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State Vows Changes After Feds Blast Unsafe Conditions At Oregon State Hospital's Junction City Campus

The state hospital’s Junction City campus was cited for numerous violations in an inspection after a patient escaped during an outing.
The Oregon State Hospital campus in Junction City. | CHRISTIAN WIHTOL/THE LUND REPORT
May 25, 2022

Officials overseeing Oregon State Hospital’s Junction City campus are promising to revamp its approach to patient safety and well-being in a proposed plan to federal regulators that addresses everything from suicide prevention to patient-on-patient assaults and sexual contact. 

Oregon State Hospital submitted the plan to federal regulators after an inspection found numerous violations jeopardized patient care and safety

The Lund Report obtained a copy of the proposal on Wednesday through a public records request. The federal Centers for Medicare & Medicaid Services gave the hospital a 10-day notice earlier this month to submit a compliance plan. 

The federal agency warned that the state hospital’s Junction City facility could lose its ability to participate in Medicare on Aug. 3 if it continues to stay out of compliance. 

The hospital submitted its 39-page response and proposed plan of correction on May 14, within the federal agency’s deadline. The plan is in draft form and CMS may provide feedback that leads to changes, said Aria Seligmann, a spokesperson for the Oregon Health Authority, which runs the state hospital. Health authority officials were unable to provide a timeline of when they will hear back from the federal agency.

Oregon State Hospital treats patients who have mental health issues, with its main campus in Salem and its smaller campus in Junction City.

The hospital’s proposed plan for the 75-bed facility includes the following the changes:

  • Direct-care staff will be advised of policy requirements for making rounds and continuous patient monitoring, with the expectation that patients not be in their peers’ rooms. The plan also includes a new standardized list of unit guidelines with the expectation that patients will have no sexual contact.
  • Since the initial inspection, the hospital said it has resumed monthly drills for direct care nursing staff in response to findings about patient-on-patient assaults. 
  • The hospital’s plan for suicide attempt prevention includes an updated list of contraband not allowed and inproved procedures in the mailroom to prevent it from entering patients’ rooms.
  • Various procedures and policies will be updated, with training for staff to address issues like patient security and documenting incidents.

Inspectors visited the hospital in December 2021 and January and made a series of findings about the facility’s management.

Those 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. 
  • 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. 

Patient Escape Sparks Investigation 

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 investigation found the hospital had vague and incomplete policies for off-campus supervised outings for patients. The patient ran away from the group and 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 escapee 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 found in an Oregon coastal community on Dec. 27, the report said.

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.

Even so, by Jan. 17 – more than a month after the escape incident – the hospital had not changed any policies to prevent future occurrences. 

In its proposal, the hospital said it would halt off-campus outings for patients until its plan of correction is put in place, except for those that are necessary, such as medical appointments.

The hospital also plans to retrain security staff and other staffers in patient personal searches for contraband and procedures for patient outings, including transportation, communication, patient supervision and documentation.

Other Changes 

Other fixes that the hospital proposes are: 

  • Hiring a designated on-site administrator for the facility. The inspection found the hospital didn't have a designated adminstrator.
  • Responding to patient grievances within seven business days, with exceptions for cases that require a detailed investigation such as alleged staff abuse or civil rights violations.
  • Developing a team to improve the hospital’s system for tracking incidents that merit investigations.
  • Periodic audits in areas such as patient safety and staff training. 

For most measures, state officials estimated they will be in place by June 14.

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.