Federal inspectors found Oregon State Hospital’s Junction City campus out of compliance after a complaint investigation uncovered a slew of problems related to patient care and mismanagement of the state-run mental health facility.
They include a failure to investigate and prevent patient-on-patient assaults and contraband in patient rooms. The hospital also failed to have adequate safeguards in place during a patient group outing, when one patient escaped for 25 days.
Hospital administrators are now scrambling to put together a plan of correction by May 15. The federal Centers for Medicare & Medicaid Services gave the hospital 10-day notice to submit a compliance complaint in a Thursday letter. If the Junction City hospital doesn’t fix the deficiencies, the federal agency could terminate its participation in Medicare on Aug. 3, the notice said.
In a statement on Monday, state officials said they take the findings seriously.
“Our staff at the Oregon State Hospital want to provide the highest quality care to our patients so they can recover and return to live healthy and productive lives in their communities,” state hospital superintendent Dolly Matteucci said. “We look forward to addressing each of the administrative, documentation and supervision issues highlighted in this report.”
The federal inspection took place in December 2021 and January. Surveyors in the Oregon Health Authority’s Health Care Regulation and Quality Improvement completed the inspection on behalf of federal regulators. The health authority also runs the state hospital, which has 141 patients at its Junction City campus and 545 patients at its main Salem campus. The Salem campus has 1,809 employees and the Junction City campus has 404. The potential decertification would only apply to the Junction City campus, not the Salem campus.
The 134-page notice and inspection report uncovered a range of problems, from a lack of a designated administrator to a failure to follow-up on patient-to-patient sexual contact.
Its findings include the following:
- Staff told an inspector during a December 2021 visit that the hospital had no designated on-site administrator since the last one retired a year earlier.
- When a patient reported in July 2021 that their roommate sexually assaulted them, the hospital reported the incident to law enforcement and moved the roommate to a different room. But the hospital failed to complete its own internal investigation and allowed the roommate to stay in the same unit, the inspection found. A hospital staffer was unable to tell the inspector if the hospital even interviewed the patient accused of sexual assault.
- In another case, two patients were moved to separate rooms after they told hospital staff they had consensual sex. But the hospital failed to adequately document and investigate the incident, the inspection said.
In a statement, Oregon Health Authority Director Patrick Allen said, “I appreciate the rigor and thoroughness of our state health care regulatory surveyors, who in their role of acting on behalf of CMS, took the opportunity to conduct a broad review of state hospital administrative structures and procedures. The state hospital will act promptly and transparently to fix these gaps.”
Patient Escapes Hospital
The inspection and an investigation started after a patient escaped from custody during an off-campus activity on Dec. 2, 2021. Such escapes are called “elopements.”
The follow-up investigation found the hospital’s policies and procedures for off-campus outings for patients were incomplete and vague prior to the patient running away from the group. The patient also had a cell phone. Hospital staff told the inspector “good question” when asked if the patient’s cell phone was purchased through an approved vendor, records show.
The investigation found the person asked another patient to give up his slot on the outing so they could go instead. The patient was free for 25 days and finally was located on Dec. 27 in an Oregon coastal community, the report said. Authorities transferred that patient to the Salem campus.
Investigators found the hospital failed to assess the patient’s behavior, discuss rules with the patients before outings and failed to be aware of red flags, such as the patient’s request to use the restroom and efforts to put space and distance between them and others in the group.
But by Jan. 17 — more than a month after the patient’s escape — the hospital had failed to change any policies to prevent future patient escapes.
The inspection also flagged a failure to address and help a patient who attempted suicide. In one instance, a patient attempted suicide twice with two different methods a month apart.
The investigation found multiple failures, such as failure to complete a patient assessment and follow procedures. For example, after the second suicide attempt, hospital staff waited 16 hours after their initial response to search the room for contraband, the report said. That put another patient at risk because two patients shared the room, the inspection found.
The inspection found the hospital failed to adequately document, investigate and prevent future incidents in assault cases. Those assaults included:
- One patient hit another patient in an unprovoked manner in the face, giving them a split lip and abrasions.
- In another case, hospital staff heard patients yelling “fight, fight” and found two of them fighting in a hallway. The initial staffers who responded could not separate the patients and needed backup. One of the patients was sent to a hospital emergency room for treatment.
- One of those two patients was involved in another assault — just two days later. When another patient asked him about his rings, that patient hit his peer repeatedly in the face, the report said. When the patient’s chair crashed to the floor, the assault continued, with punches and kicks to the head and stomach.
Despite the same patient being involved in two assaults, the investigation found “no documentation” of whether the patient was under staff supervision of his movement and behavior, the report said.
“There was no evidence of plans to prevent recurrence for those patients and other patients,” the report said.
That individual, called “Patient 5” in the report, was also harmed, the report found.
“In addition to the patients who were injured during the altercations described above, Patient 5 was also a victim of the hospital’s failure to provide supervision and other interventions to prevent his/her behaviors,” the report said. “Those failures resulted in the use of physical restraint and locked seclusion for Patient 5 and also placed Patient 5 at risk for injury.”
Contraband is also a problem at the hospital, the investigation found. In one case, a patient needed help after they burned their eyes with ammonia and dye from a hair coloring kit they were trying to use without any staff permission. Yet the hospital’s documentation didn’t suggest a plan to prevent that from happening again or say how the patient managed to have two chemical bags in their room without staff noticing, the report said.
On multiple fronts, inspectors found shoddy and incomplete record-keeping. Patient grievance records were vague and incomplete. In a patient-on-patient assault report, the hospital had no follow-up records to show what investigation and plan it put in place to prevent future recurrences.
The investigation also found spotty and incomplete records of the state hospital’s internal monthly inspections. In some cases, staff didn’t conduct needed follow-up on documentation. For example, in one patient unit, the requirement for an accessible and complete fire drill coordinator kit was “non-compliant” in four monthly inspections between July 2021 and November 2021.
The inspection also found unsanitary conditions in patient rooms and the medication room of one unit. Patient rooms had objects strewn about beds and floors and, in one case an overflowing garbage bag with used face masks and drinking cups.
In a hallway and a patient dining room, there were warped and stained tiles.