After a patient dies, federal inspectors put Oregon State Hospital on notice over reimbursements

Federal inspectors found disorganized emergency medical supplies at Oregon State Hospital’s admissions area when they visited the state-run psychiatric residential facility in Salem after a patient’s unexpected death this spring, public records show. 

The failure to keep the supplies all in one place could cause staff to lose valuable time in cases of medical emergencies, they said, placing the Oregon State Hospital in “immediate jeopardy” status. That means the hospital could become ineligible to receive federal Medicaid and Medicare funding through the federal Centers for Medicare and Medicaid Services. The state hospital has about 680 patients and most of them are patients who needed treatment in order to face pending criminal charges and aid in their defense. Relatively few are on Medicaid, making the federal reimbursements only a fraction of the hospital’s funding.

Oregon State Hospital officials on Monday said in a press release they are working on a plan to correct the problems and have already started to make changes in how emergency medical equipment is stored. They also said the shortcomings did not contribute to the patient’s death. 

Amber Shoebridge, a spokesperson for the state hospital, declined to answer questions about the circumstances of the patient’s death, including the day the patient died, whether it was natural causes and why the death was reported to the federal agency, citing federal and federal privacy laws.

The notice and federal report, obtained by the Capital Chronicle through a public records request, said the hospital put out a directive on April 19 requiring that when patients are not responsive in admissions that staff immediately assess the patient for a medical emergency. That means the patient died either on or before April 19. 

Report: Emergency supplies scattered in four spots

Inspectors flagged shortcomings about how the hospital stored emergency medical equipment used to resuscitate patients in life-threatening situations. 

“Emergency supplies and equipment were disorganized and not maintained together in one easily retrievable place to ensure a timely and efficient response,” the report. “Various emergency items were found in at least four different locations on and off the admissions unit.”

In one instance, the contents in a duffel bag of supplies did not match the accompanying list, the report said. Federal inspectors did not blame the hospital for the patient’s death in the notice, but warned that the lack of organization could lead to delays and the loss of valuable time during resuscitation attempts.

“There is likely (a) serious adverse outcome to patients who enter the hospital through the admissions unit should their conditions require a medical emergency response,” the report said.” “It is likely that chaotic delays in appropriate emergency care would occur as (a) result of staff, lacking policy or specific roles in emergency, would simultaneously attempt to gather all necessary equipment and supplies located in multiple areas.”

The report notes hospital staff gathered the emergency medical equipment together on a push cart and stored it in one room when federal inspectors were at the facility. But the storage room with all the equipment still had a misleading sign with multiple handwritten entries that directed staff to other locations to obtain supplies and equipment, the report said.

“The primary concern was that all code blue equipment for the admissions area was not in the same room. We have already rectified this,” Dr. Sara Walker, interim superintendent and chief medical officer, said in a statement. “I am confident that together we will make the necessary changes to provide a safer environment for patients.”

The state hospital is also creating a plan that will describe how and when the hospital will correct other outstanding issues, including updating the signage, state officials said. That plan will go to federal officials and, if accepted, CMS officials will make another on-site visit.

Oregon State Hospital operates on a two-year budget of about $800 million, or about $400 million annually. Federal funding from Medicare and Medicaid is a relatively small part of the hospital’s budget – slightly more than 4%. That’s about $19 million annually.

Last year, Oregon State Hospital officials also needed to fix problems with patient transports and security after a patient jumped into a state van and led police on a high-speed chase southbound on Interstate 5. Federal inspectors who followed up after the escape found instances of lax security that allowed patients to wander to unauthorized parts of the hospital. Since then, the state hospital has upgraded its transport and security practices.

Oregon Capital Chronicle is part of States Newsroom, a nonprofit network of news bureaus supported by grants and a coalition of donors. Oregon Capital Chronicle maintains editorial independence. Contact [email protected]

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Ben Botkin - Oregon Capital Chronicle

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.