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Oregon State Hospital managers told state lawmakers they are creating a “culture of safety” following a string of patient deaths and violations of care standards. A lawmaker questioned how a patient could be in seclusion for months while hospital workers failed to follow minimum federal requirements.
The director of the Oregon Health Authority, Dr. Sejal Hathi, told state lawmakers Wednesday, June 17, that the circumstances surrounding the Oregon State Hospital’s past use of extended seclusion periods are “confusing.”
Hathi, a medical doctor, offered no explanation as to why the state psychiatric hospital’s seclusion practices had failed to follow basic requirements required of similar facilities nationwide. And she told a legislative panel she didn’t want to speculate on the reasons for past decisions.
“If there were seclusions that needed to be reauthorized by the medical leadership of the hospital over and over and over again, why was it reauthorized over and over and over again?” Hathi said at a joint hearing of the House and Senate behavioral health committees. “And I think the important element to emphasize is that (the) leadership team has changed, and I don’t want to speculate as to why those decisions were made, why this was not understood to be unacceptable, why it was normalized.”
Hathi was joined by the hospital’s interim superintendent, James Diegel, and its chief medical officer, Dr. Amit Bhavan, as they briefed lawmakers about Oregon State Hospital.
Also Wednesday, the hospital announced the hiring of a new permanent superintendent, Sean Murphy. Murphy’s career includes time as deputy assistant secretary for the Washington State Department of Social and Health Services. He also was an assistant secretary for Washington Behavioral Health Administration, a role with responsibility for the oversight of that state’s psychiatric hospitals.
Murphy, who starts July 13, arrives after a tumultuous period at Oregon State Hospital, which has a main Salem facility and a satellite campus in Junction City.
The hospital has experienced five unexpected patient deaths since November 2023, including a Lane County resident who died there in March 2025 after spending months in seclusion.
Kenneth Hass fell three times the same evening he died without staff entering to check on him until after he was motionless. Regulators with the federal Centers for Medicare & Medicaid Services, known as CMS, found multiple violations with his care and with the response the night he died.
Sen. Sara Gelser Blouin, D-Corvallis, pressed Hathi and Oregon state officials on why the hospital has struggled.
“How did we get to a point where we had a state hospital that apparently was not even aware of what the federal requirements were?” Gelser Blouin said. “The death is the one piece — but the extremity of that suffering and violation of CMS standards for a long period of time leading up to that — that’s confusing.”
Hathi agreed that it is indeed confusing.
“It’s confusing to all of us, and that’s why so many changes have been instituted to make sure that this never happens again,” Hathi said. “Processes have been changed, leadership has been changed, protocols have been changed.”
State officials, including Hathi, knew seclusion was a problem that needed to be addressed months before Hass’ death, records show.
In November 2024, Hathi and state hospital executives received a consultant’s summary analysis that found Oregon State Hospital kept patients in seclusion for “days and weeks” without justification, Lookout Eugene-Springfield reported this week.
Chartis, a consulting company, found that the use of seclusion was a high priority issue that needed immediate attention.
Four months later, Hass, who was homeless in Lane County before entering the state hospital, died in a seclusion room.
In the aftermath of the March 2025 death, Dr. Sara Walker, the interim superintendent and chief medical officer, resigned after Gov. Tina Kotek learned more details of the case.
Moving forward, Hathi and other officials said they are focusing on the change in leadership at the state hospital and steps they’re taking to ensure compliance.That includes staff huddles to review seclusion cases and ongoing reviews, especially when a patient doesn’t quickly exit seclusion.
Gelser Blouin said she appreciates the efforts to improve, but reminded state officials that the regulations the hospital is trying to meet are not unique to Oregon.
“How could someone be in seclusion for months and months and months on end while maintaining any remote consistency or adherence to the Medicaid and CMS regulations?” Gelser Blouin asked. “How could that not be known to the medical director, the OHA director, the superintendent of the state hospital, since these are so far beyond what is medically appropriate or allowed under federal law?”
In response, Diegel stressed the hospital is focused on a culture of safety, with a built-in response to elevate cases so patients get the care and attention they deserve.
“I can’t speak to what was,” Diegel said. “I can speak to what is, and what continues to be at the state hospital.”
Bhavan, the hospital’s chief medical officer, is new to the role but also has a six-year career at the hospital. He said he’s seen the culture shift so that staffers want to help find a solution when a patient is facing 24 hours in seclusion.
“Everyone’s ears perk up, everyone’s alarm signs get raised, and everyone is saying, ‘How can I help, and what can we do to get this adjusted, or get interventions in place to reduce the length of this time?’” he said.
Lawmakers, staffers and a handful of media outlets toured Oregon State Hospital’s main Salem campus after the hearing.
Amber Shoebridge, a spokesperson for Oregon State Hospital, said the facility could not allow a Lookout reporter to be on the tour because of security measures and the number of people already joining the event.
Staff with three other Oregon media outlets were on the list of people approved to join the tour.
