Security lapses at the Oregon State Hospital contributed to recent patient-on-patient assaults, according to a federal report on the state’s safest inpatient psychiatric facility.
The investigation by the Centers for Medicare and Medicaid Services found that staff did not always properly supervise their patients and the hospital did not fully investigate acts of aggression. Oregon Public Broadcasting reported.
The federal agency opened an investigation after receiving four complaints. Its findings were released following an unannounced on-site investigation conducted at Salem Hospital earlier this year.
A major incident detailed in the report occurred on Feb. 10, when a patient placed another patient in a chokehold until he lost consciousness. The victim required “extensive” medical treatment for his injuries, according to the report.
Investigators also determined that the hospital failed to prevent sexual assault and sexual contact between patients.
In January, a patient was transferred out of a unit because of another patient’s “hypersexual behavior,” according to the report. But in the new unit, the patient said he was forced into sex.
The hospital received the federal report, known as a deficiency report, on May 1. He has 10 calendar days to respond with a plan of correction.
“There will always be things we can improve upon, and we will continue to do so, but what endures is our dedication to the humans we are privileged to care for,” said Interim Superintendent Sara Walker in a press release.
Once the Centers for Medicare and Medicaid Services approves the plan, it will conduct another unannounced investigation to review its implementation.
The public hospital has long struggled to overcome staff shortages, overcrowding and other security breaches.
Just days before receiving the deficiency report, the hospital was placed in “immediate jeopardy” by CMS after a patient died shortly after arriving at the facility. The federal agency found that emergency response equipment was not stored in an organized manner in the intake area. They found that while it did not contribute to the patient’s death, it posed a potential risk to future safety, the Oregon Health Authority said in a statement.
The danger status has since been lifted, state health officials said.
Last summer, a man newly transferred to the hospital managed to escape while he was fully chained and left in a stolen van. It was found in a pond and then taken into custody, authorities said. A subsequent federal investigation found that the hospital failed to properly supervise and transport the patient.
