Safety lapses contributed to patient assaults at Oregon State Hospital, federal report says

Safety lapses at Oregon State Hospital contributed to recent patient-on-patient attacks, a federal report on the state’s safest inpatient psychiatric facility has found.

The Centers for Medicare and Medicaid Services investigation found that staff did not always adequately supervise their patients and that the hospital did not fully investigate acts of aggression, Oregon Public Broadcasting reported.

The federal agency opened the investigation after receiving four complaints. The findings were published following an unannounced on-site investigation conducted at Salem Hospital earlier this year.

A major incident detailed in the report occurred on February 10, when a patient placed another patient in a chokehold until he was unconscious. According to the report, the victim required “extensive” medical care for his injuries.

Investigators also found that the hospital failed to prevent sexual violence and sexual contact between patients.

In January, a patient was transferred from a unit due to “hypersexual behavior” by another patient, the report said. But in the new department, the patient reported that he was forced to have sex.

The hospital received the federal report, known as a statement of deficiencies, on May 1. The hospital has ten calendar days to respond with a correction plan.

“There will always be things we can improve, and we will continue to do so, but what endures is our commitment to the people we have the privilege of caring for,” Interim Superintendent Sara Walker said in a statement.

Once the Centers for Medicare and Medicaid Services approves the plan, it will conduct another unannounced study to assess its implementation.

The state hospital has long struggled to address staffing shortages, overcrowding and other security shortcomings.

Just days before the statement of deficiencies was received, the hospital was placed on “immediate jeopardy status” by CMS after a patient died shortly after arriving at the facility. The federal agency noted that emergency equipment was not stored in an organized manner in the recording room. They found that while this did not contribute to the patient’s death, it posed a potential future safety risk, the Oregon Health Authority said in a statement.

The danger status has since been lifted, state health officials said.

Last summer, a man recently taken to hospital escaped while completely chained up and drove away in a stolen van. He was found in a pond and then taken into custody, authorities said. A subsequent federal investigation found that the hospital failed to adequately supervise and transport the patient.