Federal health authorities have blamed a fatal overdose at Oregon State Hospital on lax security screenings that allowed drugs to enter the facility as well as inadequate overnight monitoring of patients.
The federal investigation is the latest in a string of probes that have repeatedly found unsafe conditions at the Salem psychiatric facility as well as its satellite in Junction City. In the latest report, investigators also faulted hospital management for a flawed review of a different patient’s unexpected death last year as well as of an incident in which a male patient entered the room of a pair of female patients.
The Oregon Health Authority, which oversees the state hospital, announced the outcome of the investigation on Monday. Now management has until Oct. 24 to win federal approval of its plan to address the safety issues or risk loss of federal funding.
“We have been entrusted with the care of some of Oregon’s most vulnerable residents,” Dr. Sara Walker, the state hospital’s interim superintendent and chief medical officer, said in a statement. “Their safety and well-being are our top priority. We will continue to make the changes necessary to protect our patients.”
The newly released 96-page report from the Centers for Medicare and Medicaid Services sheds light on why, in May, the state hospital suspended in-person visits for the 600 patients at its Salem campus in May in response to a suspected drug overdose.
On the morning of May 24, a nurse opened the patient’s door letting them know it was time for their medications and that biscuits and gravy would be served for breakfast. The nurse later told investigators that the patient “plays possum” at times.
Four and a half hours later, after the patient did not show up for their medications, another nurse went to their room and asked them to sit up. When the patient did not respond, a nurse turned on the light and tried to shake the patient awake, finding the patient “unresponsive, cold to the touch, and not breathing in their room,” according to the report.
While medics tried to resuscitate, another patient shared speculation with staff that a family member who visited the day before may have provided contraband, according to the report. Emergency response workers found a rolled-up bill and a small amount of white powder.
The drug that caused the overdose is not identified in the report, but it states that another patient told a manager the deceased patient had offered them a drug the night before that looked like fentanyl.
The report faults hospital staff for not keeping a close eye on the patient during a visit with a family member. The report also found that security staff did not properly screen visitors entering the facility.
Hospital nurses are required to periodically make sure that patients are still alive during the night by observing their chests rise and fall or approaching them and pulling covers back to listen for breathing. The report, however, found that nurses had not been checking patients adequately.
Even after the patient died, investigators found that nurses still were not properly checking to make sure patients were alive during the night. When regulators showed staff videos showing inadequate checks, a manager responded that they did not need to see more videos and that “We understand what you’re showing us,” according to the report.
The report also found problems with the hospital’s review of the death of a patient whose legs buckled in November while getting their medications. Staff took the patient, who is described as “morbidly obese” with metabolism problems, to a seclusion room where they complained about being unable to breathe and repeating “I feel like I’m going to die.”
Investigators found inconsistencies in the review of the patient’s death and a failure to consider corrective actions.
