures” occurred at the facility in 2002.

Two days after the suicide, Efton Hall Jr., the interim chief executive officer of the medical center, issued a memo saying that he had ordered “an intensive review and analysis” of the problems facing the psychiatric hospital. He put the medical center’s director of quality and compliance in charge of making any “changes to the structure, leadership and operational aspects of care” to the psychiatric hospital she deems necessary.

In addition, he hired Brown & Raleigh, a San Francisco public relations firm specializing in crisis communications in hospitals, at $175 per hour for 50 hours to answer media queries.

Hall has declined to return calls. At Hall’s direction, Mary Ferguson, administrative director of quality and compliance for the medical center, referred all questions to the public relations firm.

Board of Supervisors President Gail Steele criticized the hiring of the public relations firm, saying: “I just don’t like spin. I think the public can understand what is right and what isn’t right. I just have a visceral dislike of PR.”

Jeff Raleigh, a partner in the public relations firm who serves on the San Francisco General Hospital board, said the medical center’s spokeswoman left her job last week, creating a void.

In addition to putting Ferguson in charge of any changes at the psychiatric facility, Raleigh said the medical center is requiring that 10 more nurses, or two per shift, be placed on duty. After the physician was killed, the medical center immediately asked the Sheriff’s Department to assign two deputies to the facility around the clock.

Sheriff’s Capt. Gary Schellenberg said the deputies only patrol the hospital’s common areas, and were not in a position to prevent the suicide in the patient’s room.

He said the deputies walked through the hallway that passes the patient’s room several times the day he hanged himself. The door to the room is recessed about 6 feet from the hallway and has a small observation window, but deputies do not look inside.

Schellenberg said the patient was under a suicide watch and a “danger to others” watch and hospital staff members were supposed to be checking on him every 15 minutes. Staff members were to sign a log to document the checks, Schellenberg said.

Schellenberg said there may have been a gap of time when the patient wasn’t checked every 15 minutes between 2 and 3:45 p.m. on the day he died. “It was reported to me that the log showed nobody had signed off every 15 minutes” during that time, he said.

But the checks are documented after 3:45 p.m., he said.

“The records state he had been checked every 15 minutes from 3:45 p.m. until the body was found about 5 p.m.,” Schellenberg said.

Raleigh disputed Schellenberg’s version of events, saying that the patient who killed himself was not on a suicide watch.

“He was being watched as all patients are being watched,” he said. “What is under investigation is that the best way to watch that patient.”

“He was considered a danger to other people,” Raleigh said.

Oyarzo was brought to the psychiatric facility Nov. 27 by Hayward police because he was considered a danger to himself and others, according to sheriff’s Lt. Michael Hart.

Hart said Oyarzo was found with a shoelace wrapped around his neck.

“We do have a policy of taking away shoelaces and other things,” Raleigh said.

Another patient, a 35-year-old woman with a history of suicide attempts, hanged herself at John George facility in April 1998, a review of the state health agency’s file on the facility revealed. She was hanging from a sheet placed in a gap in a poorly constructed toilet stall.

A year later, in July 1999, a woman patient was found hanging in the bathroom with a gown tied around her neck.

She was cut down and resuscitated. The stalls still hadn’t been repaired, according to the state health department inspection report.