This article has been updated to include additional reporting.
Oregon State Hospital staff have committed numerous safety lapses jeopardizing patients in their care, according to a new federal inspection report released Wednesday morning.
Not only that, but top leadership was dismissive of patient safety concerns, and also that staff were coached on what to tell the inspectors — at least, according to what some staff members told the inspectors.
The report details an investigation launched by the Centers for Medicare and Medicaid following the unexpected death of a patient in March, the third unexpected death at the facility in the past year.
In its letter to the state dated May 22, the federal agency gives the hospital until Aug. 4 to address the problems or face losing its federal funding. This is the latest such warning the hospital has received over the years from federal investigators.
With facilities in Salem and Junction City, the state psychiatric institution confines hundreds of people whose mental illness makes them unable to stand trial.
The death in March highlighted longstanding concerns over the quality of care at the facility and what outside inspectors have long characterized as leadership’s failure to establish a culture of safety.
The 245-page, heavily redacted report echoes earlier such reports finding problems with facility policies and procedures. The lapses cited in the newest report concern training, patient rights, patient safety and the use of seclusion cells for patients.
Scathing findings
The investigators cited unsolicited input from numerous hospital staff who reported:
- Concerns over patient deaths and serious patient harm were “ignored and dismissed” by the executive leadership, specifically the superintendent and the chief medical officer.
- Staff were coached on what to and what not to say to investigators.
- After the hospital was found back in compliance, a number of corrective actions and monitoring activities were discontinued, and processes returned to pre-investigation status.
Other findings focused on the use of seclusion and restraints:
- Hospital staff failed to observe and monitor patients in seclusion
- Patients in seclusion were allowed to have contraband items that could be used to harm themselves or as potential weapons against others.
- Patients were locked in seclusion improperly, possiblyas retaliation or punishment.
- One patient was “accidentally” locked in seclusion overnight, and management took no steps to prevent that from happening again.
- The hospital’s failure to provide care or medical response that potentially contributed to harm and death of one patient and created the likelihood of harm to others.
To read the full report, click here.
In a prepared statement, Oregon Health Authority Deputy Director Dave Baden, who spent several weeks as the hospital’s acting superintendent, said the state is already making changes that will address the problems the report highlights. But, he added, “Sustained and ongoing cultural changes at the hospital will take time.”
Troubled history continues
The three deaths this past year are part of a larger web of problems entangling the state’s largest psychiatric facility.
A linchpin between the state’s criminal justice system and health care agencies, the state hospital has evolved from serving people civilly committed to the state’s custody to becoming almost overwhelmingly dedicated to housing criminal defendants deemed unable to “aid and assist” in their defense.
The staffers and providers charged with adapting to a new patient population have themselves been plagued by persistent vacancies — requiring the hiring of costly temps at a cost of tens of millions of dollars to fulfill a new state nurse-staffing law.
For years, the institution has been the target of disturbing reports over its operations, staffing and safety issues, including a 102-page report issued by federal investigators in 2023 indicating a pattern of systemic problems. That investigation was triggered after a patient accused of aggravated murder and other crimes escaped after being left unattended in a van with the keys left in the ignition.
The hospital is also at the center of multiple lawsuits against the Oregon Health Authority, some of them saying the state’s behavioral health failures have forced jails and hospitals to house patients without appropriate care.
On Friday, a federal judge ruled the state was in contempt for the hospital’s failure to house court-ordered patients in a timely manner. The ruling imposed fines of $500 a day for each person experiencing mental illness who spends more than a week in jail after a finding that they are not competent to stand trial. The judge also appointed a “court monitor” to hire staff and watchdog operations at the Oregon State Hospital.
Two hirings for top job failed
The hospital hasn’t had a permanent superintendent since Dolly Matteucci resigned in March 2024.
Chief Medical Officer Sara Walker then agreed to serve as interim superintendent while a national search was launched to hire a permanent leader for the troubled institution. Since then, two formal hirings for the job have failed to produce a replacement. It’s unclear whether that’s because candidates declined the job or were not considered sufficiently qualified.
In April, after initial news broke revealing some of the treatment failures associated with the death of a patient the previous month, Gov. Tina Kotek ordered the Oregon Health Authority to install new leadership, and Walker was “asked” to resign.
Baden has served as acting superintendent since then. In late May, the state tapped Dr. Jim Diegel, the former president and CEO of the Redmond-based St. Charles Health System, to take over as interim superintendent at the hospital. He is the third interim to fill the spot in just over a year.
The plan in hand
Following the turmoil in leadership in April, the health authority released a so-called 30-day stabilization plan to improve operations at the hospital. The three-page plan provided few details, but stressed the need to focus on preventing deaths, increasing staffing to operate more like a 24/7 hospital, and providing clearer direction and empowerment to staff to keep patients safe.
In her 2025-27 budget proposal, Gov. Kotek has included a 20.5% increase for the state hospital, bringing its total funding to over $1 billion, with the goal of reaching sustainable staffing levels and bringing it compliance for safety requirements.
The state also needs to find additional funding to cover the fines from this month’s contempt ruling, which are expected to cost $7 million yearly.
