An investigation by the Centers for Medicare and Medicaid Services revealed safety deficiencies at the Oregon State Hospital, the state’s most secure psychiatric facility, contributing to recent patient-on-patient assaults. According to Oregon Public Broadcasting, the federal report highlighted lapses in staff supervision and inadequate investigations into aggressive incidents.

Prompted by four complaints, the federal agency conducted an unannounced onsite survey earlier this year. One significant incident outlined in the report occurred on February 10, where one patient rendered another unconscious through a chokehold, necessitating extensive medical treatment.

Furthermore, investigators found that the hospital failed to prevent instances of sexual assault and inappropriate sexual contact between patients. In one case, a patient reported being coerced into sexual activity after being transferred to a new unit due to another patient’s “hypersexual behavior.”

The hospital has received the federal report and must respond with a corrective plan within 10 days. Interim superintendent Sara Walker emphasized ongoing dedication to patient care while acknowledging room for improvement.

Upon approval of the corrective plan, the Centers for Medicare and Medicaid Services will conduct another unannounced survey to review its implementation. The hospital, grappling with longstanding issues such as staffing shortages and overcrowding, faced immediate jeopardy status from CMS following a recent patient death. Although the jeopardy status has been lifted, the hospital continues to address safety concerns.

Additionally, last summer, a patient managed to escape while restrained and stole a van, later found in a pond. A subsequent federal investigation highlighted inadequate supervision and transport procedures at the hospital.