Oregon State Hospital patient chokes to death after series of staff errors

Date: 2012-06-30
Source: The Oregonian

Dozens of times in her short life, Nikolina Stoyanova tried to hurt herself. She stabbed herself with pens, cut herself and even ran in front of a moving car -- outward signs of the anguish tormenting the adopted Bulgarian girl who was sexually abused from the time she was 10.

In the end, Stoyanova died while in the care of those who were supposed to help her.

Stoyanova, a patient at the Portland branch of the Oregon State Hospital, choked to death on a tiny bottle of medicine that a contract nurse had handed to her -- despite Stoyanova's history of swallowing items.

The mistakes didn't end there, according to documents obtained by The Oregonian, official reports and tapes of 9-1-1 calls. Among the problems:

The night supervisor couldn't figure out how to use the hospital's cordless phone or cell phones, delaying a call to 9-1-1. Nurses prepared to give Stoyanova oxygen -- only to find that the oxygen tank on their emergency cart was empty. And as Stoyanova lay unconscious on the hospital room floor, paramedics were waiting outside the wrong entrance to the building.

Lisa Bayer-Day, Stoyanova's court-appointed guardian, said she's frustrated by the lack of a detailed explanation from the hospital and about the errors -- including that the nurse provided what Bayer-Day called "the weapon" that helped Stoyanova kill herself.

"It's all over the (medical) chart that she swallows things," Bayer-Day said. "What changes in policy are they going to implement so that this doesn't happen again?"

Oregon State Hospital administrators declined to comment on specifics of Stoyanova's case.

But they said they're changing some of their practices to try to prevent anything similar from happening again. For example, staff members will now include a patient's risk factors on the daily sheets that typically record a patient's mood and other noteworthy items. Such information is already on a patient's medical chart, but the redundancy will help keep the risk "front and center," said Dr. Rupert Goetz, the hospital's chief medical officer.

In addition, staff members must now make daily checks of emergency equipment, such as oxygen tanks. To cut down on confusion, they will go outside the building to look for ambulances and direct them to the right entrance. And they will undergo additional training on how to use the phones to ensure they can dial out in stressful situations.

"We know we have the state's most vulnerable and sick patients here and the reason we're in this work is to try to help them into recovery," Goetz said. "What I really want to say most is how much of a tragedy this is and how much we want to use this as an opportunity to grow and improve our skills."

Stoyanova's history of harming herself was well-documented with dozens of episodes since 2002, when she was taken from her adoptive parents, Justin Smith and Janis Kuchler. The Pendleton couple had adopted her and a younger boy from orphanages in Bulgaria in 1993. Stoyanova was 4.

But Smith, also known as John Harold Kuchler, started raping and molesting Stoyanova when she was 10, according to a 2005 affidavit from Stoyanova. Janis Kuchler even restrained the girl during one rape, holding her hand over Stoyanova's mouth to muffle any cries, according to Stoyanova's 2005 civil complaint against her adoptive parents. The parents -- who pleaded guilty to criminal sexual abuse charges -- agreed to pay her $70,000, Bayer-Day said.

In the past 10 years, Stoyanova had spent much of her time in and out of care facilities including the state hospitals in Salem and Portland.

The Portland branch of the psychiatric hospital houses an adult-treatment program for people who have been committed to the hospital in civil actions. Although the hospital has trained medical staff around the clock, it doesn't always have a doctor on site, relying on 9-1-1 for emergencies and an on-call doctor who can arrive at the hospital within 20 minutes.

It had seemed she was getting better -- the modest stretches when she wouldn't hurt herself were getting longer, said Bayer-Day, who lives in Beaverton and was appointed her legal guardian last February by a state judge. Stoyanova went 16 days without hurting herself and then 21 days.

"That is a huge deal," Bayer-Day said. "I thought we were making big progress."

They also talked about Stoyanova's upcoming birthday -- she would be 24 on May 25. Stoyanova asked for balloons, a manicure and cupcakes.

"She just wanted fun colors," Bayer-Day said, "blues and bright pinks and yellows."

Stoyanova had long-term goals, said her brother, Andre Matteson, who lives in Gresham. Her favorite movie growing up was "Free Willy," he said, and she had hoped to someday become a marine biologist. She cherished her friendships and "loved connecting with people," he said.

This is another poem by Nikolina Stoyanova.
On April 20, Stoyanova seemed in good spirits, according to incident reports filed by hospital staff members. She had enjoyed ice cream, watched television and played cards. She was laughing at a TV show when a contract nurse, Elsa Renthal, arrived at 10:10 p.m. to give her medication.

Renthal hadn't been with the hospital long, hospital administrators said, although she had successfully completed orientation and mentorship requirements.

Stoyanova took some pills from the nurse. Renthal then took out a small bottle of Atropine eye drops and handed it to Stoyanova, she told state investigators.

Stoyanova looked at the bottle for a second -- and then threw it in her mouth, the hospital's incident reports state.

Renthal later admitted that she recognized her mistake immediately, according to a report by the state Office of Investigations and Training, which found that the nurse had neglected Stoyanova's care in violation of Oregon administrative rules. She declined to comment for this story.

Renthal tried to get the bottle out of Stoyanova's mouth, but Stoyanova had swallowed it. The nurse and others tried to force it out with the Heimlich maneuver. For a moment, the bottle came up, but Stoyanova swallowed it again. This time, it lodged in her airway.

As Stoyanova turned blue, the nursing supervisor called 9-1-1 from a phone at a back office. After giving the 9-1-1 dispatcher the initial information, she was told to call back from a phone where she could see and help Stoyanova.

But the supervisor couldn't work the cordless phone to call back, she told investigators. Then, as other nurses called out for oxygen for Stoyanova, the supervisor retrieved a mask and an oxygen tank from the "crash cart." The tank, however, was empty and staff members had to get a new one, said the supervisor, Rhonda Shechtman.

Then, she tried to call 9-1-1 from the hospital's cell phones, but erroneously dialed 9 before pressing 9-1-1. She finally used a staff member's cell phone to reach 9-1-1.

By that time, the ambulance had arrived at the Northeast Portland building that the hospital shares with Legacy Health Systems. But the paramedics went to the Legacy entrance, about 50 yards away. It took a few minutes before staff members found them and brought them to Stoyanova, who was unconscious on the floor.

Stoyanova was pronounced dead at 11:07 p.m. State police concluded her death was a suicide.

--Helen Jung

Photo Captions
Nikolina Stoyanova, 23, loved her friends, swimming, camping and connecting with people, said her brother, Andre Matteson. Stoyanova died on April 20 after choking on a small medication bottle at the Oregon State Hospital-Portland.

Nikolina Stoyanova seemed to show more hope for her future, her guardian said. She wrote this poem, New Start, about two weeks before her death.
Stoyanova was admitted most recently last November.

This is another poem by Nikolina Stoyanova.

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