Federal regulators put Oregon State Hospital on notice after patient death

Staff at Oregon State Hospital failed to make hourly checks of a patient who died of a suspected fentanyl overdose in May, public records and hospital staff said.

On May 24, the patient was last observed alive four and a half hours before staff found the person in their room unresponsive, federal regulators said in a Thursday notice to Oregon State Hospital, the state-run secure psychiatric hospital in Salem. As a result, the federal Centers for Medicare and Medicaid Services put the Salem hospital in “immediate jeopardy” status, which means it could lose its certification and eligibility for federal funding if it doesn’t make swift changes to fix the problem.

Staff “who conducted continuous rounds during that night shift failed to determine whether or not the patient was alive,” federal regulators wrote in the notice, obtained by the Capital Chronicle through a public records request. 

The death was at least the hospital’s second fatality since April that federal officials have connected to inadequate medical attention for patients, public records show. Each time, the hospital has faced the threat of losing its federal certification, which also demonstrates whether it is capable of meeting essential standards for hospitals.

In the latest instance, federal officials determined the hospital failed to ensure the patient’s safety based upon a review of security video footage, which showed staff didn’t determine whether each patient was “alive and breathing,” the notice said.

The document doesn’t disclose the cause of the patient’s death, but Oregon State Police and hospital staff have told the Capital Chronicle the patient died of a suspected fentanyl overdose. The state police agency is investigating the death, which is standard procedure for all unattended deaths at the state hospital. 

After the death, the hospital suspended all outside in-person visits with patients, citing an unspecified incident with contraband that a visitor brought in to a patient.

The hospital sent an email on May 29 to remind staff to check patients on their rounds. But a video review afterwards of two night shifts showed “minimal to no change” in how staff did their work. 

“The time and proximity of staff looking through the windows of closed (patient) room doors into darkened rooms were not sufficient to assess whether patients were alive,” the document said. The report also said in one instance, a patient entered and stayed in the room of two other patients of the opposite gender without detection.

The hospital cares for more than 600 patients at any one time, mostly suspects who need treatment to face charges.

In response to the report, the state hospital is directing staff to make regular, thorough checks that ensure the patients are alive, hospital officials said in a release. The hospital plans to submit a detailed plan early next week to CMS. If approved, the federal agency will visit the hospital again to ensure compliance.

“We know that patients find viability checks disruptive of their sleep,” Interim Superintendent and Chief Medical Officer Dr. Sara Walker said in a statement. “We hope to find a technology solution that will be less intrusive. It is our responsibility to ensure the safety of our patients day and night.”

In a memo to staff, Walker said the checks mean they may see more patient activity at night and encouraged staff to work with patients who have difficulty with the adjustment. 

“As challenging as responding to CMS investigations can be, it does help us identify and close gaps in our procedures and keep patients safe,” Walker wrote in the email, obtained by the Capital Chronicle. “It’s hard when the ground feels like it is constantly shifting underneath us. It’s hard to keep up with all of it. But I am confident we can do it.”

The case is the latest in a string of incidents at the state hospital. In April, another patient, Skye Baskin, 27, was declared dead 69 minutes after his arrival and federal inspectors determined staff failed to check his vital signs immediately upon arrival. Federal officials have also found blind spots in the security camera system and inattentive staff that failed to stop a patient-on-patient assault. Last year, a patient escaped in a transport van and led police on a high-speed chase down a highway. 

Oregon Capital Chronicle is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Oregon Capital Chronicle maintains editorial independence. Contact Editor Lynne Terry for questions: [email protected]. Follow Oregon Capital Chronicle on Facebook and Twitter.

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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.