The Oregon State Hospital plans to hire an administrator and retrain staff by mid-June to fix patient safety problems uncovered by an investigation at the Junction City campus.

Hospital officials provided a corrective plan on Saturday, May 14, to the Centers for Medicare & Medicaid Services. The federal agency demanded the plan earlier in the month.

The Oregon Health Authority released the plan on Wednesday following a public records request by the Capital Chronicle. A spokeswoman said it was a draft and that CMS would likely make changes.

In an email to federal authorities on May 14, Kimberly Ross, Oregon State Hospital’s quality management director, said that implementation of the fixes was underway. The 38-page corrective plan states that dozens of changes will be completed by June 14, a month and a half ahead of the deadline set by federal regulators.

Dolly Matteucci, the hospital’s superintendent, will oversee the changes.

The federal agency said in a Jan. 17 report of an investigation in December and January that the hospital had violated 18 requirements involving patient safety, treatment, rights and nursing care. The investigation was prompted by the escape of a patient at the Junction City campus in an early December outing in Eugene. The man was found 25 days later at the Oregon coast.

The violations included a requirement to hire a separate administrator to oversee the Junction City campus, which had been supervised by an administrator in Salem, where the main campus is located. There are about 140 patients being treated by the Junction City campus and nearly 550 in Salem.

The corrective plan said the hospital will hire a Junction City administrator by June 14 – and make all of the other fixes by then as well. In the meantime, the campus has an interim administrator, the plan said.

The hospital didn’t immediately respond to a request for the administrator’s job description or salary. A job ad on that was initially posted in late January, with a deadline of Feb. 13 for applications, sought a lead manager for the Junction City campus. The ad seeks an executive with six years management experience and pays between $8,009 and $12,389 a month. The ad was reposted at the end of April.

It’s not clear where the hospital’s hiring process stands. It is also in the process of trying to fill nearly 230 positions, including nurses, for both campuses.

Along with hiring a new administrator, the correction plan said hospital officials will make administrative changes, including to data collection of incident reports, to separate the two campuses. The plan said the hospital will conduct quarterly performance reviews to monitor the changes.

The plan said the hospital will update its patient grievance policy and require appropriate staff to undergo annual grievance training. The investigation found the campus was lax in responding to patient complaints, including from the patient who escaped in December. It said the man had filed several grievances in the latter part of last year, including one in which he said he didn’t feel safe.

The plan said it will refrain from letting patients go on outings while the fixes are being made.

The hospital will review all incidents of unauthorized leave by patients, the plan said.

The investigation also said the hospital didn’tprevent sexual interaction among patients and patient-to-patient attacks. To fix that, the plan said the hospital will issue guidelines “which will include the expectation of no sexual contact between patients.”

To prevent violence, nurses will undergo monthly training and a committee will recommend a prevention strategy.

Other planned fixes include:

  • Developing a new list of prohibited items to prevent suicide attempts
  • Removing trash and unneeded items like laundry from patient rooms
  • Tracking the location of “sharp tools”
  • Developing an incident response protocol
  • Establishing a “leadership governance team” to ensure that clinical and administrative operations are working together

Retraining figured heavily in the corrective plan. It said that the hospital will conduct new training for  security personnel, staff who accompany patients on outings, medication nurses, personnel responsible for patient monitoring, staff in charge of documentation and buyers to ensure they don’t purchase a potentially harmful object.

The plan said the hospital will conduct audits to ensure the training is done.

Disability Rights Oregon, which has sued the state to get the hospital to admit patients more quickly, said it will be tracking changes at the hospital. “Our primary concern is the safety and well-being of the patients on both of the Oregon State Hospital campuses,” said KC Lewis, managing attorney for the organization. “We will be monitoring the implementation of this corrective plan closely, and hope to see positive progress.”

Oregon Capital Chronicle

Oregon Capital Chronicle is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Oregon Capital Chronicle maintains editorial independence. Contact Editor Lynne Terry for questions: Follow Oregon Capital Chronicle on Facebook and Twitter.

Lynne Terry has more than 30 years of journalism experience, including a recent stint as editor of The Lund Report, a highly regarded health news site. She reported on health and food safety in her 18 years at The Oregonian, was a senior producer at Oregon Public Broadcasting and Paris correspondent for National Public Radio for nine years. She has won state, regional and national awards, including a National Headliner Award for a long-term care facility story and a top award from the National Association of Health Care Journalists for an investigation into government failures to protect the public from repeated salmonella outbreaks. She loves to cook and entertain, speaks French and is learning Portuguese.