Rosemary Torgesen’s last months

Over 99 days as a Smokey Point patient, Rosemary Torgesen’s condition deteriorated while the hospital struggled to keep patients and staff safe and comply with regulatory standards. Below are events documented in her medical record, and other incidents involving the hospital drawn from 911 calls, police reports, inspections, regulatory complaints and other public records.

Rosemary Torgesen



March 15, 2018

Regulators find “immediate jeopardy” to patient safety that posed a “high risk of serious harm, injury and death.”

Day 1

March 22, 2018

Rosemary Torgesen is admitted to Smokey Point on a court order after refusing to eat, drink and take medications for her schizophrenia

March 22, 2018

April 3, 2018

Smokey Point sends Rosemary to Providence Regional Medical Center’s emergency room for “abnormal labs”

April 3, 2018

April 6, 2018

A Smokey Point staff member recommends Rosemary “be sent to a more medical psych unit”

April 6, 2018

Day 30

April 20, 2018

April 20, 2018

April 24, 2018

Smokey Point sends her to Providence’s emergency room for the second time for refusing to eat, drink and take medications

April 24, 2018

April 27, 2018

Patient attempts suicide by overdose

April 30, 2018

Patient taken to ER with “intractable headache” a week after doctor had ordered CT scan that was never scheduled

May 5, 2018

Patient punches nurse in head and face

May 6, 2018

Patient arrested after punching another patient in head and face

May 8, 2018

Smokey Point sends Rosemary to Northwest Hospital to be evaluated for admission, but she is returned that day after being medically cleared

May 8, 2018

May 9, 2019

Patient complains to DOH of understaffing and "extreme amount of violence by patients."

Day 60

May 20, 2018

May 20, 2018

May 28, 2018

Smokey Point sends her to Providence’s ER for the third time for abnormal labs

May 28, 2018

May 30, 2018

Patient taken to ER after overdose

May 31, 2018

Christina Perry, a nurse, resigns citing understaffing and unsafe conditions

June 4, 2018

Hospital error results in giving patient medication meant for another, requiring medical follow-up

June 5, 2018

A patient with cornea scarring told Department of Health he hadn't seen an opthamologist despite a doctor’s order more than two weeks before

June 6, 2018

Alfie Alvarado-Ramos, director of state Department of Veterans Affairs, emcees ceremony for new military unit at Smokey Point

June 7, 2018

Regulators return to inspect Smokey Point and find serious violations “resulted in an unsafe environment for patients”

June 16, 2018

Rosemary falls at Smokey Point and is taken to the emergency room at Cascade Valley Hospital, where she is diagnosed with a broken arm

June 16, 2018

June 19, 2018

Smokey Point sends her to Providence’s ER for the fourth time for refusing to drink any fluids

June 19, 2018

Day 90

June 20, 2018

Smokey Point records refer to her as being “bedbound”

June 20, 2018

June 24, 2018

Smokey Point records show she has developed a bed sore

June 24, 2018

June 28, 2018

Smokey Point sends her to Providence’s ER for the fifth time for refusing to eat, drink or take medication

June 28, 2018

Day 99

June 29, 2018

Smokey Point sends her to Providence a sixth time and refuses to accept her back

June 29, 2018

July 17, 2018

Regulators return to inspect Smokey Point and find serious violations “resulted in an unsafe environment for patients”

July 18, 2018

Providence physicians discover she has a broken right hip, apparently from a fall four weeks earlier

July 18, 2018

July 19, 2018

US HealthVest CEO pitches a third psychiatric hospital in Washington, pledging to boost the region’s mental-health workforce and saying Smokey Point “demonstrates our strategies are successful.”

Day 120

July 20, 2018

Rosemary Torgesen dies, with malnutrition given as the primary cause on her death certificate

July 20, 2018

Smokey Point Behavioral Hospital
(Selected events)


April 15, 2018 - INSPECTION VIOLATIONS

Regulators find “immediate jeopardy” to patient safety that posed a “high risk of serious harm, injury and death.”

