Oregon hospital cited with immediate jeopardy — again

Salem-based Oregon State Hospital again has been cited with immediate jeopardy, this time over disorganized medical supplies that could delay lifesaving treatment for a patient in an emergency, The Lund Report reported April 29.

The Oregon Health Authority submitted the citation April 29 following an investigation into a patient death at the psychiatric facility's main campus. During the visit, inspectors found emergency supplies and equipment spread among four locations in its admission area. It also said a list of items in a duffel bag did not match its contents and noted that a defibrillator was located down another hallway and a suction machine was in another inpatient unit.

"There is likely serious adverse outcome to patients who enter the hospital through the admissions unit should their condition require a medical emergency response," the notice said. "It is likely that chaotic delays in appropriate emergency care would occur as a result of staff, lacking policy or specific roles in emergency, would simultaneously attempt to gather all necessary equipment and supplies located in multiple areas."

The location of the equipment did not contribute to the patient's death, according to the statement, but it was concerning enough to put the hospital in immediate jeopardy status.

"The primary concern was that all code blue equipment for the admissions area was not in the same room. We have already rectified this," Sara Walker, MD, the state hospital's interim superintendent and chief medical officer, said in a statement shared with Becker's. "I am confident that together we will make the necessary changes to provide a safer environment for patients."

The hospital submitted a corrective plan that was approved by CMS after an on-site visit May 2, the Statesman Journal reported May 7. The hospital is no longer in immediate jeopardy, but it will continue to work with CMS to improve emergency medicine response, the hospital told the Journal.

Oregon State Hospital was last cited with immediate jeopardy in September after a patient escaped the facility.

Editor's note: This article was updated May 7.

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