Oregon State Hospital in Salem, March 8, 2023.
Kristyna Wentz-Graff / OPB
The Oregon State Hospital in Salem, the state’s only public psychiatric hospital, is facing multiple lawsuits alleging retaliation against those who have formally raised serious issues about the way it is treating — or failing to treat — its patients.
OSH has been out of compliance with federal standards in recent years, and it has been found in contempt of court for not admitting mentally ill criminal defendants quickly enough.
Last year, Lindsey Sande, the deputy chief nursing officer at OSH, was so concerned she made a formal complaint. But she says nothing was done, and the patient died 9 days later. She says she was demoted shortly thereafter, along with two other whistleblowers.
We’ll talk with Lillian Mongeau Hughes who covers homelessness and mental health for The Oregonian/Oregonlive.com. And we hear directly from Sande about how she sees OSH patients being cared for and how employees who speak up are being retaliated against.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. About a year ago, a longtime nurse leader at the Oregon State Hospital was concerned about the care that a patient was receiving. She was concerned enough that she filed a formal complaint with the Oregon Health Authority. Nine days later, the patient was dead. A few months after that, the nurse, along with two others who’d spoken out, all had lower level jobs. Those nurses have now announced their intent to sue the state for retaliation.
One of those nurses, Lindsey Sande, joins us now, along with Lillian Mongeau Hughes. She covers homelessness and mental health for The Oregonian and she wrote a recent article about this. Welcome to you both.
Lindsey Sande: Thank you.
Lillian Mongeau Hughes: Thanks, Dave.
Miller: Lillian, I want to start with you and start with some of the basics here. Can you just tell us who the patient population is at the state’s only public mental hospital?
Mongeau Hughes: So the Oregon State Hospital, as you say, is the state’s sole psychiatric hospital, where they take in anybody who needs that extra care. Historically there have been a lot of civil commitments there, so people with extreme mental illness whose family decide they need treatment. In the last few years, that has shifted. The primary population now is people who are on what we call “aid and assist,” and that means they’re people who aren’t competent to stand trial, and they’re supposed to be at the hospital for a shorter period of time to get them competent. There’s also people who are there who’ve pled guilty except for insanity. There’s a little more than 600 people at the Oregon State Hospital across two campuses, one in Salem and one in Junction City.
Miller: There have been issues at the Oregon State Hospital on and off for years, really for decades. What led you to report on the hospital recently?
Mongeau Hughes: We now know that the patient’s name was Kenneth Hass – when he died last March, he died after having spent most of seven months in seclusion. And it was kind of like a mini explosion.There had been, let’s say, lots of mini explosions, and this was a bigger one. I heard when this happened, we reported on it, but just gave out the information we had from the Oregon State Hospital. And I pretty immediately heard from staffers, nurses, mental health technicians, which are the baseline floor staff, were all writing to me and calling me and saying “something bigger is wrong here, you need to look into this.” I wasn’t able to do that at the time. I was new in the role covering homelessness in Portland. But then when the whistleblowers approached me at the beginning of this year, and they were willing to put their names on it and say this happened and step forward, we were able to move forward much more quickly.
Miller: I want to take a step back. Lindsey, you started to work at the state hospital about 16 years ago, is that right?
Sande: I started November of 2010.
Miller: So what was patient care like there in the 2010s?
Sande: I would say the overall mission and vision of the hospital was very clear. Everyone knew their role and how to function, their little niche as part of the hospital. Treatment was the focus. Everybody wanted to provide the best treatments possible, we had a lot of robust disciplines to help provide that treatment. I would say the hospital’s culture in general, you felt very open to talk and discuss challenges with different leaders. I personally toured the superintendent late at night at all different hours, so he had the opportunity to talk with direct care staff.
Miller: He would choose to be there late in the night?
Sande: He did indeed choose to be there late in the night.
Miller: When did all that start to change?
Sande: I would say the pandemic is really when it started to change and then we’ve just never been able to get back on track. I mean really, the Oregon State Hospital was kind of the pinnacle state hospital. We were really proud of the work we did.
Miller: What led you to file a formal complaint with the Oregon Health Authority about the hospital a little more than a year ago?
Sande: I was aware and had reiterated my concerns about the ongoing seclusion, specifically about the patient, Kenny. I felt, and my boss felt, that we just were not making any traction on making changes as fast as we felt that we needed to. And I think it came to a point where I felt so helpless that I was willing to take the risk that I knew was probably coming my way to make the formal complaint about his care.
Miller: As I noted, nine days after that formal complaint about his care, 25-year-old Kenneth Hass died. What happened to him?
Sande: I can’t speak about the details that happened to him, but I can tell you that he passed away while in seclusion.
Miller: Do you think that his death could have been prevented if the warning that you had made had been paid attention to?
Sande: I believe that is the case, yes.
Miller: Do you think that his case was an outlier or an example of more systemic problems?
Sande: I certainly believe it’s an example of more systemic problems.
