Oregon State Hospital boosting security after federal report details patient assaults
PORTLAND, Ore. (KOIN) – Oregon State Hospital is planning on hiring more security positions after a federal investigation found the hospital has failed to protect patient-to-patient physical and sexual assaults.
The investigation was conducted by the Centers for Medicare and Medicaid Services during an unannounced visit to the hospital’s Salem and Junction City campuses in February and March 2024, as first reported by Willamette Week.
The investigation was sparked after a “serious incident of patient-to-patient aggression” in February and led CMS to also review three other incidents from previous years, including cases of physical aggression between patients and sexual contact.
The report states the hospital failed to develop and implement procedures to prevent physical and sexual assault, failed to ensure staff carried out their duties, and failed to ensure all high-risk patient areas were monitored 24/7 with security cameras.
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After the investigation, CMS released a 102-page report of deficiencies they found at the hospital.
According to the CMS report, four complaints against Oregon State Hospital were substantiated.
The CMS report cited one patient grievance form from August 2023 in which a patient said they filed two grievances over a three-day period about another patient’s aggressive behavior.
The behavior included one instance when the patient was punched in the head, and other cases when the instigator tried to provoke another fight with them and other patients.
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In the grievance form, the patient claimed hospital staff failed to intervene, adding “This is systemic supported abuse and violence.”
According to the CMS report, hospital staff resolved the issue, and the patients no longer live in the same unit.
The report described another attack among patients in February 2024 in which one patient was in a chokehold in a patio area. The patient was found unconscious with a bleeding laceration on their face, the CMS report described, noting a Code Blue was called, along with 911, and the patient was taken to an emergency department.
The patient who instigated the attack was under observation orders; however, there was a lack of staff to ensure observation assignments were followed, the report said, noting some staff contracts were terminated following the incident.
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It was not known if security cameras showing the patio where the attack happened were being monitored at the time, the report stated, however, blind spots in the area were identified, including where the victim was “thrown and laid,” CMS said.
During the investigation, CMS learned the Salem campus has around 1,083 security cameras, with three stations where staff monitor live camera feeds.
Oregon State Hospital is working on a corrective plan, which includes hiring more staff to monitor the cameras. OSH told KOIN 6 News they initially planned on hiring 75 people to monitor the feeds but said that number may evolve.
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After CMS approves the corrective plan, the federal surveyors will make another unannounced visit to the hospital to ensure the plan is being implemented.
In a statement regarding the investigation, Oregon State Hospital Interim Superintendent and Chief Medical Officer, Dr. Sara Walker, said “There will always be things we can improve, and we will continue to do so, but what persists is our dedication to the humans we are privileged to care for.”
Plans to boost security come after CMS placed the hospital in immediate jeopardy status in late April following a patient’s death. The status was in place because Code Blue equipment — including emergency gear such as a defibrillator, overdose reversal drug Narcan, and an oxygen tank– was not stored in an organized manner, which posed a future safety risk.
While CMS lifted the immediate jeopardy status in early May, Oregon State Hospital could have lost eligibility to receive Medicare and Medicaid reimbursement totaling $37 million to $38 million, or just over 4% of the hospital’s biennial budget, if the status was not removed, officials told KOIN 6 News.
“The primary concern was that all Code Blue equipment for the admissions area was not in the same room. We have already rectified this,” Walker said. “I am confident that together we will make the necessary changes to provide a safer environment for patients.”
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