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Feds say Oregon State Hospital was slow to address safety after dangerous patient escaped

For the second time in two years, federal regulators have ordered the state hospital to take action to address unsafe conditions
Oregon State Hospital in Salem. | BEN BOTKIN/THE LUND REPORT
September 20, 2023

Oregon State Hospital administrators failed to take immediate action to ensure safety after a dangerous patient escaped using a van with the keys left in it, federal regulators found.

The criticism came in the form of a one-page notice finding a situation of “immediate jeopardy” sent to administrators of the Salem-based psychiatric facility on Sept. 15, two weeks following Christopher Lee Pray's capture after escaping from the state hospital while fully shackled. The notice is the second time in two years that federal regulators have ordered state health officials to correct safety conditions at the state hospital after a patient escaped. 

“The hospital has not demonstrated that it has taken sufficient immediate actions to correct this noncompliance and prevent serious injury or death,” reads the notice from Centers for Medicare and Medicaid Services.

According to the document, the “hospital’s failure to fully cooperate slowed” the work of federal regulators. While the notice does not include details on the state hospital’s alleged foot-dragging, it states that it did not affect the underlying recommendation reached by federal regulators. 

The document does not mention Pray’s name, but describes details that make clear it is based on his escape. It states that the hospital failed to meet federal regulations that put Pray and others “at high risk for serious injuries or death.” 

Hospital staff left Pray, who is accused of aggravated murder and other crimes, unattended in a van with the keys in the ignition following a supervised medical outing, according to the notice. After commandeering the van, Pray drove erratically at high speeds with his ability to drive limited by the restraints, the notice states. Days after escaping, Pray was taken back into custody after he was was found stuck in a bog in Portland and taken to a hospital. 

State hospital spokesperson Amber Shoebridge told The Lund Report in an email that the facility's management "responded immediately" to the federal inquiry and provided "all non-privileged information." That included "incident reports, video recordings, medical records, policies and procedures, information about OSH’s secure medical transport process, and access to all OSH personnel."

The hospital also launched an "immediate investigation" into its policies, practices and procedures regarding secure medical transports, Shoebridge said. The investigation revealed areas of improvement that the Oregon Health Authority, which oversees the state hospital, included in a four-page corrective plan it submitted to federal regulators. The health authority announced the plan in a press release Wednesday. 

Under the plan, only vans with a barrier between the front and back seats will be used for the medical transport of patients who require restraints. Additionally, the plan directs all secure medical transports to be loaded and unloaded from secure ports and for drivers to have control of vehicle keys at all times. The hospital is updating its policies to reflect the plan, according to the press release. 

State health officials disclosed Friday that federal regulators put the state hospital on notice that conditions at the facility put patients in “immediate jeopardy.” The warning is the most serious kind issued by the Centers for Medicaid and Medicare Services. 

The agency did not release the “immediate jeopardy” notice until Wednesday morning the health authority in response to a records request filed Saturday by The Lund Report. Just 16 minutes later the agency issued its press release with a link to the document, as well as to the state’s corrective action plan.

The state hospital came under scrutiny last year when federal inspectors found a range of problems at the Junction City campus that put patients at risk. The problems, described in a 134-page notice and inspection report, faulted leadership for failing to prioritize safety. It also cited a lack of safeguards during a group outing when one patient escaped for days. Hospital staff also failed to investigate and prevent patient-on-patient assaults and keep contraband out of patient rooms. 

Federal regulators initially rejected state health authorities’ proposed fixes to the campus as inadequate. However, federal inspectors eventually found the hospital to be in “substantial compliance” following a review in late 2022 that still identified some lingering issues over cleanliness, food storage, safety and patient grievances. 

You can reach Jake at [email protected] or via Twitter @jakethomas2009.


Submitted by Richard Valencia on Tue, 10/17/2023 - 10:09 Permalink

After reading this article and all attached reports and surveys, It's apparent that the problems lie within leadership, or lack of. Also, with the hiring process, which is challenging these days. Hiring within a problem that already exists, is a problem in it's self. Hiring individuals who do not understand the commitment required and who do not possess the work ethics to achieve success for the organization, will lead to failure, for that organization. The State of Oregon possess all the above concerns, within the majority of it's departments, especially within OHA. Also, these same concerns lie within just about all medical centers and hospitals, state wide. 

In the case of Oregon State Hospital and it's remote site, the incident of the escaped patient was a case of error and poor judgement and can be corrected immediately, but is clearly a part of a complacent environment within it's system.