Miller: Lillian, you noted that the hospital had been out of compliance with federal quality standards for most of 2022, a few months of 2023, and most of 2024. Why? What does this mean?
Mongeau Hughes: I should add, also much of 2025 in the end.
So I want to say quickly to what Lindsey was saying, we found in our reporting a lot of data supporting everything she said about there not being massive problems at the hospital again until recently. So we know that before 2008 there were problems. Then a lot of the time she was talking about at the beginning, the seclusion rates were lower, they had fewer what they call “sentinel events.” There weren’t massive issues that made somebody have to come in and investigate from the federal side.
What happened in these years, 2022, 2023 through 2025, was that they had several sentinel events, I want to say it was eight. And that means like somebody escaped in a way that they thought “something went wrong and that’s why someone escaped,” or somebody died in what they call an “unanticipated way.” Of course, in some ways, most deaths are unanticipated, but this is like something clearly happened that went wrong and that could have resulted in the death, so we need to investigate it and see what it was. And so those are the reasons that they ended up out of compliance for all of that time, because the federal investigators came in and found problems, and determined that the hospital was at risk of losing its federal money.
Miller: You were able to look at an unredacted copy of a federal investigation into Hass’s death. What did that investigation find?
Mongeau Hughes: Well, it’s a 242-page investigation, so I will say that it found a lot. To sum up, I think they found major problems with their restraint and seclusion policies and practices, and they found major problems with the culture at the hospital and the leadership’s willingness to listen to staff warnings. Those were the two things that put them in immediate jeopardy of losing their Medicaid and potentially Medicare funding.
So those are the two biggest findings, but they also found findings like there was a code blue response when Kenneth Hass fell. That’s part of what happened, he was in seclusion and he fell off of a toilet and hit his head. And the code blue response was slow, it was poorly performed. They saw all this on video, so the investigators found that. They also looked at eight other patient cases where people were in seclusion and found similar problems across all the cases, not just this one patient.
Miller: Lindsey, as I think you know, officials from the Oregon State Hospital … First of all, I should say that we invited them to join us on today’s show, they declined to join us. But they did provide a statement that was a response to a number of very specific questions that we asked. I want to run a couple of those responses by you over the course of this conversation today.
Among other things, they said that extended seclusion times have gone down over the last year. They wrote that for a three month period about a year ago, the average duration was nearly 28 hours. And over a recent three month period, that was down to about four hours. They said they were able to do this through a variety of means, including by implementing a seclusion or restraint consult team and by increasing oversight of extended seclusion events, bringing more hospital leadership into, it seems like, a conference room to talk about what was happening if somebody was being secluded for 24 hours or more.
What do you make of these changes?
Sande: I’ll speak directly to the extended seclusion and restraint team. That team was one of the things that we were pushing for prior to Kenny’s passing. Since the time we initiated it, which was about the middle of March 2025 kind of unformally, and more formally on April 7, that official team was disbanded in the beginning of October. So I’m unaware currently in my role of official seclusion and restraint team that is targeted towards those long-term seclusions. If there is one, that information isn’t necessarily transparent to the organization.
Miller: So they’re saying this team exists, you’re saying you don’t see evidence of it?
Sande: I don’t see evidence or information about that team.
Miller: What about the numbers themselves? They seem to reflect a dramatic change in the actual practice happening, from 28 hours average duration to about four hours. Do you see that?
Sande: There’s not data that’s shared transparently, again across the organization. I’m not going to dispute those numbers. I think when sharing those numbers, it’s important to look at it from a holistic perspective. So with those numbers, it would be great to also see assault numbers, both patient to patient assaults and patient to staff assaults. Because again, if you’re only focusing on one part of maintaining a safe milieu, you’re missing the other part, which is ensuring that adequate treatment is provided by those individuals.
Miller: I’m glad you brought that up. We did ask them about that as well. The hospital sent us data about what it categorizes as “aggression events.” They range, as they say, from verbal threats to what would be considered an assault. The data they gave us compared the first three months of last year to the same period this year, January to March of 2025 and 2026. They said aggression between patients was up 43% last year to this year, and aggression to staff was up 31% last year to this year. What does that tell you?
Sande: That tells me that they’re focusing only on seclusion and restraint, and not how to support staff supporting patients and providing adequate treatment.
Miller: They’re not here so I can’t ask them this question, but I’ll ask you, what do you see as a way to do both of those things? To provide the best possible care to a very vulnerable and sometimes violent population, and do that in a way that keeps staff like you as safe as possible?
Sande: I think I’ll lean on what we used to do, which was again, leadership of the hospitals was incredibly connected to the staff. And when I say leadership, I’m talking about your top tier leadership. They frequently made rounds, interviewed staff. And then any initiative to improve safety, often they would use help from their labor partners and identify direct care staff to help participate in different initiatives. And again, that may be going on right now. That information is just not shared more broadly.
Miller: Lillian, you found that OHA leadership had been told about allegations of a culture of retaliation going back at least two years. What did you find?
