Commission finds ‘serious threat’ to patient health, safety at Oregon State Hospital

PORTLAND, Ore. (KOIN) — National healthcare regulators have determined Oregon State Hospital poses a “serious threat” to the health and safety of its patients, one week after a sudden death at the facility.

On Wednesday, the Oregon Health Authority reported that the Joint Commission preliminarily stripped the Salem psychiatric hospital of its accreditation following a survey conducted from March 24 to March 25.

The public agency said the survey was “in response to a sentinel event.” OHA previously revealed that a patient unexpectedly died on March 18.

Surveyors have since identified several health and safety risks. According to The Joint Commission’s letter to OSH’s Interim-Superintendent Sara Walker, the facility has failed to “provide a safe environment [to] a patient in extended seclusion” and “failed to effectively implement policies and procedures related to patient assessments/re-assessments.”

The commission also noted there was no evidence that the hospital’s emergency responders followed the proper protocols for immediacy and communication.

In response, OHA said the facility has assigned workgroup leads to address each of the identified issues. The agency reported that OSH has already seen results after launching its pre-existing plan to form a seclusion-response team.

The commission further advised the hospital to conduct further education and training on assessments when patients fall. Staff will additionally be trained on how to respond to different codes, and clinical administration workers “will have more direct oversight over the clinical care delivered.”

OHA reported that TJC’s follow-up survey is slated for Thursday, Apr. 17. The organization will then determine whether or not the hospital has addressed its failures.

The commission’s findings have added on to a list of several issues OSH has faced the past few years. Most recently, in August 2024, the Centers for Medicare and Medicaid Services gave the facility three months to implement a corrective plan after it found it was “not in substantial compliance” with federal standards.

The hospital was also placed on “immediate jeopardy status” in September 2023, April 2024 and June 2024 after a patient who was in custody for attempted aggravated murder escaped the facility.