Oregon State Hospital failed to keep patients safe from assault, federal report finds

By Amelia Templeton (OPB)
May 3, 2024 4:03 p.m.
FILE - A courtyard area inside the Oregon State Hospital in Salem, March 8, 2023. A federal investigation found the hospital failed to keep patients safe from assault.

FILE - A courtyard area inside the Oregon State Hospital in Salem, March 8, 2023. A federal investigation found the hospital failed to keep patients safe from assault.

Kristyna Wentz-Graff / OPB

The Oregon State Hospital, the state’s most secure inpatient psychiatric facility, has only a limited ability to keep its patients safe from each other.


The safety lapses contributed to a serious choking attack, injuries and sexual assaults. The hospital also didn’t adequately investigate the incidents after they happened.

Those are the conclusions of an unannounced, onsite federal investigation conducted at the Salem hospital earlier this year by the Centers for Medicare and Medicaid Services, or CMS.

CMS opened its investigation Feb. 28 after receiving four complaints about the hospital.

OPB received its report through a public records request. The report doesn’t detail who filed the complaints, or why, but federal officials opened their investigation a few weeks after a patient assault on Feb. 10.

That day, out of sight of staff, a patient at the hospital picked up another patient and held them in a chokehold until they lost consciousness. The victim in the attack required extensive medical care.

The investigation found other serious incidents of patient-to-patient aggression, and failures by staff to adequately supervise their charges.

Investigators also found evidence of sexual assault and sexual contact between patients. About half of the hospitals’ units are mixed gender, where male, female and nonbinary patients live together.

Investigators found that the hospital distributed condoms to any patient who requested them and that, in at least once case, it led a patient to wonder whether sex with peers was permitted at the hospital.

CMS is currently conducting an additional investigation into an unexpected patient death that occurred this year. The agency hasn’t released that report yet.

Physical fights

The most thoroughly documented incident in the federal safety investigation took place Feb. 10. A patient, referred to only as Patient 23, sat down that morning in a small outdoor courtyard to eat a banana and drink a warm beverage.

Another patient, Patient 22, entered the courtyard.

No one witnessed what took place next, but it was captured on surveillance video, which the federal investigators watched.

“Patient 22 lunged toward Patient 23 from behind, placed their arm around Patient 23′s neck in a ‘chokehold’ manner, and lifted Patient 23 to a standing position,” the investigators wrote.

FILE - Staff members walk in an outdoor plaza at the Oregon State Hospital in Salem, March 8, 2023.

FILE - Staff members walk in an outdoor plaza at the Oregon State Hospital in Salem, March 8, 2023.

Kristyna Wentz-Graff / OPB

After a brief struggle, Patient 23′s arms fell to their sides and they went limp. “Over the next 16 seconds Patient 22 maintained the ‘chokehold’ while they also shook Patient 23′s limp body, which was lifted off the ground,” the investigators wrote.

Patient 22 released the chokehold and threw Patient 23 to the ground.

Thirty seconds later, a third patient entered the courtyard, saw Patient 23 lying unconscious on the ground, and called for staff to help. Patient 23 was rushed to the emergency department with a major head injury, and needed extensive medical care over the following weeks.

The federal investigators found numerous lapses of policy related to the attack. For example, staff were supposed to be closely supervising patients in common areas at all times.

At least eight staff were in the unit where the attack took place. Video showed them spending most of their time hanging out at the nursing station, not interacting with and watching patients.


Following the assault, state hospital employees involved in the incident were placed on administrative leave, and contract workers were terminated, according to the report.

The report also found considerable warning that Patient 22 might hurt somebody. That patient had been under enhanced supervision and had threatened to kill hospital staff.

A note in the patient’s file from three days before the attack indicated the patient had said, “I’m homicidal,” and, “I feel like killing someone again, grab someone around the neck and strangle the fuck out of them.”

Other deficiencies contributed to the attack, investigators found. There are more than 1,000 security cameras installed at the state hospital, and a security team monitors a live video feed. But with so many cameras, it is impossible to monitor them all at once. The security team didn’t see the attack when it happened, and after Patient 23 was thrown to the ground, they were no longer visible on any of the facility’s cameras.

Investigators reviewed reports of several other patient-on-patient attacks, and found additional safety and patient rights lapses.

Those included a failure to adequately investigate a serious attack that sent a patient to the emergency department. Investigators found little evidence the crime was reported to law enforcement, even though the patient requested a police investigation.

Evidence of sexual assault

Investigators also found the state hospital had inadequately investigated sexual contact and sexual assault, and had been handing out condoms to patients wtihout a clear policy to prevent abuse.

A review of the hospital’s incident log showed an increase in reports of “sexual contact” between patients this spring.

FILE - The Oregon State Hospital in Salem, March 8, 2023.

FILE - The Oregon State Hospital in Salem, March 8, 2023.

Kristyna Wentz-Graff / OPB

From August 2023 to January 2024, there were one or two “sexual contact” incidents per month at both the state hospital campuses in Salem and Junction City. In February, that increased to seven. There were four more incidents in the first 10 days of March.

One recent case involved a vulnerable patient referred to as Patient 25 in the report. The report describes Patient 25 as suggestible and unable to consent to sexual contact due to their mental illness. In January, Patient 25 was transferred out of a unit after being victimized by another patient’s “hypersexual behavior.”

Federal investigators couldn’t find any record that the hospital had investigated that January sexual assault.

After Patient 25 was transferred, their care plan included a note that staff needed to redirect any behavior that could lead to them being victimized again by their peers.

In the new unit, Patient 25 was given $2 and a card that said “I (heart shape) you” by another patient. Patient 25 then reported being coerced into sex. Staff found a condom wrapper in the room where the reported assault took place.

The state hospital did investigate Patient 25′s second assault. The investigation notes revealed that Patient 25 had seen staff distributing condoms to patients and had found it confusing. Patient 25 had asked staff if the prophylactics meant patients should be engaging in sexual contact.

According to that report, staff had tried to educate Patient 25 that the condoms “were not for peer to peer use” and that sexual contact is not permitted at the hospital.

The Oregon State Hospital confirmed to federal investigators that nurses provide condoms to patients, and that there was no written policy governing when it is acceptable to do so.

“It was unclear why the hospital would engage in the practice of condom distribution to any patient who asked without a written policy and procedure that ensured the protection and safety of all patients,” investigators wrote.

They also questioned why the hospital’s internal review of the incident found “no gaps in care” for Patient 25.

Amber Shoebridge, a spokesperson for the hospital, said staff were distributing the condoms to make masturbation more sanitary.

“We are looking at no longer distributing them,” Shoebridge said.

The Oregon State Hospital received the investigators’ report, known as a statement of deficiencies, on May 1. It has 10 calendar days to respond with a plan of correction.

“There will always be things we can improve, and we will continue to do so, but what persists is our dedication to the humans we are privileged to care for,” interim Superintendent Sara Walker said in a press release.

Once CMS approves the plan, it will conduct another unannounced survey to review its implementation.