March 15, 2018 - INSPECTION VIOLATIONS

March 22, 2018

Rosemary Torgesen is admitted to Smokey Point on a court order after refusing to eat, drink and take medications for her schizophrenia Rosemary Torgesen is admitted to Smokey Point on a court order after refusing to eat, drink and take medications for her schizophrenia Rosemary Torgesen is admitted to Smokey Point on a court order after refusing to eat, drink and take medications for her schizophrenia

April 3, 2018

Smokey Point sends Rosemary to Providence Regional Medical Center’s emergency room for “abnormal labs”

April 6, 2018

A Smokey Point staff member recommends Rosemary “be sent to a more medical psych unit”

April 20, 2018

April 24, 2018

Smokey Point sends her to Providence’s emergency

April 27, 2018 - 911 CALL

Patient attempts suicide by overdose

April 27, 2018 - 911 CALL

April 30, 2018 - SAFETY CONCERN

Patient taken to ER with “intractable headache” a week after doctor had ordered CT scan that was never scheduled

April 30, 2018 - SAFETY CONCERN

May 5, 2018 - 911 CALL

Patient punches nurse in head and face

May 5, 2018 - 911 CALL

May 6, 2018 - 911 CALL

Patient arrested after punching another patient in head and face

May 6, 2018 - 911 CALL

May 8, 2018

Smokey Point sends Rosemary to Northwest Hospital to be evaluated for admission,

May 9, 2018 - COMPLAINT

Patient complains to DOH of understaffing and "extreme amount of violence by patients."

May 9, 2018 - COMPLAINT

May 20, 2018

May 30, 2018 - 911 CALL

Patient taken to ER after overdose

May 30, 2018 - 911 CALL

May 31, 2018 - SAFETY CONCERN

Christina Perry, a nurse, resigns citing understaffing and unsafe conditions

May 31, 2018 - SAFETY CONCERN

June 4, 2018 - MEDICATION ERROR

Hospital error results in giving patient medication meant for another, requiring medical follow-up

June 4, 2018 - MEDICATION ERROR

June 5, 2018 - SAFETY CONCERN

A patient with cornea scarring told Department of Health he hadn't seen an opthamologist despite a doctor’s order more than two weeks before

June 5, 2018 - SAFETY CONCERN

June 6, 2018 - OFFICIAL VISIT

Alfie Alvarado-Ramos, director of state Department of Veterans Affairs, emcees ceremony for new military unit at Smokey Point

June 6, 2018 - OFFICIAL VISIT

June 7, 2018 - INSPECTION VIOLATION

Regulators return to inspect Smokey Point and find serious violations “resulted in an unsafe environment for patients”

June 7, 2018 - INSPECTION VIOLATION

June 16, 2018

Rosemary falls at Smokey Point and is taken to the emergency room at Cascade Valley Hospital, where she is diagnosed with a broken arm

June 19, 2018 - COMPLAINT

Former Smokey Point pharmacist files complaint to DOH about lack of staffing

June 19, 2018 - COMPLAINT

June 20, 2018

Smokey Point records refer to her as being “bedbound”

June 24, 2018

Smokey Point records show she has developed a bed sore

June 28, 2018

Smokey Point sends her to Providence’s ER for the fifth time for refusing to eat, drink or take medication

June 29, 2018

Smokey Point sends her to Providence a sixth time and refuses to accept her back Smokey Point sends her to Providence a sixth time Smokey Point sends her to Providence a sixth time and refuses to accept her back

July 17, 2018 - INSPECTION VIOLATION

Regulators return to inspect Smokey Point and find serious violations “resulted in an unsafe environment for patients”

July 17, 2018 - INSPECTION VIOLATION

July 18, 2018

July 19, 2018 - REGULATORY

US HealthVest CEO pitches a third psychiatric hospital in Washington, pledging to boost the region’s mental-health workforce and saying Smokey Point “demonstrates our strategies are successful.”

July 19, 2018 - REGULATORY

July 20, 2018

Rosemary Torgesen dies, with malnutrition given as the primary cause on her death certificate


Continue reading the three-part investigation by The Seattle Times

PART TWO
Coming soon
PART THREE
Coming soon