A federal inspection of Oregon State Hospital’s Junction City campus found issues relating to patient care and mismanagement. The facility is now facing threats of decertification if it remains noncompliant by Aug. 3. The state-run facility has already submitted its proposal of changes which include more training for staff and monthly drills. Joining us is senior reporter for the Lund Report, Ben Botkin. He shares details of the investigation and helps explain what decertification could mean for this institution.
The following transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. The Oregon State Hospital’s Junction City campus has major problems with patient safety. That’s according to a recent federal inspection. The problems are serious enough that the facility is now facing threats of Medicare decertification in early August if it doesn’t address its problems. The state-run mental hospital has already submitted proposed changes, including more training for staff and new safety measures. Ben Botkin has been writing about this as a senior reporter for the Lund Report. He joins us now to talk about what he has found. Ben, welcome back.
Ben Botkin: Glad to be here.
Miller: First of all, what’s at stake in this? What would decertification even mean?
Botkin: This certification comes through the federal centers for Medicare and Medicaid Services, and it allows hospitals to be eligible for funding. Now that’s not necessarily a big deal for Oregon State Hospital because its amount of Medicare funding is pretty small. The state pays for that up front. However, this is really about whether or not the hospital can meet industry standards that set a basic baseline of how hospitals are supposed to be, from a quality standpoint.
Miller: I want to go through some of the biggest issues that the investigation turned up. What happened after a patient told hospital officials last July that their roommate had sexually assaulted them?
Botkin: What happened was they reported that to law enforcement. They then moved that patient’s roommate to another room on the same unit. Beyond those two things, the inspector found that really there had been no follow-up. So when they asked staff, ‘Hey did you interview the person accused of the assault?’ staff weren’t even able to tell them if there had been a follow-up interview with the people involved.
Miller: What’s supposed to happen after allegations of an assault like that?
Botkin: Generally with high profile incidents like this, there’s supposed to be an internal investigation that runs parallel to what police do. That means you interview all the people who may have been involved, potential witnesses, and then perhaps take administrative action regardless of what law enforcement does. This could potentially mean moving the patient to another unit, for example.
Miller: In another case, you note that two patients were moved to separate rooms after they told hospital staff that they had had consensual sex. What else is supposed to happen after a report like that in a hospital setting?
Botkin: What needs to happen is you need a policy that really discourages this kind of behavior. You also need to have an understanding and a patient’s medical records of whether or not they can even give consent. That was another issue that came out of the inspection.
Miller: This overall inspection was prompted by a patient who escaped while on a field trip. Can you tell us what happened?
Botkin: Sure. In early December of last year, there was a group of patients that went on an outing outside the hospital campus. One of the patients stayed a small distance away from the group and eventually ran away. Staff tried to get him, but they weren’t able to get him back. That patient then was not found for several weeks. Police found that person several weeks later in a different community along the Oregon coast. That’s really what sparked the investigation and the additional findings that the inspectors found.
Miller: What else did the investigation turn up in terms of the hospital’s protocols, specifically in terms of keeping patients safe either from themselves or each other?
Botkin: Lots of the problems had to do with a lack of documentation and a lack of follow-up investigation into things that happened. For example, there was one patient: This patient assaulted another patient. Two days later, the same patient assaults someone else in a second incident. Yet, when they look at the records, there’s no record of that patient, after the first incident, receiving any kind of special supervision or special care. There’s things of this nature where there’s a lack of follow up after a serious incident happens that the inspectors flagged.
Miller: What else stood out to you in this report?
Botkin: Another thing that stood out was, you had a general lack of training for staff. Staff are not being trained on a regular basis on things like drills for when there’s a patient-on-patient assault. That’s another thing that’s in their plan to add. Also just issues of overall cleanliness and security of the facility. One final thing that stood out is, you had an attempted suicide… A patient was removed from the room. The roommate is still in there, but they waited 16 hours before they actually searched the room for any contraband or any materials that the other patient could have potentially found and used to harm themself.
Miller: Staff told an inspector, during a visit in December of last year, that the hospital had no designated on-site administrator since the last one had retired a year earlier. Does that mean that nobody in the building was actually officially in charge?
Botkin: My impression was they distributed those duties among other staffers. The problem is, under federal regulations, you need a designated point person, a designated administrator, who is accountable for the facility. So that’s one other issue where they’re planning to hire someone.
Miller: One of the details that stood out to me is that the surveyors who work for the Oregon Health Authority actually did the inspection on behalf of federal regulators. Doesn’t that mean that the agency that runs the hospital was, in a sense, investigating itself?
Botkin: I guess you could argue that’s technically the case. However, they do send those findings to the federal agency which then reviews the information, then makes the decision about the notice of potential decertification. That’s also a similar system that’s used in place for, say, inspections of nursing home facilities.
Miller: How did state officials respond publicly when the results of this federal investigation were released?
Botkin: Publicly they said they’re working on a plan to address it. They released the inspection findings and, by all indications, they appear to be taking it seriously.
Miller: What did the hospital or the state put forward in its plan to federal regulators? What do they say they’re going to change?
Botkin: There’s a lot of systemic changes you’ll see, beyond just hiring an administrator. That includes things like additional training for staff, drills for staff on how to respond to critical assaults – incidents like that, training for staff on how to properly handle patient outings. There’s a lot of things of that nature where they’re planning to do better record keeping and better follow-up of tracking incidents and training staff.
Miller: I think our audience is pretty used, at this point, to hearing about problems at the Oregon State Hospital in Salem. But we hear less about the newer and smaller campus in Junction City. Does this issue of potential decertification apply to both?
Botkin: This would only apply to the Junction City facility.
Miller: What’s the time frame right now in terms of the implementation of the changes the state is saying they’ll make and a decision from federal authorities?
Botkin: They sent their proposed plan already, and they’re waiting on answers from the feds. The feds could suggest different things they need to do. They also say that they’re going to implement most of these changes by June 14. Then the final deadline for them to have a plan that the federal government agrees on is August 3. So there’s a couple of weeks here where they can work on the goals and then a longer period, if they miss those goals, to fix everything.
Miller: Ben Botkin, thanks very much.
Botkin: Thank you.
Miller: Ben Botkin is a senior reporter for the Lund Report. He joined us to talk about safety problems that were identified in a recent federal inspection at the State Mental Hospital in Junction City.
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