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Oregon State Hospital is working to address findings from recent Centers for Medicare and Medicaid Services (CMS) surveys related to patient safety.

OSH is working on a Plan of Correction (PoC) related to a CMS statement of deficiencies following a February and March 2024 CMS survey prompted by a serious incident of patient-to-patient aggression in February 2024. CMS surveyors also reviewed three other incidents from previous years; these four patient safety events were instances of patient-to-patient aggression or sexual contact.

The deficiencies identified in the report relate to staff presence in the milieu; quality of incident investigation and response, including required clinical documentation; patient grievance response; and training and competency verification. OSH has 10 calendar days to respond with its PoC. After CMS approves the PoC, CMS will conduct another unannounced survey to review implementation.

“There will always be things we can improve, and we will continue to do so, but what persists is our dedication to the humans we are privileged to care for," said Interim Superintendent and Chief Medical Officer, Sara Walker, M.D. 

On May 2, CMS cleared OSH of immediate jeopardy status related to an active CMS survey concerning an April 2024 patient death. CMS surveyors were on the Salem campus after OSH reported a patient death shortly after arrival. While on site, CMS surveyors noted Code Blue emergency equipment in the Admissions area was not stored in an organized way. The equipment storage was identified as a potential future safety risk.

“The primary concern was that all Code Blue equipment for the admissions area was not in the same room. We have already rectified this," Walker said. “I am confident that together we will make the necessary changes to provide a safer environment for patients."
OSH is awaiting CMS' statement of deficiencies related to the April 2024 survey.