Oregon State Hospital bringing in outside help after multiple violations and patient deaths 

The Oregon Health Authority oversees the Oregon State Hospital in Salem. (Oregon Health Authority)

The Oregon State Hospital has hired a consulting firm to help it address safety violations that federal inspectors have flagged after three patient deaths and other issues like sexual contact between patients. 

The hospital has contracted with Chartis and will pay the company up to $1.7 million for months of work at the hospital, said Amber Shoebridge, a spokesperson for Oregon State Hospital. The psychiatric hospital in Salem, run by the Oregon Health Authority, has more than 500 patients, many of them needing mental health care so they can return to their communities and face criminal charges. 

The hospital has repeatedly violated federal regulations and been cited by  the federal Centers for Medicare and Medicaid Services, which funds about 4% of its budget of about $400 million annually.  

“They will help the OSH shift from a reactive approach to a proactive approach for quality-oriented culture and patient care,” Shoebridge said in an email to the Capital Chronicle. 

Chartis, a health care consulting firm, has offices across the United States, including Chicago, Boston and San Francisco and has helped health care providers in areas like compliance, strategy and technology. 

The company comes highly recommended and has experience working with large forensic state hospitals like Oregon State Hospital, Dr. Sara Walker, interim superintendent and chief medical officer, said in a staff memo on Monday obtained by the Capital Chronicle. She heard about the experiences of others while at a conference for psychiatric state hospitals.

“I think of bringing in this particular consulting team in the same way as an athletic team hiring a coach,” Walker said. “Top performers in other fields bring in people to observe their performance and provide advice and guidance as to how to improve. In my view, this is no different.”

Violations found in three deaths

In three separate patient deaths since November, inspectors found the hospital violated regulations and came up short in patient care and security. 

In August, a 96-page federal report found problems with two separate patient deaths. 

Federal inspectors flag problems in 2 deaths at Oregon State Hospital 

In one, a patient died on Nov. 2, 2023, after he was placed in a seclusion room. That happened after he went to a nurse’s station and said he felt like he couldn’t breathe. The month before, the patient complained about chest and leg pain and shortness of breath, but nursing staff failed to write up a treatment plan, the report said. 

That report also found inadequate checks of patients at night and security problems after a patient died of a suspected fentanyl overdose. 

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

In April, a patient was declared dead 69 minutes after arriving at the hospital from Douglas County Jail. The federal review found nursing staff failed to immediately assess his condition or seek a physician’s help when his head slouched to one side and he was unresponsive. 

Six months of work

Chartis will work with the state hospital on its plans of correction. 

The work starts soon: Company representatives are due to arrive Tuesday and stay through March 31, 2025, Shoebridge said.

The team that will arrive will include two physicians, four registered nurses, a quality and patient safety expert and a physical environment specialist, Walker said in her memo. 

Federal regulators have rejected two hospital proposals to fix its problems, Shoebridge said, but she was unable to provide information on which cases and issues those plans covered. Another plan has been submitted and is awaiting approval. 

A fourth plan has been approved for new security measures after a patient escaped from the state hospital. 

Walker encouraged her staff to be honest and share ideas. She said there is a “public misperception” of the state hospital and its care, despite its innovation.

“But the reality is that bad things can happen in any hospital,” Walker said. “We’ve seen that this year, and I’m not trying to minimize how awful these incidents were. But we can’t go back in time or make those things un-happen. What matters is what we do about it.”