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Oregon State Hospital hit with new patient safety warning by federal regulators

State hospital staff kept emergency response equipment in different rooms, sparking concern. State officials say they’re fixing it
Oregon State Hospital in Salem, Oregon, on Nov. 21, 2023. | JAKE THOMAS/THE LUND REPORT
April 29, 2024

The federal government has again warned the Oregon State Hospital about unsafe conditions after inspectors found disorganized medical supplies that could delay life-saving treatment for a patient in an emergency.  

The Oregon Health Authority indicated in a statement Monday that federal health officials have placed the psychiatric facility’s main campus in Salem in “immediate jeopardy status.”

Such notices put facilities at risk of losing eligibility to receive Medicare or Medicaid reimbursements if the unsafe conditions are not rectified. For the Oregon State Hospital, it represents just the latest such warning from federal regulators over conditions at the facility. The statement did not fully explain what alarmed federal inspectors, but indicated the problems would be resolved. 

Inspectors with the Centers for Medicare & Medicaid Services were called to the state hospital after administrators reported a patient death, according to the statement. At the hospital, they found emergency equipment spread among more than one room in its admission area. 

Inspectors wrote in the April 26 notice to the state hospital that they found emergency supplies and equipment in the admissions area and adjacent units “disorganized and not maintained together in one easily retrievable place to ensure a timely and efficient response.” 

“There is likely serious adverse outcome to patients who enter the hospital through the admissions unit should their condition require a medical emergency response,” reads the notice. “It is likely that chaotic delays in appropriate emergency care would occur as result of staff, lacking policy or specific roles in emergency, would simultaneously attempt to gather all necessary equipment and supplies located in multiple areas.”

The notice stated that, “Various emergency items were found in at least four different locations on and off the Admissions Unit including in a ‘duffle’ type bag, a ‘tackle’ type box.”  

The notice further stated that the list of items in the duffle bag did not match its contents. Additionally, a defibrillator was located down another hallway and a suction machine was in another inpatient unit, according to the notice. 

The location of the equipment did not contribute to the patient’s death, according to the statement, but regulators found its dispersal concerning enough to put the state hospital on immediate jeopardy status. The statement did not detail the equipment or the hazard it posed, but noted it was for “Code Blue” situations, which could be life-threatening. 

“The primary concern was that all Code Blue equipment for the admissions area was not in the same room. We have already rectified this,” Dr. Sara Walker, the state hospital’s interim superintendent and chief medical officer, said in the state press release. “I am confident that together we will make the necessary changes to provide a safer environment for patients.”

According to the release, a team of clinical and administrative personnel is working on a plan to resolve any other problems identified by federal regulators, such as updating signage. The state hospital plans to submit the plan early this week. 

If the plan is approved, a federal inspector will follow up with an unannounced visit to review its implementation, according to the state.

Inspectors have found unsafe conditions at the hospital in the past, including at its Junction City campus. The Joint Commission, which sets standards for facilities, and the state version of OSHA have chimed in as well. Reports by federal officials and The Joint Commission both questioned whether the agency has prioritized a culture of safety at the facility’s locations.

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