Managers at the Oregon State Hospital distributed condoms to patients but did not protect them against being sexually assaulted or attacked, according to a new federal report.
A federal inspection of the psychiatric institution’s main campus in Salem faulted managers for lax oversight that led to a patient requiring emergency care from an assault and a botched investigation into illicit sexual contact, among other lapses.
The Centers for Medicare and Medicaid Services issued a “statement of deficiencies” concerning its findings, marking the latest of several reports in recent years to raise alarms over patient safety and poor management.
The 102-page report describes how staff, as a matter of practice, distributed condoms to patients housed by the state, but failed to adequately monitor patients and follow up on incidents that included sex by patients lacked the capacity to give consent.
Distributing condoms is an issue because so many of the people housed by Oregon State Hospital are there because they are experiencing serious mental illness, are highly vulnerable to assault and lack the ability to give consent. Facility rules prohibit patients from having sex.
Moreover, employees there have been accused of harassing patients and grooming them for sex.
Assaults, sexual contact cited
Lack of oversight contributed to four instances of patient-on-patient assault and sexual contact, the inspection found. The report found that hospital staff did not follow up on police reports related to assaults or grievances and failed to coordinate responses to emergencies. Inspectors saw a staff member on security camera footage looking at their phone instead of monitoring patients.
After reviewing hospital records, video recordings and interviewing staff, inspectors concluded the hospital “failed to ensure each patient’s right to provision of care in a safe setting, the right to freedom from all forms of abuse and neglect, and the right to prompt and appropriate response to grievances.”
“Those failures resulted in actual and potential physical and psychological harm to patients,” reads the report.
Dr. Sara Walker, the state hospital’s interim superintendent and chief medical officer, responded to the inspection with a press statement.
“There will always be things we can improve, and we will continue to do so, but what persists is our dedication to the humans we are privileged to care for,” she said.
“Those failures resulted in actual and potential physical and psychological harm to patients,”
Top managers called condoms ‘self-care’
During an interview with top hospital managers including its compliance director, program director and nurse manager inspectors were told that staff handed out condoms to patients for “self-care use,” according to the report.
However, the report states that the hospital does not have a policy governing the distribution of condoms. Moreover, the hospital does not allow sexual contact between patients.
“It was unclear why the hospital would engage in the practice of condom distribution to any patient who asked without a written policy and procedure that ensured the protection and safety of all patients,” reads the report.
One patient asked staff why they were giving out condoms, saying that it “makes people think about sex,” according to the report. Staff replied that they were “not for peer to peer use.” Citing hospital records, the report found that the same patient was “a vulnerable person who was easily influenced (and ) would not meet criteria for informed consent.” The report stated that they “appeared to be the victim” of another patient’s “sexual behaviors.”
The report describes another incident in 2022 where a patient’s urinalysis identified the presence of sperm and the patient “themself could not be the source of the sperm.” The patient is described as “highly dysregulated” and didn’t know where she was. The patient was unable to tell hospital staff about any recent sexual encounters. However, the report states that staff only reviewed 48 hours and “three other short time periods” of videos that monitored facilities and did not identify when the patient could have engaged in sexual contact.
In 2022, lawyers filed a suit accusing Oregon State Hospital of allowing an employee to allegedly groom a patient there for sex. He then contacted her after her release, even showing up at her church.
“OSH has a culture of tacitly approving inappropriate relationships between staff at OSH and patients or former patients,” the suit claimed. “Other staff knew of (the nurse’s) continued stalking and sexual grooming behaviors … and did nothing to stop it. Staff know that OSH will not investigate reports of abuse by patients and there is a culture of retaliation when reports of abuse are made.”
In the past, the state has defended its oversight of the institution and promised to fix issues raised by federal inspectors and other outside entities such as The Joint Commission, Oregon OSHA and the group Disability Rights Oregon.
Follow up
Hospital administrators have 10 business days to respond with a plan of correction. According to the hospital press release, federal regulators will conduct another unannounced investigation after the plan is submitted.
The state hospital announced the inspection just two days after it had been put on notice that it was at risk of losing federal funding over a different problem, unsafe conditions in its admission area.
