Salem-based Oregon State Hospital released a 30-day stabilization plan that aims to improve patient safety after receiving its fourth immediate jeopardy citation in 16 months, the Statesman Journal reported April 30.
The plan was requested by Gov. Tina Kotek and comes shortly after Dave Baden was appointed acting superintendent on April 11.
The plan has three objectives: Find the next sentinel event before it happens, operate like a 24/7 hospital, and clarify roles and shared responsibility. This includes addressing staffing shortages in the medical clinic, acting upon poor conditions with urgency, and ensuring staff have a clear understanding of requirements and protocols.
“Frequent policy changes (from audits and other compliance actions) have resulted in unclear expectations, inconsistent application of policies, and no consequence for failure to follow policies,” the plan says. “There must be a shared responsibility for patient safety.”
The psychiatric hospital has faced scrutiny for a series of patient-safety events in the past few years. In 2024, the hospital 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.
Most recently, the hospital was placed in immediate jeopardy after a patient in seclusion fell, became unconscious and died on March 18. The hospital is still in immediate jeopardy. The facility is working with healthcare system consultant The Chartis Group to address issues.
“We also have long term problems that are outside of the incident that happened, so that 30-day plan is not just gonna be incident-specific, but also talking about where we’re gonna be in 30 days, 60 days, hopefully 90 days to stabilize services at the state hospital,” Ms. Kotek said on April 21.
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.