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Feds' threat to decertify state hospital over safety is not the first

Inspectors fault state hospital for adopting bad policies and then not following them, as well as unlocked doors and unsupervised patients. State leadership say they're addressing the issues.
Oregon State Hospital in Salem, Oregon, on Nov. 21, 2023. | JAKE THOMAS/THE LUND REPORT
December 14, 2023

For the fourth time in two years, an outside watchdog is raising concerns that the Oregon State Hospital isn’t doing enough to protect the safety of patients and staff. 

On Monday federal officials called out ongoing problems at the hospital from an inspection that cited faulty or nonexistent training as well as failure to maintain documentation, provide supervision and follow-up — all of which potentially put patients in danger.

The inspection was triggered by a highly publicized incident in September in which a patient accused of aggravated murder and other crimes escaped after being left unattended in a van with the keys left in the ignition.

Centers for Medicare & Medicaid Services officials described in their 102-page report many lapses that allowed the patient to take control of the van and flee, driving at speeds as high as 100 mph. Days later, he was taken into custody after being found bogged down in a muddy pond in Portland.  

They also described a pattern of systemic problems, citing their review of records, staff interviews, and several other incidents — ones that weren’t as severe as the escape, but were still serious enough to put the hospital on track to lose Medicare funding if doesn’t produce a satisfactory plan of correction by Dec. 21

One patient slipped away from their unit after tricking a psychologist into thinking they were a staff member by dressing well, smiling and having good hygiene and social skills, according to the report. However, inspectors found no investigation or follow up to prevent future incidents. 

The report also noted multiple incidents where patients were able to access parts of the hospital through unlocked doors unsupervised. One patient who has a history of checking for unlocked doors was found in the hospital room using the treadmill while wearing a jacket “over flowing with items such as magazines.”

“[Patient] was not receptive to instructions on how to use the Treadmill,” reads the report. “[Patient] was setting it too fast and then jumping off of it.”

The report found no documentation of an investigation into the incident. It also found that staff were given unclear and incomplete training on how to securely transport patients who’ve been accused of crimes. 

The report describes how one patient who didn’t require restraints was taken to Salem Hospital for medical treatment in shackles. The patient was confused and agitated by the restraints and was struggling to use a urinal in their hospital bed, the report states. A state hospital staff member removed the patient’s restraints, which had been on too tight and left red marks, according to the report. 

As it has with prior incidents, the Oregon Health Authority communications office issued a press release stating that hospital administration had already been addressing the issues raised. 

However, the release stated that in light of the new report, the state hospital “convened a workgroup earlier today to begin developing additional corrective actions …  The workgroup includes OSH staff representatives from nursing, communications, clinical disciplines, security, staff training, technology services, and standards and compliance teams.”

String of negative reports

The release addressed the incident in isolation. But it comes on the heels of several others over the last 19 months. Some have been reported previously, while others were documented in public records obtained by The Lund Report.

The reports share a common theme, that the state hospital is an agency where safety is not a priority — echoing historic complaints by employees

Asked for comment on the recurring accusations that the health authority has failed to establish a culture of safety at the hospital, Superintendent Dolly Matteucci issued a statement through an Oregon Health Authority spokesperson: “Safety is our top priority at Oregon State Hospital. That means we are continuously assessing, questioning and looking for ways to improve how we work to ensure that patients, staff and the public are safe and secure. Reports from the CMS, Joint Commission and OSHA give us additional review of our processes and provide opportunities to do better. We appreciate the thoroughness of these reviews because we are committed to a safe environment for everyone. We will continue to look for ways to improve internally, as well as from the learnings of outside agencies. As a large and complex organization, these partnerships and collaborations ensuring quality and continuous improvement serve us all well.”

The incidents include the following:

In September, federal regulators found that the state hospital was slow to take action after the patient escaped with the van in September.  Their report said that the hospital “has not demonstrated that it has taken sufficient immediate actions to correct this noncompliance and prevent serious injury or death.” It also found that the “hospital’s failure to fully cooperate slowed” the federal investigation. 

Before that, following an August inspection, the Joint Commission, a national health care accreditation nonprofit, found “no evidence” that hospital leaders “regularly evaluated the culture of safety and quality” as required. 

Six months before that, a previous inspection by commission staff detailed safety issues at the state hospital laboratory. Those included not periodically reviewing the competence of laboratory staff and using equipment properly.

In September 2022, regulators with the Oregon Occupational Safety and Health Division (known as Oregon OSHA) fined the state hospital $54,180 for not investigating 78% of worker injuries tied to violence. According to the citation, the hospital had 336 workplace injury cases in 20201 that meant employees missed a combined 2,844 days of work. 

Additional problems

The latest round of CMS findings follow an earlier set of scathing reports issued by the federal agency.

In May 2022, Centers for Medicare & Medicaid Services threatened to decertify the state hospital’s Junction City campus after inspectors found staff didn’t properly investigate or monitor allegations of patient-on-patient violence along with other serious problems. Regulators initially rejected the state hospital’s plan to correct the problems as “generally unacceptable.”

In January 2023, as reported by the Oregon Capital Chronicle, the state hospital passed its federal inspection and was deemed to be in “substantial compliance.” 

But regulators’ report still raised issues about cleanliness, food storage and patient safety. The inspection called out how some screens between patios and other areas on the Salem campus had gaps large enough for patients to pass contraband items or let rodents in. Additionally, medication and a syringe set were unlabeled and food was found without expiration dates.