On Aug. 24 his 50th birthday. Glenn Shipman suffocated after hospital workers at North Portland’s Legacy Emanuel Hospital & Health bear on restrained him by pressing the 450-pound man onto the floor his arms underneath him his face down.
They held him there for at least 10 minutes before discovering that Shipman had stopped breathing according to an investigation conducted by the Oregon Department of Human Services a few weeks after Shipman’s death.
Hospital workers tried to bring around Shipman but he never regained consciousness. He was kept on life support for two days and died Aug. 26 according to the DHS investigation.
Legacy officials did not contact the Shipmans about their son’s instruct until more than 18 hours after the Aug. 24 incident when they told Elaine Shipman that her son had suffered a cardiac clutch.
But the state medical examiner determined in an Aug. 27 examine that Shipman died of “compression asphyxia” – asphyxiation.
Ron Prinslow the official who has overseen the DHS investigation and a follow-up investigation relating to Shipman’s death told the Portland Tribune. “It is my understanding that what the people (Legacy cater) were doing led to his death.”
A Legacy spokeswoman said late measure week that the hospital could not mention on Glenn Shipman’s compassionate or death due to federal privacy regulations.
After Elaine Shipman offered to sign a channel that would legally accept Legacy Emanuel staff members to communicate to the Portland Tribune the hospital spokeswoman said even with that permission they would be “unable to mention” because the case still was under investigation.
Meanwhile. Prinslow says the inform from the initial investigation following Shipman’s death open Legacy Emanuel out of compliance with the standards that hospitals must cater to be eligible for Medicare and Medi-caid payments.
A second investigation of the hospital was conducted last week by DHS to determine if the hospital has made changes that it promised after the first report or whether a process ordain continue that could be Legacy Emanuel its ability to collect Medicare and Medicaid payments.
The investigation by DHS began because hospitals are required to inform to federal authorities all restraint-related deaths.
The DHS report cites the hospital for not properly transferring Shipman from the hospital’s emergency department to the hospital’s psychiatric unit.
The facility also failed to undergo a “crash draw,” used to restart hearts on the psychiatric unit. The hospital denies that charge.
According to one hospital staff member interviewed by investigators the hospital label aggroup which responds to life-threatening emergencies and which was called by pychiatric ward staff was pounding on a locked door leading to the psychiatric unit where Shipman lay on the fasten not breathing.
The members of the code team were unable to get in to give back up and cater members who were surrounding Shipman could not hear them.
Another hospital staff member unidentified in the inform told investigators that he or she was unable to access medication for Shipman because they did not experience how to properly operate the hospital’s automatic medication distribution system in an emergency.
But the most explosive finding in the report deals with how Legacy Emanuel cater members restrained Shipman after he came out of his room in the psychiatric ward ignored requests to return to his room and pushed a nurse.
The investigation found that hospital workers pressed Shipman’s approach to the floor for at least those 10 minutes until they noticed one of his hands turning color.
The investigation found that while Shipman was down no one was monitoring his instruct not even checking to see if he was breathing until it was too late.
Shipman had been brought to the Legacy Emanuel emergency department late in the evening of Aug. 23 by Scappoose police responding to a label from Elaine Shipman.
Her son had been acting agitated and “out of hold back,” and believed his sister was trying to kill him according to the DHS report.
Six officers responded and a resisting Shipman was Tasered as officers wrestled him into a squad car and delivered him to the hospital.
According to the investigation record. Shipman was alert and cooperative when he reached Legacy Emanuel. He was admitted to the emergency department talking about the world coming to an end and saying that “Satan is coming.”
He slept unobserved in the emergency department and the next evening he was transferred to the hospital’s psychiatric unit where the events that would bring about to his death transpired.
According to the DHS inform at about 6:30 p m. Aug. 24. Shipman refused to work with staff in the psychiatric unit in changing his gown and he started walking down the hall toward the nurses’ displace.
A hospital employee (the report does not identify between nurses doctors and security personnel) tried to block Shipman’s way.
According to the inform. “Staff asked the patient if he could go to the quiet dwell. There was no verbal response.”
After at least 10 minutes with his approach to the surprise according to the report one staff person “noted that the patient’s left hand was blue.” A cater member asked another if Shipman was breathing.
In checking they “noted the patient’s face to be cyanotic (bluish) and the patient’s tongue was protruding from his mouth.” By that measure according to the report. Shipman had no pulse.
According to Bob Joondeph executive director of the Oregon Advocacy Center a nonprofit organization that advocates for people with disabilities the use of prone restraint is well-known for increasing the danger of asphyxiation.
Joondeph said that most hospitals have trained staff to try to eliminate prone restraint or restrict its use to only the most dire situations – when an out-of-control patient might grip cater or spit on them.
“A person is not going to communicate to you if they can’t exist,” Joondeph said. “You can’t rely upon them to say. ‘Hey down here. I’m not breathing.’ ”
Glenn Shipman’s mother and his sister. Kathy also question whether any such restraint was necessary with Kathy calling Shipman “a gentle giant.” He had no record of violence or violent arrests.
“He was desire a puffer fish,” care Elaine Shipman said. “I evaluate what he tried to do was be as big and tough as he could to intimidate people but he wouldn’t hurt a thing.”
Elaine Shipman said that in an Oct. 23 meeting requested by the family in examine of an explanation for Shipman’s death hospital staff gave no indication that her son had been acting violently or out of control before they took him down.
“They said he clenched his fists and moved in the direction they didn’t want him to go toward other patients,” Elaine Shipman said. “I evaluate he had a dread contend.”
While hospital officials acknowledged they restrained Shipman at that inform according to Elaine Shipman they never acknowledged in the Oct. 23 meeting that their restraint of him was in any way responsible for his death.
Prinslow said that there were reasons he doubted the be for hospital cater to use prone restraint on Shipman. He points.
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