The tragic stabbing death last July of 26-year-old mental health worker Haley Rogers occurred in a facility marked by safety lapses — including a knife drawer secured so poorly that it could be opened with a spatula, newly released records show.
That’s what Oregon Occupational Safety and Health investigators reported finding last year when they inspected nonprofit Cascadia Health, which operated the Gresham independent living facility where Rogers worked. A patient who resided there, James Calvin Smith, faces charges for alleged murder.
Based on the inspection, Oregon OSHA fined Cascadia $7,250 for failing to adequately prevent violence against its employees. The fine has not previously been reported.
Records spanning nearly 600 pages disclosed by the state in response to a request paint a picture where lack of resources and an overstretched system contributed to shortcomings cited by investigators, staff who worked there, or both. Among the observations cited:
- Cascadia Health management kept the facility staffed with only one employee overnight.
- Due to lack of beds elsewhere, McCarthy Place was admitting clients who were not considered ready for such an unsecured facility, employees said.
- Workers weren’t provided basic safety devices, such as walkie talkies and body alarms and the facility lacked security cameras.
- Though residents are able to bring weapons in and out of the unlocked facility, investigators reported that Haley’s attacker used a spatula to pry open a locked kitchen drawer to get a knife.
In addition, the newly released records say that the alleged attacker had been refusing medication and that his mental condition was deteriorating, a condition known as decompensating. Workers told OSHA that Cascadia lacked a system to effectively alert them when patients posed a threat.
Asked about the findings, Cascadia Health spokesperson Stephanie Tripp told The Lund Report in an email that Cascadia has taken steps to address problems identified in the investigation and all overnight shifts are staffed by two workers. It has budgeted $1 million toward safety measures over the next year and hired a consultant to provide a safety assessment. The nonprofit cooperated with the Oregon OSHA investigation and will not contest the penalties, she added.
“Everyone at Cascadia takes safety very seriously and strives to build a culture of safety agency wide,” she said. “Many of the people we serve live with severe and persistent mental illness. But not all clients are dangerous.”
Michell Rogers, the mother of Haley Rogers, commented on the findings in an email to The Lund Report.
“My daughter did not have the resources to survive that night,” she wrote. “She was trapped, she had nowhere to run, no one that had the capacity to come to her aid or call for help heard her screaming or fighting for her life.”
She said the Oregon OSHA report shows that there needs to be “big changes” in how client information, particularly on those with a history of violence, is shared with behavioral health workers.
The records’ release come amid a backdrop of raised concern over rising violence against health care workers and as state officials seek to expand behavioral health resources.
Cascadia plays a crucial role
The Portland-based nonprofit plays a major role in the region’s social safety net. In 2022 it reported revenues of $84.5 million, provided health services to nearly 10,000 people and served 165 people in 19 residential treatment programs. McCarthy Place has about 15 staff members including skills trainers, a case manager, mental health aides, residential counselors and a licensed medical professional, according to Tripp.
Before being housed by Cascadia, Smith had been diagnosed with schizophrenia and had been found guilty except for insanity in 2001 on charges of second-degree assault and unlawful use of a weapon. The charges stemmed from Smith stabbing a stranger.
A judge ordered Smith to Oregon State Hospital and committed him to the jurisdiction of the Psychiatric Security Review Board, which supervises people who successfully assert the guilty except for insanity defense.
In 2012, he was admitted to Cascadia Health and McCarthy Place.
The OSHA investigators detailed how the physical layout and design of McCarthy Place made workers less safe. The facility’s kitchen had a locked drawer that contained knives and other sharp utensils, according to a document. But staff didn’t conduct a regular inventory of the drawer, and there was enough space between the top of the drawer and the countertop for someone to pry it open.
“A large sharp metal BBQ style spatula was available to clients,” reads the document. “This was used to pry open the knife drawer.”
Other aspects of the building also put staff at risk. The front doors didn’t have windows to observe people coming in and out. The inside door handle had to be turned to open it instead of a push bar. Staff had to use a baby monitor with poor reception to keep an eye on the facility’s south wing from an office in the north wing. Additionally, staff complained that the keys didn’t didn’t work well and the front doors remained unlocked all night.
“(Cascadia Health) has an inconsistent approach regarding evaluation of individual work sites to consider employee health and safety,” reads the inspector’s report.
The inspector found that prior to Rogers’ death, “there was no consistent assessment of staffing level needs to ensure employee health and safety.” Staff weren’t given basic safety devices, such as personal alert systems, panic buttons, or two-way radios, the inspector found.
