A federal inspection sparked by the escape of a patient from Oregon State Hospital in a vehicle found violations in patient rights and security and transportation procedures.
Now, the state-run residential psychiatric hospital is working on a corrective action plan to submit to the federal Centers for Medicare and Medicaid Services, Oregon Health Authority officials said on Tuesday. That plan is due by Dec. 21.
CMS inspectors visited the state hospital in September and October after the Aug. 30 escape of a state hospital patient who jumped into the driver’s seat of a state van and led police on a high-speed chase southbound on Interstate 4. Firefighters rescued the patient from a muddy pond in north Portland 36 hours after his escape and took him to a local emergency room where a hospital employee recognized him.
In late September, hospital officials announced immediate changes to transportation procedures, such as requiring state hospital employees to maintain control of vehicle keys at all times. During the escape, the patient got control of the vehicle when the driver exited the van and left the keys unattended.
The federal report and results of the inspection, which state officials received Monday, found other shortcomings in hospital safety procedures. While less dramatic than the escape, the inspection uncovered instances of lax security that allowed patients to wander to unauthorized parts of the hospital.
In one case, a patient walked away from their unit after a staff psychologist assumed the patient was a staff member, mainly because they were well-dressed, new to the hospital and well-spoken and smiling, the report said. There was no follow-up documentation of an investigation, the report said.
The inspection’s review found other cases in which patients wandered into areas of the hospital unattended. One patient went into a laundry room. In another instance, a patient was in a fitness room unsupervised and using a treadmill.
“The safety of patients, staff and the public is our number one priority at Oregon State Hospital and we are taking immediate measures to ensure we meet the CMS requirements and continue to keep patients, staff and the public safe and secure,” OSH Superintendent Dolly Matteucci said in a statement.
The hospital formed a workgroup with staffers from nursing, security and other areas to respond to the findings.
The corrective plan is needed to avoid potential termination of the state hospital’s Medicare agreement with CMS. If the state hospital were to lose its CMS certification, it could not bill Medicare.
For most patients, state funding directly pays for health care. But the Medicare revenue is about $14 million annually, said Larry Bingham, a spokesman for the Oregon Health Authority.
If CMS considers the plan satisfactory, the hospital will avoid a cancellation of its certification, which could come as early as March 10, 2024 if the two sides can’t agree on corrective actions.
The hospital in Salem has the capacity to treat 700 patients, and its satellite facility in Junction City can treat about 175. A majority of the patients in the hospital are aid-and-assist cases who are treated according to a court-determined timeline of 90 days to a year, depending on the severity of the charges.
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Ben Botkin covers justice, health and social services issues for the Oregon Capital Chronicle. He has been a reporter since 2003, when he drove from his Midwest locale to Idaho for his first journalism job. He has written extensively about politics and state agencies in Idaho, Nevada and Oregon. Most recently, he covered health care and the Oregon Legislature for The Lund Report. Botkin has won multiple journalism awards for his investigative and enterprise reporting, including on education, state budgets and criminal justice.
