Months before a patient died alone at Oregon State Hospital, agency boss was warned about seclusion practices

When Kenneth Hass was languishing in a seclusion room at Oregon State Hospital in October 2024, a social worker paid him a visit and wrote a report about what he saw. 

Among the social worker’s observations: Hass habitually urinated and defecated in his bed. He had never been out of seclusion for more than 48 hours at a time due to his mental health and how it affected his interactions with others.

Hospital staff speculated he may have had an unknown brain injury or other undiagnosed condition in addition to his official diagnosis of schizophrenia with paranoia and delusional beliefs. Hass’ condition had not “markedly improved” since his admission in March 2023 on a civil commitment order. (In 2022, he also had been in Oregon State Hospital for evaluations due to criminal charges that were dismissed after he was found unfit to proceed.) 

Hass lived just five more months, dying March 18, 2025, at age 25 in a feces-filled seclusion room at the state hospital in Salem, which serves nearly 600 patients. Before entering the hospital, he was homeless in Lane County. 

His death sparked intense scrutiny of the hospital, which is overseen by the Oregon Health Authority, the state’s health agency. The hospital is responsible for treating the state’s most vulnerable residents — people suffering mental health crises often need care so they can defend themselves against criminal charges in court.

Hass’ death was the fifth unexpected fatality for the hospital since November 2023. In Hass’ case, he was primarily in seclusion or restraints from July 2024 until his death. The night he died, he fell three times in the bathroom in the span of an hour with no staffers entering to check on him. He also drank extensive amounts of water and jumped from the top of the toilet, according to a confidential report Lookout Eugene-Springfield obtained. 

Fallout after Hass’ death was swift. In April 2025, Dr. Sara Walker, Oregon State Hospital’s interim superintendent and chief medical officer, resigned after Gov. Tina Kotek learned more details about the death. State officials also tried to conceal from the public details of the death and the hospital’s violations, which Lookout first documented nearly a year ago in June 2025.

Since then, a spokesperson for Dr. Sejal Hathi, the Oregon Health Authority’s director, has said Hathi did not realize the extent of the issues surrounding the use of seclusion rooms until after Hass’ death in March 2025.

The first statement went to The Oregonian, the state’s largest newspaper, when it published an investigation this month about the death and the hospital’s higher-than-average use of extended seclusion compared with other facilities nationwide. 

A second, similar statement was sent June 11 to Lookout after the news outlet asked when Hathi became aware of the overuse of seclusion. 

“The Director became aware of the scale and severity of prolonged seclusion at OSH (Oregon State Hospital) after the patient’s death in March 2025,” Amber Shoebridge, a spokesperson for the health authority, said in a statement Hathi approved. “We wish OSH leadership had elevated this appropriately and earlier, and significant changes have been made since.”

Further, Shoebridge told Lookout: “Previous hospital leadership did not elevate the underlying data, scope or severity of long-term seclusion to the Director while this was occurring.”

However, public records obtained by Lookout show that statement offers an incomplete picture.

Four months before the death, Hathi, alongside other authority bosses and Oregon State Hospital leaders, directly received word from the health authority’s consultants that the overuse of seclusion was an urgent problem. In a written presentation, state-contracted consultants with Chartis told Hathi and other officials that patients were staying in seclusion “days and weeks” longer than necessary, the records show.

The Chartis consultants color-coded their finding about seclusion red, meaning it was an issue they believed required immediate attention. 

That information was emailed to Hathi, Walker and others in November 2024 — one month after the social worker visited Hass in a seclusion room and four months before he died. 

Hathi declined Lookout’s request for an interview. An agency spokesperson, Marsha Sills, defended the agency’s record, noting the agency was dealing with other compliance issues in November 2024 that had been raised in federal surveys, including contraband, aggression, secure transport and responses to medical emergencies.

“Access to a broad gap-analysis summary from Chartis does not mean prolonged seclusion was an issue elevated to the director,” Sills said in a written statement.

This is the account of what Oregon State Hospital’s hired outside experts told the health authority’s top leaders about the facility’s use of seclusion rooms months before the March 18, 2025, death shook the hospital to its core. 

‘Excited and energized’ 

In August 2024, seven months before Hass died, Oregon Health Authority officials realized they had a problem. 

By then, the state hospital had experienced several patient deaths and other high-profile problems related to patient care and safety. In November 2023, for example, a patient was sent to a seclusion room and died after he went to a nurse’s station and complained about breathing difficulties. 

In August 2024, Hathi and other state officials had an initial call with Chartis, a national health services consulting company with a record of helping psychiatric hospitals improve their performance. A Chartis representative emailed Hathi, thanking her for organizing the call. 

“We left the call excited and energized about a potential collaboration with Chartis,” Hathi responded Aug. 23, 2024. 

A few days later, Chartis sent Hathi an overview of potential services, which she forwarded to state hospital administrators. Dr. Sara Walker, the hospital’s interim superintendent, notified the executive team that the hospital would work with the company. 

