A federal report finds patient safety concerns and condom distribution at Oregon State Hospital

Oregon State Hospital has a security camera system with blind spots and has failed to prevent patient-on-patient assaults or stop patients from having sexual contact with each other, a federal report found. 

Federal inspectors found that the state-run psychiatric hospital in Salem passes out condoms to patients – even though patients aren’t allowed to have sex with each other. That, too, is a problem, the federal agency found. 

Officials with the federal Centers for Medicare and Medicaid Services visited the hospital, which is overseen by the Oregon Health Authority, after a patient-on-patient assault in February. They issued a 102-page statement of deficiencies that looked at the hospital’s protocols in areas like security, handling patient grievances and adequately monitoring patients. 

The report, obtained by the Capital Chronicle with a public records request, offers a richly detailed glimpse at the hospital’s inner workings, how staff respond to crises and the challenges of running a facility that has about 680 patients. It shows the failures and challenges of keeping people safe. For instance, the hospital’s security director told officials the hospital has nearly 1,100 security cameras at its Salem campus – too many for the security staff to continually watch. Yet the hospital has no written guidance advising staff which ones to monitor, the report said. 

State hospital officials said they are working on a plan to correct the problems and will submit them to the federal agency within 10 days. 

“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,” said Dr. Sara Walker, the interim superintendent and  chief medical officer for the hospital. 

Patient assault

The patient-on-patient assault that spurred the federal visit unfolded in a dayroom area of the hospital, but with no staff present – even though some were assigned to the area. One patient put their arm around the other patient’s neck and lifted them up in the air out of a chair and shook them, the report said.

The patient dropped to the ground and lay there unconscious. For 34 seconds, no one was aware of the attack. Another patient who entered the area called for help. An ambulance rushed the patient to Salem Hospital’s emergency room for an X-ray and sutures.

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A review of security camera footage confirmed that no staffers were present, and that the hospital had failed to adequately supervise staff to ensure they worked in their assigned locations. The report indicates that staffers were placed on administrative leave during an investigation of the incident.

Federal inspectors who reviewed the footage found that during eight minutes before and during the assault no staff were present.

What’s more, the report found, the security camera in the area had a blind spot in the room’s southwest corner where the patient had been tossed and laid so security staff couldn’t see them. 

Other problems found 

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In reviewing the incident and others at the hospital, federal inspectors found systemic problems to address.

They said the hospital needs to track patient-on-patient injuries and their follow-up health needs, including emergency department visits and hospitalizations. 

Inspectors also found instances in which  hospital staff failed to adequately monitor patient care areas on security cameras or in person and had a chaotic response to emergency incidents.

The hospital also failed to prevent patients from having sex with each other and handed condoms out, despite a policy of not allowing sex between patients. 

A review of patient chart notes found this confused patients.

“Why are you handing out condoms?” one patient asked. “Does this mean we should be getting busy?”

When federal inspectors interviewed staff about them, they said the condoms were available to anyone for “self care.”

But when asked for a copy of the hospital’s policies about condoms, the state hospital told inspectors they had no written policy or procedure for their distribution.

“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,” the federal report said.

Follow up

After the state hospital sends a plan of correction to the federal agency, officials will need to approve it.

They’ll also follow up with an unannounced site visit to check for compliance.

This is the third time in less than a year that CMS officials have cited the hospital for problems, including an escape last August. 

Federal officials also followed after an unexpected death this spring in the hospital’s admission area. They cited the hospital after finding that life-saving resuscitation equipment was scattered throughout different rooms of the admissions area. CMS has approved the hospital’s plan for correction.

The state hospital also anticipates an unannounced visit for that plan too.