Salem-based Oregon State Hospital is accused of coaching hospital staff on how to respond to CMS surveyors and returning to previous practices after submitting a corrections plan, the Statesman Journal reported June 11.
Here are nine things to know:
1. 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 most recent incident that placed the hospital in immediate jeopardy happened on March 18, when 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.
2. The hospital is no longer in immediate jeopardy status, a hospital spokesperson told the Statesman Journal. However, it was set to resubmit a plan of correction to CMS on June 13, after the prior submission was rejected.
3. On May 22, CMS sent a 245-page report to the hospital on its findings. The hospital released the report on June 11 after it redacted more than 50 pages. The redactions removed information that could identify patients to remain in compliance with HIPPA, spokesperson Amber Shoebridge told OPB.
4. The report said CMS surveyors found hospital staff reported being “coached” on how to respond, and that corrections put in place were halted and reverted to previous practices after the hospital was found in compliance. CMS surveyors also found the hospital bylaws were outdated, with some medical protocols being last reviewed in 2016 or earlier. The hospital’s policies and procedures were also unclear on use of seclusion and restraints.
5. The report also found that hospital staff indicated they brought numerous warnings and problems to the attention of hospital leadership but that those concerns were largely ignored. Multiple reports also said concerns were dismissed by the hospital’s superintendent and chief medical officer.
6. On June 6, a federal judge found the state in contempt of court for failing to comply with orders to admit patients deemed unable to defend themselves in court to the hospital within a week. The judge called for the state to be fined $500 a day for every person waiting to be admitted. It is estimated the state could rack up fines of $250,000 to $500,000 a month.
7. In April, Gov. Tina Kotek named new leadership after the chief medical officer and Sara Walker, MD, the superintendent, both resigned. Dave Baden was appointed acting superintendent.
8. Once the hospital submits its updated corrective plan, CMS will make an unannounced visit to see what changes have been made. The hospital is still at risk of potentially losing its Medicare payments further down the line, the Statesman Journal reported.
9. 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 those who entered an insanity plea.