Chartis would go on to work with Oregon State Hospital and provide advice, recommendations and input to help the hospital regain compliance with the federal Centers for Medicare & Medicaid Services, which conducts investigations after unexpected patient deaths, escapes or other adverse events.

Chartis’ work involved a variety of recommendations and a gaps analysis to show areas that need improvement, ranked in order of priority. The company has done similar work at other psychiatric hospitals. 

That same day, Shoebridge, the spokesperson, emailed Hathi and other leaders about tentative plans for a press release about Chartis after the all-staff email went out. 

In an email, Hathi questioned that plan to release the information: “Are you sure we should be (sic) issue a press release? My preference would be no.”

Shoebridge’s recommendation was for a release, saying it would show the hospital is “transparent and proactive” after a year of multiple investigations. Hathi and other health authority officials overruled that recommendation, saying she should write a statement for reporters who asked about Chartis.

The following year, state officials took a similar approach after Hass’ death, when the federal Centers for Medicare & Medicaid Services put the hospital in immediate jeopardy, which puts the hospital at risk of losing federal funding due to violations. At that time, as Lookout previously reported, a communications aide for Gov. Tina Kotek’s office urged the agency not to put out a press release, arguing that the state already had suffered through “a couple of tough news cycles.”

In all, the Oregon Health Authority has contracted with Chartis for $6.85 million. On Sept. 20, 2024, the state’s first contract was signed, and the company provided consultation services to Oregon State Hospital in 2024 and 2025 for $4.36 million. The state signed a second contract for Chartis services in 2025 for $2.49 million. That contract ends June 30. 

The work started in September 2024 and quickly advanced.

By November 2024, Chartis was ready to present its analysis to health authority and state hospital executives. Records show Hathi attended the meeting, which was moved a day to accommodate her schedule.

During that Nov. 15, 2024, meeting, Chartis laid out a variety of findings about the state hospital, some more serious than others. 

The highest priority items were labeled: “high priority — should be corrected ASAP,” the report said. 

One of those high-priority items was seclusion, according to a PowerPoint of the presentation that was emailed to Hathi and other officials the same day.

“Patients held in seclusion for days and weeks without justification and not released at earliest time possible,” Chartis wrote in the presentation. (The words “seclusion for days and weeks” were in bold-face type in the presentation.)

The full analysis the hospital received offered more insights from Chartis. 

“The frequency and duration of seclusion and restraint at OSH is higher than in comparable hospitals,” a draft of the analysis said. “The factors are complex and likely vary from unit to unit, but it is necessary to implement policies and practices to bring the number of seclusion and restraint events and their duration into line with the average of similar facilities.”

Meanwhile, Hass was shuffled in and out of different seclusion rooms, often with staff moving him elsewhere after his living area became soiled, reports show. A root cause analysis of Hass’ death, obtained by Lookout, found staff reported he “was able to have goal-directed, linear conversations, but was anxious, depressed, and despondent about being in prolonged seclusion.”

Before Hass’ death, the gap analysis recommended steps to take, including designated teams for seclusion cases, more training and including the issue in daily and weekly meetings for awareness. 

That same month the analysis was presented, November 2024, Oregon State Hospital had 125 seclusion events averaging nearly 35 hours.

From October 2024 to January 2025, the state hospital had a four-month average of 560 seclusion events averaging 28.1 hours. 

The hospital’s actions to drive down extended seclusion since then shows officials recognized the use of the practice needs more oversight. The hospital’s steps include face-to-face follow-up visits by a psychiatric provider within an hour of every seclusion event, increased oversight of extended seclusion events that last more than 24 hours, and updated chart logs to track room cleanliness and emergency response, Shoebridge said in an email to Lookout. 

From October 2025 to January 2026, the four-month average was 451 seclusion events averaging 4.5 hours.

Sills, a spokesperson for the authority, said the hospital took action between November 2024 and March 2025, when Hass died, to respond to Chartis’ findings about extended use of seclusion.

“On the recommendation of the Chartis consultants, OSH was building an incident response system that had not previously existed,” Sills said in an email. “During that time, OSH made the use of seclusion or restraints internally reportable incidents, so each incident would be reviewed by an OSH multi-disciplinary panel.”

Even without the scrutiny around seclusion practices, Oregon State Hospital has faced years of litigation about its pace at admitting patients who need treatment to face charges in court. Disability Rights Oregon, a federally chartered organization, has led that charge to hold the state accountable in court and also keeps an eye on related issues like the hospital’s use of seclusion.

“As a former psychologist, seclusion of a person in a mental health crisis can be profoundly harmful and should be extremely rare,” Dave Boyer, managing attorney of Disability Rights Oregon’s Mental Health Rights Project, told Lookout in a statement. “When a hospital is frequently secluding patients, it raises questions about leadership and staff culture that must be addressed.”

After receiving the gap analysis from Chartis, state officials took time to weigh the impacts of the document’s release, especially after a reporter with the news website Oregon Capital Chronicle requested it. 

For the section about seclusion, Shoebridge wrote: “This section has my highest level of concern.”