Cascadia Health recorded 16 assaults since 2023, according to the records. There were at least four workplace violence incidents, including the alleged stabbing, at McCarthy Place in that time period, according to documents. One employee was punched by a client. Another was chased and punched multiple times in the face. The other employee was shoved. None of them requested medical treatment.
Staff cite lack of appropriate facilities in system
In interviews, employees at McCarthy Place told Oregon OSHA their goal was to help clients move toward independent living, helping them with medication, laundry, meals, and taking them to appointments. Clients came from more secure locations, such as psychiatric hospitals.
“Employees stated that clients coming to McCarthy were not always ready to be in an unsecure program,” reads the document. “Often, due to a lack of secure facility beds, clients often came to reside at McCarthy anyway.”
Staff told investigators that clients “had the right to refuse their psychiatric medication” and they could be sent to the hospital or respite program if they had been deemed to be a threat. However, staff noted that respite and other services were hard to obtain and that “clients often came back from the hospital after a day or two before they were stabilized.” A Cascadia executive also told investigators that getting higher levels of care for clients was one of their biggest issues.
Employees shared the most-up-to-date information on clients in shift notes and emails, the report states, but some staff told investigators they didn’t have access to the files or time to read them, the report states.
The Oregon OSHA inspection noted that clients “have the right” refuse their medication.
“This can lead to a destabilizing decompensation process,” reads the report. “Clients may experience increased paranoia. They may also experience delusions and hallucinations (auditory and visual) during decompensation.”
Inspectors found Cascadia Health had safety committees but lacked a written policy that laid out employee involvement and how management would respond to their concerns, documents show. Most employees at MacCarthy Place told investigators they didn’t know the safety committee existed.
Cascadia Health staff are trained in violence awareness and deescalating situations within 90 days of their start date, but OSHA said more training should be provided.
“The employer did not implement feasible measures to prevent or mitigate workplace violence in the form of employee assaults,” reads a Nov. 27, 2023 OSHA notice to Cascadia.
The state also issued a $450 penalty to Salem-based Health Care Services, a staffing company contracted by Cascadia Health. The inspection found that at least two people from Health Care Services were working at McCarthy Place without deescalation or crisis intervention training.
An Oregon manager for Health Care Services in October submitted a letter to Oregon OSHA stating that all staff have been assigned a course on deescalating workplace violence.
Safety improvements
Along with the penalty, Oregon OSHA directed Cascadia Health to improve safety, providing a list of possible actions. Those included offering more frequent deescalation training for staff, regular safety assessments of facilities, as well as cameras to monitor hallways and other areas.
The agency’s recommendations include flagging clients’ files with previous incidents of violence, increasing staffing for potentially dangerous situations, better monitoring of signs of a client’s declining mental health and implementing a comprehensive workplace violence program with input from employees and commitment from management. It also called for providing employees with safety equipment, such as walkie talkies, intercoms, body alarms and a panic button.
Cascadia Health has hired a safety administrator and has installed an updated camera system.
Included in the documents is an internal review by Cascadia Health responding to concerns that Rogers was working by herself during the overnight shift. The review points out that while state regulations only require one staff member for overnight shifts, the nonprofit was now expecting two on staff on these shifts.
The nonprofit also committed to “continue to work with the county and the Oregon Health Authority to ensure appropriate funding for our existing workforce — and increased workforce needs” as well advocating to change state staffing regulations “and the payment structure to support better staffing,” according to the review.
The review also stated that Cascadia will require sharps to be put in lock boxes and walkie talkies and body alarms will be available to all staff.
Aftermath of Haley’s death
Smith has pleaded not guilty to murdering Rogers and his trial is scheduled for May.
In September, Portland attorney Nick Kahl filed a pre-lawsuit notice with the state. It claims state officials should have known that placing Smith at McCarthy Place “placed all persons working there in grave physical danger.”
After Haley’s death, Oregon AFSCME, a union that represents Cascadia Health employees, issued a statement saying its workers had identified safety as a top concern for contract negotiations last year. The union said that over the years workers had frequently raised concerns about scheduling just one staff person to oversee a facility, program or outing, as well as weapon risk protocols.
David Kreisman, spokesman for Oregon AFSCME, told The Lund Report in an email that the union will support a legislative effort in the upcoming session intended to improve safety of behavioral health workers.
“Employees are safe when there is enough staff to respond to emergencies, when employees are properly trained, and when workers feel supported and heard by their employer,” he said.
