Oregon State Hospital failed to respond immediately to unconscious patient who later died

The Oregon State Hospital is in immediate jeopardy of becoming ineligible to receive Medicaid and Medicare reimbursements following its failure to respond quickly to a patient held in seclusion who lost consciousness and later died.

“The hospital’s medical emergency response to the patient’s loss of consciousness was not timely or effective,” reads preliminary findings from The Centers for Medicare & Medicaid Services, which administers public health insurance money.

While the hospital has taken some actions in response to the March 19 patient death on its Salem campus, more is needed, according to the partially redacted report obtained by The Oregonian/OregonLive.

“The responses do not adequately address the failure to ensure an immediate response to patients in seclusion,” the report states.

A spokesperson for the Oregon State Hospital said the hospital would be working with The Chartis Group, a health care system consultant with which it already has a relationship, to address the issues and pull itself out of “immediate jeopardy.”

“A core team of clinical and administrative personnel are creating an immediate jeopardy removal plan, describing exactly how and when the hospital will correct the cited issues and ensure patient safety,” wrote Oregon Health Authority spokesperson Amber Shoebridge in an email to The Oregonian/Oregon Live on Tuesday.

The hospital has provided few details surrounding the death of the patient, citing patient privacy laws. But it appears from two reports on the actions of hospital staff that a patient in seclusion fell and became unconscious and that staff did not provide a thorough check or initiate a timely emergency response.

A second report comes from the Joint Commission, a nonprofit responsible for accrediting thousands of hospitals nationally. That report is also redacted and is a result of the commission’s review of the hospital’s actions March 19.

In a letter released by the Oregon Health Authority on March 26, the commission pointed to problems with the care offered to patients in seclusion and the safety of the seclusion space. The commission also found evidence that the emergency response to the patient who died was not immediate, nor was the emergency communication procedure correctly followed.

As a result, the commission issued a “preliminary denial” of the Oregon State Hospital’s accreditation, which is now in limbo with the hospital responsible for quickly correcting the identified problems.

The Oregon State Hospital was also placed in immediate jeopardy last spring by the Centers for Medicare & Medicaid Services following several incidents, including three patient deaths. Federal investigators determined that hospital staff neglected to conduct hourly checks to ensure patients were alive and breathing, a failure that led to a patient being found dead last May.

The hospital took corrective action at that point that brought it back into compliance as of Oct. 25, Shoebridge said.

If the hospital’s current issues with the Centers for Medicare & Medicaid Services are not resolved, it stands to lose $13.8 million in annual reimbursement funding, or about 3% of its $417.5 million budget, according to 2024 estimates by the Oregon Health Authority.

A total of 21 patients have died at the Oregon State Hospital since 2020, nine of whom died unexpectedly, according to the agency. The hospital hasn’t made available any information about the patient who died in March due to federal and state privacy laws, Shoebridge said.

More than half of the nearly 700 patients across the hospital’s two campuses are there to be restored to a level of psychiatric wellness that would allow them to be tried on criminal charges. Another 40% are there after pleading guilty except for insanity. The hospital has been the subject of an ongoing federal lawsuit since 2002 regarding the speed at which it admits and treats patients.

Lillian Mongeau Hughes covers homelessness and mental health for The Oregonian. Email her with tips or questions at lmhughes@oregonian.com. Or follow her on Bluesky @lmonghughes.bsky.social or X at @lrmongeau.

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