Regarding a separate finding about a lack of incident reporting for restraint and seclusion, Shoebridge wrote: “Restraint and seclusions not being reported is a high level of concern. Reporters may connect to worst thing they’ve seen in movies.”

Timeline

Here’s a timeline of recent events surrounding the Oregon State Hospital’s uses of seclusion and restraints for its patients.

Nov. 2023-2024: Oregon State Hospital has a series of several unexpected patient deaths, including a man in November 2023 who died after he was placed in a seclusion room after complaining at a nurse’s station about breathing difficulties.

Aug. 15, 2024: Dr. Sejal Hathi, the head of the Oregon Health Authority,  has a meeting with Oregon State Hospital staffers who raise concerns about the hospital’s culture, including safety, retaliation and a failure to follow rules. 

Aug.  22, 2024: Hathi organizes a call with the consulting firm Chartis, which talks to the OSH team. Source: Chartis’ Andrew Resnick’s Aug. 23, 2024, email to Sejal Hathi: “Sejal, thanks for organizing the call yesterday.” 

Aug. 23, 2024: Hathi replies to Resnick: “We left the call excited and energized about a potential collaboration with Chartis.” Oregon State Hospital officials, including Dr. Sara Walker, are copied on the email. 

Aug.  28, 2024: Chartis directly sends Hathi an overview of potential services for Oregon State Hospital. Hathi forwards it to Oregon State Hospital officials. 

Aug. 28, 2024: Walker notifies the OSH executive team that Chartis is the consulting agency that will work with the hospital.

Aug. 29, 2024: Oregon State Hospital starts drafting a statement of work for Chartis, per an email to Hathi, Walker and Kristine Kautz, a deputy director. 

Aug. 30, 2024: Chartis sends a letter of engagement to Kautz outlining its understanding that it will provide the state hospital various services, including a gaps analysis, after the hospital’s repeated statements of deficiencies from the Centers for Medicare & Medicaid Services regarding “patient care and adverse events.”

Sept. 8, 2024: Hathi and Kautz receive a draft statement of work for the Chartis contract. 

Sept. 16, 2024: Hathi and Kautz receive a draft of the contract with Chartis. 

Sept. 20, 2024: Contract is signed. Original dates for agreement and services: Sept. 23, 2024, through March 31, 2025. 

Sept. 20, 2024: Shoebridge, the OSH spokesperson, emails Hathi and Walker and others about tentative plans to send out a draft news release about Chartis after an all-staff email goes out about the contract. A reporter had inquired about Chartis. 

Sept. 20, 2024: Hathi emails back: “Are you sure we should be (sic) issue a press release? My preference would be no.”

Sept. 21, 2024: Shoebridge responds, saying that a press release would show OSH is “transparent and proactive” after “a year of multiple CMS investigations.” Instead, agency officials decide to draft a “holding statement” for outlets that ask about the contract. 

Nov. 12, 2024: Kim Wilson, a Chartis representative, notifies Kautz and Walker that “Dr. Hathi can’t make the OSH report on Thursday” and requested the report be moved to Friday (Nov. 15, 2024). 

Nov. 15, 2024: The gap analysis overview meeting with executives is held. Hathi attends. Source: Scheduling emails and Hathi’s calendar. 

Nov. 15, 2024: Wilson, with Chartis, emails Hathi and other agency and hospital executives: “I’ve attached the document we reviewed during the presentation.” 

Nov. 15, 2024: That overview document Hathi received, also dated Nov. 15, 2024, includes an orientation to “conditional level findings” in different areas for the hospital and sorts issues into three categories: “high priority  should be corrected ASAP”; “moderate priority issue,” to be reserved in the next three to six months or sooner; and “low priority issue.” 

Among its findings: “Patients held in seclusion for days and weeks without justification and not released at earliest time possible.” (The words “seclusion for days and weeks” were printed in bold-face in the report.)

Dec. 3, 2024, and Dec. 5, 2024: Hospital staffers have initial team meetings about the issue. 

Feb. 14, 2025: The contract with Chartis is amended to continue beyond March 31, 2025, to May 2, 2025, raising the maximum amount from $1.73 million to $2 million. Source: contract amendment.

March 18, 2025: A patient dies in a seclusion room at Oregon State Hospital. Centers for Medicare & Medicaid Services finds various violations around the use of seclusion and a lack of staff training. 

April 2, 2025: Wilson, with Chartis, writes to Kautz, who forwards the message to Hathi. It says: “there was a bit of unloading occurring by staff members to the survey team” of Centers for Medicare & Medicaid Services investigating the death. Chartis wanted Kautz and Hathi to “have some awareness” about the concerns raised by staff members to federal officials.

April 4, 2025: The Chartis contract is extended again from May 2, 2025, to Aug. 29, 2025. The maximum amount is increased to $2.5 million. Eventually, the first contract’s amount reached $4.36 million. 

June 18, 2025: The health authority executes a second contract with Chartis for $2.49 million. That contract is due to end June 30, 2026.