Salem-based Oregon State Hospital has been placed in immediate jeopardy after another patient’s death, OregonLive reported April 2.
On March 18, a patient in seclusion fell and became unconscious, later dying. Investigators from both CMS and The Joint Commission filed reports on the incident and found issues with how often staff checked on patients in seclusion, the timeliness of emergency response and safety issues with the seclusion space itself.
As a result of the death, CMS placed the psychiatric facility in immediate jeopardy and The Joint Commission issued a preliminary denial of the hospital’s accreditation.
Oregon State Hospital has taken corrective actions, including establishing a code blue team, improving staff training and response to codes and creating a seclusion-response team. The Joint Commission surveyors will conduct a follow-up survey April 17 to determine whether the improvements will reaffirm the accreditation status.
The psychiatric hospital has faced scrutiny for a series of patient-safety events in the past few years. Most recently in 2024, it was placed in immediate jeopardy three times after patient deaths and a patient escape. The last of these immediate jeopardy warnings were removed on Oct. 25. The facility is working with healthcare system consultant The Chartis Group to address issues.
“A core team of clinical and administrative personnel are creating an immediate jeopardy removal plan, describing exactly how and when the hospital will correct the cited issues and ensure patient safety,” Amber Shoebridge, Oregon Health Authority spokesperson, told OregonLive.
Oregon State Hospital houses nearly 700 patients across two campuses. More than half of these patients are there to be restored to a level of psychiatric wellness in order to be tried on criminal charges. Another 40% of these patients are there after pleading guilty except for insanity.