Late last year, a patient at Oregon State Hospital walked up to a nurse鈥檚 station and said he was having trouble breathing.
After taking the man鈥檚 vitals, nursing staff helped him walk to a seclusion room in the state-run psychiatric hospital in Salem, which has more than 500 patients. He fell on his knees in the doorway and staff moved the patient out of the way and shut the door behind them. Alone in the room, the patient 鈥渞ocked his head鈥� and rolled on the floor.
The patient, a Black man, never left the room alive.
The account is part of a 96-page released Monday on his death and another patient death in May. Investigators found that hospital staff committed numerous violations related to safety and security procedures and patient care and were faulty in investigating and correcting gaps in care.
The investigation by the federal Centers for Medicare and Medicaid Services included record reviews, interviews with staff and a look at security camera footage. The agency, which reimburses the hospital for treatment of Medicare patients, who are usually elderly, will require the state hospital to fix the problems to continue to receive that money.
The hospital鈥檚 interim superintendent and chief medical officer, Dr. Sara Walker, said the hospital will make the necessary changes.
鈥淲e have been entrusted with the care of some of Oregon鈥檚 most vulnerable residents,鈥� Walker said in a statement. 鈥淭heir safety and well-being are our top priority. We will continue to make the changes necessary to protect our patients.鈥�
The findings are the latest violations to hit the state hospital after a year of problems. Those include the escape of a patient who drove off in a hospital vehicle, a lack of patient safety and a third patient who died shortly after his arrival from the Douglas County jail.
Patient care and safety are at the root of the hospital鈥檚 problems, investigators found. They include limited screenings of hospital visitors, staff checks of less than one second per patient to ensure they are breathing and poor medical care, records show.
At times, managers at the state hospital appeared at odds with the federal inspectors. The federal agency had to repeatedly prod the hospital for patient documentation and records necessary to complete its review, records show.
The hospital needs to come up with an approved plan of correction by Oct. 24 and will face an unannounced visit by then as well.
鈥業 can鈥檛 breathe鈥�
The patient who died late last year had already been in and out of the state hospital three times. On Nov. 2 at the nurse鈥檚 station, he was desperate.
鈥淚 feel like I can鈥檛 breathe,鈥� he said.
But hospital staff focused on his mental health 鈥� and his request to enter the seclusion room 鈥� after he fell on the floor and bumped his head, the report said. Inspectors honed in on how medical staff handled the situation, including gaps in his care when problems emerged.
Fifteen minutes after his complaint, he was walked into the seclusion room.
鈥淚 feel like I鈥檓 going to die,鈥� he kept repeating as he entered the seclusion room.
Six minutes later, a staffer entered and left the room. After eight minutes, he stopped moving.
Two minutes later, staff tried to revive him. But the hospital did not call an ambulance until seven minutes after they called a 鈥渃ode blue,鈥� which indicates a life or death emergency.
This was not the first time he鈥檇 been short of breath. On Oct. 13, he told a nurse he suffered from chest pains and shortness of breath, the report said.
And on Oct. 17 he said he had left leg pain. But hospital staff did not write up a treatment plan, the investigation found.
CMS inspectors said the hospital鈥檚 review of the incident was incomplete and failed to address the gaps in its response to the patient.
The hospital also failed to initially provide much of the documentation that inspectors requested for their review, including some medical records and other prior incident reports. Eventually, hospital staff provided more documentation and acknowledged they had not shared everything with inspectors, the report said.
Likely fentanyl overdose
On May 24, a patient died unexpectedly in bed, one day after a visit from an outsider. Oregon State Police found powder residue and seized it along with foil, records show.
The federal agency鈥檚 review of the case found that staff did not conduct thorough security screenings of visitors and conducted scant monitoring of sleeping patients to determine if they are alive.
The hospital staff also failed to follow up on warning signs of problems between the visit and his death, the report found. For example, when the visitor arrived, the security screening was 鈥渋nsufficient鈥� to check for metallic objects, and the security wand did not pass over the feet. The visitor, a parent of the patient, later played with the patient鈥檚 feet under the table during the visit. Staff ignored that activity, the report said.
The hospital found him deceased the next morning. A review of security cameras and staff interviews found inadequate checks of patients at night.
In some instances, staff only stood outside and looked at the patients through the door into a darkened room. In one instance, a staff check of 12 patients happened within only 37 seconds, not enough time to check for respirations, the report said.
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.
鈥淩ather, they walked away with no sense of urgency to conduct other business,鈥� the report said.
At 8:47 a.m., a staffer discovered the patient鈥檚 body was cold.