Mongeau Hughes: I should give credit here to the Lookout Eugene-Springfield that did some great reporting on a couple of private meetings … well, their reporting was on one private meeting, but I later found out there had been two, where Director Sejal Hathi, the director of the Oregon Health Authority, came into the hospital to meet with upper level management in the hospital. She did that both on the clinical side and on the program management side, and she got pretty significant feedback from those leaders about the problems at the hospital.
One of the meetings was sort of surreptitiously recorded, that’s the one the Lookout got and published. And so there were actual quotes in there from what people were saying to Hathi. And they were things like “retaliation is alive and well here,” “people feel helpless, they can’t make change,” and “nobody believes that management’s going to do anything for them anymore.” Hathi in the meeting acknowledged those concerns. We were able to check those quotes with the specific people that said them during our reporting and they were all verified. So, we know that they knew that there were problems.
Miller: What came from those meetings?
Mongeau Hughes: From what I understand, not very much. That all happened before the problems came to light with Hass. So for months afterwards, the situation didn’t change significantly. They did add “radar meetings,” that was a few months before Hass passed. And those were like meetings in the morning every day where hospital leaders were involved in the meetings and had to hear specifically about restraint and seclusion, among other things, so that everybody was tied in. But those meetings went on for months with no change, so it’s hard to say if practices changed because of this.
Miller: Lindsey, I wanna turn to your legal assertions that you have faced retaliation for speaking out. How is your current job different from your old one, both in what you’re doing and what you’re getting paid for?
Sande: Well, I took a significant pay cut, so I’ll just say that upfront. And then in my previous role, I supervised all of the directors of nurses, which supervised the nurse managers, which supervised the mental health registered nurses and mental health therapy techs. So under the direct supervision of my boss, which was Nicole Mobley, we had about 1,200 staff that we were supervising. I was involved with staffing, I was involved with bargaining for the state, I had several administrative responsibilities.
While rewarding, it’s just very different than what I’m doing now, which is working directly with the patients, providing care, passing medications, doing direct nursing assessments.
Miller: You said that sort of org chart part relatively quickly, but so something like three levels of managers up, that’s what you were before. And now you’re a sort of a frontline nurse.
Sande: Yes.
Miller: Lillian, what can you tell us about what happened to the other two whistleblowers?
Mongeau Hughes: I want to say first, I spoke to more than just the whistleblowers for that first story, and since it came out, I’ve heard from many, many more people at the hospital who have similar stories – maybe not quite as dramatic of a drop, but similar stories of retaliation. And if anybody is interested in sharing their stories with us at The Oregonian, we’re still interested in that. You can find my name online and get in touch.
Nicole Mobley was the chief nursing officer at the hospital, she’s one of the whistleblowers. She’s now the nurse manager overseeing about 100 agency nurses. She went from supervising about 1,200 nurses to 100, specifically the agency nurses that are like the travel nurses. She said she was pushed out of her job because the new leadership basically told her they had no trust in her and she felt she couldn’t do her job, and was forced to take a lower level role.
Katie Iv, the other whistleblower that’s part of this group, she’s not a nurse actually, she was the director of nursing excellence. She kind of waited to see what would happen and ended up getting a job title change where she doesn’t have a clear job description, according to her.
Miller: Lindsey, in a statement to us this morning about the changes to roles, the hospital said this: “Nicole Mobley,” the chief nursing officer that Lilian was just talking about, “self-demoted at her request. The other two staff reported to Ms. Mobley, so any personnel actions were attributable to her.” What’s your response?
Sande: Well, I would dispute that claim.
And the other thing I would say to that, let’s just play out for a sense that that is true, that we voluntarily stepped aside in this time. I worked in that job for 10 years. Nikki was the chief nursing officer for 10 years. And since being demoted or being removed from my position, not one person on that leadership team has reached out to me. Not one person has asked for any information that I have. Not one person has asked what concerns I see working on the floor. If I was just an employee that stepped aside, that’s a very interesting approach to me in my new role, and very dismissive of the work that I did there for 10 years. I can’t speak directly for Nikki, but I would imagine that her response would be similar. Both can’t be true.
Miller: Just briefly Lillian, what did the governor’s office say about the current situation at the hospital?
Mongeau Hughes: It’s worth mentioning that the governor has been watching this pretty closely, and was involved in the dismissal, I think put pressure on the former superintendent and chief medical officer, Doctor Sara Walker to step down last April. When we contacted the governor about this story, her office said that they had faith in the current leaders and a lot had changed since last year, and that they thought that things would be better going forward.
Miller: Lillain Mongeau Hughes and Lindsey Sande, thank you so much.
Sande: Thank you so much.
Mongeau Hughes: Thank you.
Miller: Lillian Mongeau Hughes covers homelessness and mental health for The Oregonian. Lindsey Sande was a longtime nurse leader at the Oregon State Hospital.
“Think Out Loud®” broadcasts live at noon every day and rebroadcasts at 8 p.m.
If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983.
