QuickTake:

The state’s psychiatric hospital plans to look for ways to prevent catastrophic events like patient deaths, operate like a 24/7 hospital and emphasize shared responsibility among staff for patient safety.

Oregon State Hospital now has a 30-day plan to make immediate changes intended to address patient care and safety, with the aim of preventing catastrophic events like the death of a Lane County man who died March 18 while in the hospital’s care.

The hospital released the three-page plan Wednesday.  

The plan is the latest effort for improvements at Oregon State Hospital, which serves patients from a main campus in Salem with capacity for up to 558 patients and a satellite campus in Junction City that treats up to 145 patients. Most patients go there for court-ordered mental health care so they can assist their attorneys with their defense against court charges from throughout Oregon, including Lane County.  

The plan’s release follows an April 11 shakeup in which the hospital’s interim superintendent, Dr. Sara Walker, resigned after Gov. Tina Kotek learned more details about the death of Kenneth Hass, a 25-year-old patient at the hospital’s main Salem campus who was homeless in Lane County before his arrival there. Federal and accreditation inspectors found problems with the hospital’s monitoring of Hass and emergency response to him when he was unconscious, records show. 

Kotek appointed Dave Baden, deputy director of the Oregon Health Authority, to temporarily serve as the hospital’s superintendent and work with staff on the plan, which calls for increasing staffing, identifying high-risk patients and fostering an environment in which people speak up when they see a problem. 

The plan’s release comes after lingering and systemic problems at the hospital that preceded Hass’ death. In an August 2024 meeting, hospital managers raised concerns with health authority leadership about a culture that lacks accountability and fails to follow existing rules. 

The three-goal plan is broad in scope. The hospital will separately respond to findings by the federal Centers for Medicare & Medicaid Services and Joint Commission, two organizations that faulted the hospital’s response to the patient.

The plan’s first goal is to identify the next major event before it happens, including major injuries and deaths. To accomplish this, the hospital’s staff are taking “immediate steps” to survey high-risk patients and make sure they have appropriate plans in place so the hospital can “act before a patient or staff is harmed,” the plan states.

Those steps include increased awareness of workers assigned to a patient’s care team, with procedures to identify, report and act so staff respond to warning signs. The plan calls for measuring success by a decrease in incidents linked to systemic failures.

The second goal — operating like a hospital that operates 24 hours a day, seven days a week — recognizes that patients need care all the time. 

This includes better staffing at the hospital’s medical clinic and, in general, urgently acting to address unsafe patient conditions. 

This also means that the hospital would clearly identify decision-makers for when a change is needed in a patient’s care. 

The third goal, of clarified roles and shared responsibilities, comes in response to staff concerns about job expectations and training. 

“Additionally, staff have stated that expectations vary from unit to unit and that protocols are not being followed consistently,” the plan says.

The plan acknowledges that frequent policy changes from audits and other compliance-related activity have led to unclear expectations and inconsistent application of policies and “no consequences for failure to follow policies.”

“There must be a shared responsibility for patient safety,” the plan says. “This requires an environment where people are able to speak up when they see a problem, and when required actions are not taken, progressive interventions (including disciplinary measures) occur.”

To accomplish this, the plan calls for consistent policies and providing staffers sufficient training before they work in high-acuity units to ensure patient and staff safety.

Gov. Kotek, asked about the plan’s status during a press conference Wednesday, said work is continuing. 

“We are still working on the Oregon State Hospital plan,” Kotek said. “That doesn’t mean things are standing still waiting for the plan. We are reviewing protocols to make sure we can keep every patient safe, and we are continuing to work with the federal government, who’s doing their reviews at the state hospital. We’ll have more to share in a couple weeks.”

Ben Botkin covers politics and policy in Lane County. He has worked as a journalist since 2003, most recently at the Oregon Capital Chronicle, where he covered justice, health and human services and documented regional efforts to combat fentanyl addiction. Botkin has worked in statehouses in Idaho, Nevada, Oklahoma and, of course, Oregon. When he's not working, you'll find him road tripping across the West, hiking or surfing along the Oregon Coast.