The Oregon Health Authority, which manages the state hospital, has until May 15 to submit a corrective plan and until August to enact it.
If the agency fails, the state would not receive payment for seniors, people with disabilities and those on Medicaid. The loss of that funding, which is crucial for the care of the 141 patients at the Junction City hospital, would jeopardize the state’s ability to keep it open.
The Centers for Medicare & Medicaid Services said the hospital had violated 18 requirements involving patient safety, treatment, rights and nursing care. Federal authorities acted after investigating conditions at the Junction City hospital. The threat to certification wouldn’t affect the main state hospital campus in Salem.
Patrick Allen, director of the Oregon Health Authority, welcomed the investigation and promised remedies.
“The state hospital will act promptly and transparently to fix these gaps,” Allen said in a statement.
Dolly Matteucci, state hospital superintendent, echoed that sentiment in her own statement.
“Our staff at the Oregon State Hospital want to provide the highest quality care to our patients so they can recover and return to live healthy and productive lives in their communities. We look forward to addressing each of the administrative, documentation and supervision issues highlighted in this report,” she said.
The notice comes amid a hiring spree at both hospital units, which are trying to fill nearly 230 positions, including many nurses. It also follows decades of judicial actions over the hospital’s failure to admit aid-and-assist patients.
The federal notice follows a state investigation last December and January at the Junction City campus, where about half of the patients are under court order because they were deemed guilty except for insanity. The investigation followed the escape of a patient at the campus during an early December outing to the 5th Street Public Market in Eugene. The man was found at an undisclosed coastal Oregon town at the end of December – 25 days after running away.
The report faulted officials at the Junction City campus for not investigating the escape or other incidents involving sexual assault, patient-on-patient attacks and banned objects. Investigators, who combed through documents and interviewed staff along with 36 patients, indicated that the campus has a history of failing to keep patients safe, failed to document incidents and did not have its own administrator as required by law.
The report said that in mid-January, more than a month after the patient escaped, “no changes to practices had been made to prevent recurrence and protect patients during the investigation such as the temporary suspension of recreational off-grounds outings.”
They found that the patient who escaped had filed several grievances between July and the end of 2021.
In one, he said he didn’t “feel safe” with another patient in his unit. He asked for stepped up security. The hospital failed to investigate why the patient felt unsafe, the report indicated. A hospital note said “the concerns expressed in this grievance have naturally resolved due to administration changes on the unit.”
It said staff had encouraged the patient to let them know when he felt threatened.
The note failed to explain the incident, investigators said.
“It was not clear what ‘administration changes’ referred to or why that would ‘naturally resolve’ the concerns in the grievance. There were no other signatures on the form and although two staff members’ names were on the form it was not clear if either of them was the author of the form or what their position/title/roles were at the hospital,” the report said.
In September, the patient said he was harassed by a patient, and in November was attacked by another patient. The patient suffered bruises, the report said.
The attacker was moved, but investigators said hospital staff failed to explain the situation.
The patient who was attacked and later fled complained about certain employees, saying they were “demeaning,” “rude,” “condescending” and “dismissive.”
Investigators said the patient’s complaints explained his escape.
Access to medication room
The report said another patient got into the medication room at least four times by crawling through an open window and that the hospital had “significant staff and physical environment failures related to door security.”
It documented instances of a patient attacking other patients and causing injuries and said the hospital failed to investigate, and it said patients were in areas without supervision, including entering other patient’s rooms. The report said that staff had failed “to prevent patient-to-patient sexual contact, including sexual assault, and patient to patient physical altercations.”
In one instance, a patient was sexually assaulted by a roommate while sleeping.
Investigators said the hospital failed to investigate and protect patients.
“The hospital is responsible to ensure that patients receive care in a safe environment and are free from abuse and neglect, including sexual abuse,” the report said. “As of the date of this survey there was no documentation provided to reflect that the hospital had conducted a non-criminal investigation of the alleged sexual assault to identify how this was allowed to occur, to identify failures that may have contributed and to identify corrective actions to prevent recurrence” among patients.”
In one instance hospital staff said they did not investigate “because we don’t preclude people from having sexual contact.”
Staff also failed to prevent one patient from assaulting others, the report said, and failed to prevent patients from keeping banned items. In one instance, a patient made a “ligature” out of four bracelets and had bruises on the neck. That same patient had hoarded 50 to 60 pills, including Tylenol, and had a bag of “pruno,” a potentially toxic type of homemade alcohol.
Other patients were found with objects – including coins and razor blades – that could have been used as weapons.
“Multiple patient rooms were observed from the hallway to have an inordinate and excessive number of items strewn on beds, floors, and surfaces in a cluttered and disorganized manner,” the report said.
The report also faulted the Junction City operation for not having its own administrator. Because of the 65 miles between the Salem and Junction City campuses, the latter was licensed separately by the state and was supposed to be administered separately.
But the report found that Junction City was being overseen by officials in Salem. Junction City at one time had its own administrator, but that individual retired in December 2020 and the position was eliminated, according to the report. It said that three clinicians and program leaders were in charge.
Besides hiring a new administrator, the report called on state officials to improve record keeping and develop a program to improve performance.
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