Scathing Oregon State Hospital report shows employee concerns after patient death

Kenneth Hass died alone at Oregon State Hospital on March 18 in circumstances that deeply troubled staffers at the state-run psychiatric hospital in Salem. 

The 25-year-old, who was homeless in Lane County before he entered the hospital, spent his final days in a seclusion room. Initial findings from previously released reports say the hospital’s staffing to observe Hass was insufficient and that its emergency response to his loss of consciousness was not effective.

State officials Wednesday released a federal report with more findings about his death — and additional systemic problems that inspectors turned up. The 245-page report details an institution in crisis: one that has repeatedly failed to provide adequate care for vulnerable people, including those who spend time in seclusion rooms with limited contact to the outside world. 

Hass’ death sparked wide-ranging fallout at Oregon State Hospital, which has capacity for up to 558 patients and a satellite campus in Junction City that houses up to 145 patients. Most are there for court-ordered mental health treatment to face criminal charges. 

The hospital’s superintendent at the time, Dr. Sara Walker, was forced out of her job and asked to resign shortly after Gov. Tina Kotek reviewed details of the death. Inspectors with the federal Centers for Medicare & Medicaid Services launched a review, and its findings, released Wednesday, went well beyond the immediate circumstances of his case. 

The report echoes some of the same concerns that state hospital employees raised in an August 2024 meeting Oregon Health Authority Director Sejal Hathi about a culture that fails to follow existing rules and procedures. The authority runs the hospital.

“Unsolicited, numerous department, program, and unit medical staff and leaders came forward to speak to the surveyors,” the report said. “Those staff provided permission for the concerns they shared to be used in the survey report.”

To conceal the employees’ identities, the report left out interview dates and times. 

Staffers reported concerns about “patient deaths and serious patient harm that were investigated” during the last two years, the report said.

State hospital employees told the federal inspectors that department leaders flagged “numerous warnings and problems” to the hospital’s executive leadership, but to no avail. 

“Those concerns were largely ignored and dismissed,” the report said.

Dave Baden, the Oregon Health Authority’s deputy director, said the hospital is making changes to address the issues. Baden temporarily stepped in as acting superintendent in April after Walker left.

“This report is a clarion call for the need for the immediate changes being implemented now that will have impact to assure that patients at OSH are safe and receiving the care they need and deserve,” Baden said in a statement. “Sustained and ongoing cultural changes at the hospital will take time. We need to improve our processes in support of not only patients in seclusion or high-risk patients, but every patient at OSH.”

Before this case, the hospital has come under scrutiny for other patient deaths. In November 2023, a patient died in a seclusion room, where staff placed him after he complained of breathing difficulties. In April 2024, another patient died the same day he arrived from the Douglas County Jail. Inspectors found medical staff neglected to check that patient’s vitals when he arrived. In May 2024, another patient died of a suspected fentanyl overdose. 

In the new review, hospital employees told federal inspectors that in some earlier cases, staffers were “coached” on what to say or not say to the federal agency. 

The new report also quoted staffers as saying that in the past, when the hospital launched monitoring and other efforts to fix and prevent problems, it would abandon those plans after it returned to compliance. 

Federal inspectors also found medical staff who provided direct care for patients who faced neglect also were involved in the hospital’s investigations of those cases.

“That has created barriers to impartial and objective investigation and decision-making regarding deficient practices and corrective actions,” the report said. 

Overall, the report found the hospital’s staff training is “insufficient in both content and in-person teaching.” The newest employees with the least experience and training are placed in units with patients who have the highest levels of need, the report said. 

The full scope of the hospital’s failures is not known, including all the breakdowns that led to the March 18 death. The report is heavily redacted, which the health authority said is necessary to protect patient privacy and health information. The redactions obscure certain statements and text that immediately follow notations about “failures,” including details about failures to provide safe and adequate care. 

In general, inspectors found shortcomings in the use of seclusion and restraints on patients, including a failure to monitor them to observe their safety. For example, in one case, a patient was “accidentally” locked in a seclusion room, but no plans were put in place after the incident to prevent similar events from occurring.

In the long term, the hospital faces other work. It recently announced it hired James Diegel to be the interim superintendent and take over from Baden while the state searches for a permanent superintendent. 

On Friday, a federal judge found Oregon State Hospital in contempt of court for its ongoing failure to admit patients to the hospital within seven days after a court order found that they need mental health care to face charges and aid their defense attorneys.

The case and order stem from a 23-year-old permanent injunction that advocates, including Disability Rights Oregon, won in a lawsuit. That order calls for fines of $500 per person for each day they wait beyond the seven-day period.