Salem-based Oregon State Hospital has received a second immediate jeopardy warning this year after the death of a patient, the Oregon Capital Chronicle reported June 6.
On May 24, a patient was last observed alive four and a half hours before staff found them unresponsive in their room. State police are investigating the death. The official cause of death has not been released, but state police and hospital staff told the Chronicle the patient died of a suspected fentanyl overdose.
CMS cited the hospital with immediate jeopardy after it determined the hospital failed to ensure the patient's safety. The hospital is working on an improvement plan.
"As challenging as responding to CMS investigations can be, it does help us identify and close gaps in our procedures and keep patients safe," Sara Walker, MD, the system's chief medical officer and interim superintendent, said in a statement to the Chronicle. "It's hard when the ground feels like it is constantly shifting underneath us. It's hard to keep up with all of it. But I am confident we can do it."
The hospital has paused in-person visits to patients after a visitor brought contraband to a patient. On May 29, administrators sent an email reminding staff to check patients on their rounds. But video review of two night shifts showed "minimal to no change," according to the report.
This is the third immediate jeopardy warning the hospital has received since September.
The first warning was issued in September after a patient escaped the facility. The second was issued April 29 following a visit where inspectors found emergency supplies and equipment spread among four locations in its admission area. Inspectors 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. The hospital resolved both immediate jeopardy warnings.
Becker's reached out to the Oregon Health Authority, which operates the hospital, to request comment on the new situation. This story will be updated if more information becomes available.