Patients ‘accidentally’ secluded, staff concerns ignored: Federal report details failures at Oregon State Hospital

An investigation

of the Oregon State Hospital by the U.S. Centers for Medicare & Medicaid Services released Wednesday revealed significant problems with patient care, staff training and hospital policies.

The investigation was conducted in April following

the death of a state hospital patient

in March. A total of 21 patients have died at the Oregon State Hospital since 2020, according to the Oregon Health Authority.

“This report is a clarion call for the need for the immediate changes being implemented now that will have impact to assure that patients at OSH are safe and receiving the care they need and deserve,” said Dave Baden, acting superintendent of the Oregon State Hospital, in a statement. At the end of April, Baden

released a 30-day plan

to improve patient safety that the hospital has been working to implement.

Investigators found that the hospital failed to meet many of its patient rights standards, including the right to informed consent, the right to care in a safe setting and the right to freedom from restraint and seclusion, unless there is an immediate risk to the patient, other patients or staff.

Two of the incidents described in the report that illustrate these failures include medical staff waiting two weeks to inform a patient about the results of an ultrasound and a patient being “accidentally” locked into a seclusion room overnight. The report also notes that oxygen was not always readily available for medical emergencies, patients weren’t always provided with eye glasses, or other sight aids, needed to help them navigate safely and patients were not always correctly assessed after a fall.

The report also outlines a culture where workers felt their concerns about patient care were “ignored and dismissed” by Dr. Sara Walker, the former chief medical officer and interim superintendent.

Walker resigned in April

, shortly after Gov. Tina Kotek was made aware of the complete details surrounding the March death. According to available records, the patient in question was in seclusion when they died and was not properly checked on after a fall.

Workers, who are identified in the report only with initials or not at all, also reported that they felt useful training was nearly nonexistent and that “the newest, least experienced and undertrained staff” were assigned to the programs where the most severely ill patients reside.

Finally, workers told federal investigators that they had been “coached” about what to say by hospital leaders.

Baden, a deputy director at the Oregon Health Authority, was appointed as interim superintendent of the hospital in April to take over for Walker. Two weeks ago, the Oregon Health Authority

named Jim Diegel as the next interim leader

while the search for a new permanent superintendent is ongoing. Diegel started last week, but will overlap with Baden until Friday.

Investigators also found that the hospital’s governing body was not “organized or effective” and that it “failed to ensure” that the hospital followed current bylaws or that medical staff provided appropriate care.

In early May, the Centers for Medicare & Medicaid Services briefly placed the Oregon State Hospital in “immediate jeopardy” of losing federal funding. But on May 12, the federal agency removed the state hospital from that status, according to a May 22 letter from the Center for Medicare & Medicaid Services that accompanied the newly released report.

The hospital now has until Aug. 4 to prove it has fixed the problems identified by investigators.

The hospital was also placed in immediate jeopardy in spring 2024 by the Centers for Medicare & Medicaid Services following several incidents, including three patient deaths. Federal investigators at that time determined that hospital staff

neglected to conduct hourly checks

to ensure patients were alive and breathing, a failure that led to a patient being found dead in May 2024.

The deficiencies report comes out less than a week after the hospital

was ordered by a federal court

to pay daily fines, potentially running to many millions of dollars, for not admitting patients currently held in jail on a timely basis.

Lillian Mongeau Hughes covers homelessness and mental health for The Oregonian. Email her with tips or questions at


lmhughes@oregonian.com


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@lmonghughes.bsky.social

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