Neuropsychiatric admissions area at Oregon State Hospital in Salem, March 8, 2023.
Kristyna Wentz-Graff / OPB
The Oregon State Hospital has released new details about shortcomings federal inspectors found when they visited the hospital after a patient’s death on March 18.
A survey at the state’s main psychiatric facility found that failures of leadership, staff and policies there may have contributed to the death of a Lane County man who was being held in a seclusion room.
But the state blacked out more than 50 pages of the 242 page report, limiting information on how broader policy and leadership failures contributed to the patient’s death.
The Oregon Health Authority received the report from the federal Centers for Medicare and Medicaid Services, or CMS, three weeks ago. The agency delayed making it public due so it could redact the information, according to Oregon State Hospital spokesperson Amber Shoebridge. Shoebridge said the redactions remove specific information that could identify patients because the hospital must comply with the federal medical privacy law known as HIPPA.
OPB has filed a record request for an unredacted copy.
The hospital has until Aug. 4 to submit a plan of correction to CMS, or risk losing its licensure and ability to bill Medicaid.
The patient who died in Mach was Kenneth Hass, Lookout Eugene Springfield has reported. Hass, 25, worked as a landscaper and was from Cottage Grove, according to his obituary.
According to a previous report from CMS, Hass fell and lost consciousness while he was in seclusion.
Hass’ death was the latest in a series of high-profile fatalities and injuries at the facility, which works with the most complex psychiatric patients in the state.
The Oregon State Hospital treats people who have been charged with a crime but are too mentally ill to stand trial, as well as those who have been civilly committed and cannot be treated in community hospitals because they are a danger to themselves or others.
More than a month after Hass died, Oregon Gov. Tina Kotek announced she was replacing the head of the state hospital. Kotek said she took action after learning details about what had happened, but declined to be more specific.
The latest CMS report was based on interviews with hospital staff, incident reports, policy documents, medical records and video surveillance.
In a departure from past reports, it includes a number of anonymous allegations made by staff at the hospital.
“Numerous department, program, and unit medical staff and leaders came forward to speak to the surveyors,” the authors wrote.
Those unnamed staffers, who came forward unprompted, stated that they had raised concerns about safety with the hospital’s executive leadership in the past. Their concerns had been largely ignored and dismissed. Multiple people reported it was specifically the Oregon State Hospital superintendent who had responded dismissively, according to the CMS report. At the time of Hass’s death, Sara Walker was serving as interim superintendent and chief medical officer.
The unnamed staffers said during previous CMS investigations, staff were coached on what to say to surveyors.
The whistleblowers described staff lacking empathy and not understanding how to interact with patients. And they said the newest and least experienced staff had been assigned to two units housing the sickest, most challenging patients.
In a prepared statement, OHA Acting Director Kris Kautz said changes are underway. “The culture at OSH must change if we hope to ensure accountability and provide the highest quality of care for every person admitted,” she said. “There is no other option.”
The bulk of the report focuses on multiple incidents involving alleged lapses in patient safety, including Hass’ death.
CMS staff allege a number of failures in the medical care provided to psychiatric patients. For example, the hospital didn’t always promptly share the results of tests or scans with patients, in violation of their rights, according to the surveyors.
Other lapses jeopardized patient safety. In one incident, when a patient’s oxygen saturation had dropped and they needed supplemental oxygen, the staff discovered the hospital was running low on oxygen canisters. As a result, the patient was given one unit of oxygen instead of the two units that had originally been ordered.
The report also alleges failures related to the use of seclusion and restraint at the hospital. A review of documents found reports that patients in seclusion had obtained items they could use to hurt themselves, like pens, spoons and a broken toilet handle.
The surveyors also wrote that they were concerned that seclusion might be overused.
“Staff did not always exhibit behaviors that demonstrated understanding of the gravity of seclusion events,” they wrote, adding that staff did not make it clear that seclusion wasn’t intended as discipline or retaliation.
OHA Deputy Director Dave Baden, who was named OSH acting superintendent on April 11, said the hospital’s plan of correction for CMS will build on a 30-day stabilization plan developed last month.
“Two key changes implemented in the past few weeks are designed to provide more support for unit staff and leaders who are responsible for the daily care of patients. That’s our pause on telework for patient-facing staff and managers and mandatory rounding or visits to units by OSH leaders. The goal is increased visibility and improved communication between leadership and staff, as well as patients,” he said.
According to the Oregon Health Authority, the plan has three objectives: to decrease the likelihood of events that can lead to harm, injury or death, to improve OSH’s function as a 24/7 hospital, and to provide staff with clearer empowerment to keep patients safe.
