Federal inspectors point to problems in two deaths at Oregon State Hospital • Oregon Capital Chronicle

Late last year, a patient at Oregon State Hospital went to the nurses' station and said he was having trouble breathing.

After taking the man's vital signs, nursing staff helped him go to an isolation room at the Salem State Mental Hospital, which houses more than 500 patients. He fell to his knees in the doorway, and staff pushed the patient out of the way and closed the door behind them. Alone in the room, the patient “rocked” his head back and forth and rolled around on the floor.

The patient, a black man, did not leave the room alive.

The report is part of a 96-page federal report released Monday into his death and the death of another patient in May. Investigators found that hospital staff committed numerous violations of safety procedures and patient care and made mistakes in investigating and correcting gaps in care.

The investigation by the state's Centers for Medicare and Medicaid Services included a review of records, interviews with staff and a look at security camera footage. The agency, which reimburses the hospital for the cost of treating Medicare patients, who are typically elderly, will require the state hospital to fix the problems to continue receiving that money.

The hospital's acting director and chief medical officer, Dr. Sara Walker, said the hospital would make the necessary changes.

“We have been entrusted with the care of some of Oregon's most vulnerable residents,” Walker said in a statement. “Their safety and well-being are our top priority. We will continue to make the necessary changes to protect our patients.”

The findings are the latest violations at the state hospital after a year of problems, including the escape of a patient who drove off in a hospital vehicle, poor patient safety and a third patient who died shortly after arriving from the Douglas County Jail.

The hospital's problems lie in patient care and safety, the investigation found. These include inadequate screening of hospital visitors, staff checking patients for less than a second to make sure they were breathing and poor medical care, records show.

At times, the state hospital's managers appeared to be at odds with federal inspectors. Records show that the federal agency had to repeatedly ask the hospital for patient documents and records needed to conduct its review.

The hospital must submit an approved rehabilitation plan by October 24 and will also have to expect an unannounced visit by then.

A federal report identifies concerns about patient safety and condom distribution at Oregon State Hospital

“I can’t breathe”

The patient, who died at the end of last year, had already been to the state hospital three times. On November 2, he stood in despair at the nurses' station.

“I feel like I can’t breathe,” he said.

But after he fell to the floor and hit his head, hospital staff focused on his mental state – and his request to go to the isolation room – the report said. Inspectors focused on how medical staff handled the situation, including gaps in his care when problems arose.

Fifteen minutes after his complaint, he was taken to the isolation room.

“I feel like I’m dying,” he repeated over and over as he entered the isolation room.

Six minutes later, an employee entered and left the room. After eight minutes, he stopped.

Two minutes later, staff attempted to resuscitate him, but the hospital did not call an ambulance until seven minutes after the “Code Blue” alert, indicating a life-threatening emergency, was issued.

It was not the first time he had suffered from shortness of breath. On October 13, he told a nurse that he was suffering from chest pains and shortness of breath, the report said.

And on October 17, he said he had pain in his left leg. But hospital staff had not developed a treatment plan, the investigation found.

CMS inspectors said the hospital's investigation of the incident was incomplete and did not address gaps in its response to the patient.

The hospital also initially failed to provide many of the documents inspectors requested for review, including some medical records and other reports of past incidents. Eventually, hospital staff provided additional documents and acknowledged that they had not told inspectors everything, the report said.

The death of a young man reveals gaps in Oregon's mental health system

Probable fentanyl overdose

On May 24, a patient died unexpectedly in bed, a day after a stranger visited. Oregon State Police found gunpowder residue and confiscated it along with foil, records show.

When the federal agency reviewed the case, it found that staff had failed to conduct thorough security screenings of visitors and had inadequately monitored sleeping patients to determine whether they were still alive.

Hospital staff also failed to follow up on warning signs of problems between the visit and his death, the report said. For example, when the visitor arrived, security screening was “inadequate” to check for metal objects and the security baton did not pass over the patient's feet. The visitor, a parent of the patient, later played with the patient's feet under the table during the visit. Staff ignored this activity, the report said.

He was found dead in the hospital the next morning. A review of surveillance cameras and interviews with staff revealed that patients were not adequately examined at night.

In some cases, staff simply stood outside and looked through the door into a darkened room to observe patients. In one case, staff checked 12 patients in just 37 seconds, which was not enough time to check patients' breathing, the report said.

During three visual checks in less than an hour, the patient was unresponsive, but staff did not approach him to determine if he was alive.

“Rather, they left without feeling any urgency to attend to other business,” the report said.

At 8:47 a.m., a staff member noticed that the patient's body was cold.