This story has been updated with additional information.
A new safety plan issued by health officials for the Oregon State Hospital provides few specifics on changes at the beleaguered mental health institution where three patients have died in just the past year.
Essentially a three-page listing of goals and next steps, the plan focuses on identifying the risk of future deaths and major injuries, increasing staffing to operate more like a 24/7 hospital, and providing clearer direction and empowerment to staff to keep patients safe.
The Oregon Health Authority issued the so-called “30-day stabilization plan” in response to news of the latest patient death at the hospital’s campus in Salem. As part of Gov. Tina Kotek’s response, she also asked for the resignation of interim superintendent Dr. Sara Walker, temporarily replacing her with a top health authority administrator, Dave Baden..
In the past 12 months, inspectors have found the hospital in violation for conditions related to the unexpected deaths of three patients. The most recent came in March and involved a patient who was left locked in a seclusion room without adequate observation; they died after losing consciousness. The deaths are among a series of events at OSH which has federal officials, state authorities and watchdog groups calling for action to protect the safety of patients and staff.
Baden, who serves as deputy director for the Oregon Health Authority, is the third person in leadership at OSH in the past 15 months.
Walker had taken over the institution's operations after the previous interim superintendent, Dolly Mateucci, resigned in March 2024. For more than a year the state has engaged in a national search for a new superintendent but hasn’t been able to hire anyone, as The Lund Report reported last month.
The Oregon State Hospital houses vulnerable patients,most of them facing criminal charges, who are deemed either a danger to themselves or others or lacking the ability to assist in their criminal defense. It operates two campuses: the primary location in Salem can house 558 patients at a time, while the Junction City location can house up to 145 patients.
In addition to the three deaths, the hospital for years has been the target of damning reports over its operations, staffing and safety issues. Among them was a 102-page report issued by the Centers for Medicare and Medicaid Services in 2023 indicating a pattern of systemic problems. The inspection report 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.
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 30-day plan lays out three objectives:
Find the next sentinel event before it happens: Sentinel events are major injuries, deaths or significant temporary injuries. According to the plan, OSH staff are taking immediate steps to survey the number of patients who are high-risk. They will assess whether patients have appropriate plans in place to mitigate a patient’s particular risks and warning signs.
Operate like a 24/7 hospital: The patient mix at OSH has dramatically changed over the past 10 years and OSH needs to continue to adjust to address the needs of more complex and higher acuity patients, the plan states. That includes better escalation channels at all times of day or night and assuring patients have the needed treatment around the clock. The plan also calls out the need to address staff shortages at the Medical Clinic.
Clarify roles, share responsibility: Staff and managers raised concerns around job expectations and training, according to the report. Additionally, staff have stated that expectations vary from unit to unit and that protocols are not being followed consistently. The plan calls for better training and consistent protocols that don’t rely on staff interpretation. “Frequent policy changes (from audits and other compliance actions) have resulted in unclear expectations, inconsistent application of policies, and no consequences for failure to follow policies,” the plan states.
The plan called for accountability but not retaliation, calling for a shared responsibility for patient safety. It said that requires an environment “where people are able to speak up when they see a problem, and when required actions are not taken, progressive interventions (including disciplinary measures) occur.”
Baden announced when he started on April 14 that he would stay in the position for only 30 days to develop and communicate the plan. It’s unclear who will replace him.
