SALEM, Ore. — The U.S. Department of Justice has found numerous civil rights violations of patients at the Oregon State Hospital. In a report released Wednesday, federal investigators listed inadequate conditions and practices at the mental hospital ranging from life-threatening use of restraints to widespread patient-on-patient assault. Federal law entitles patients to certain standards of care. State health officials say many improvements have been made since the investigation took place in 2006, but acknowledged problems still exist. “The conditions reported on … are completely unacceptable,” said Dr. Bruce Goldberg, director of Oregon’s Department of Human Services. “It’s unacceptable as a state and its unacceptable for us as a state hospital for the health and well-being of our patients.”
The Oregon State Hospital is the state’s primary psychiatric facility for adults, which has a main hospital in Salem and other satellite facilities. Officials found violations in Salem and at its smaller Portland campus, which is used for psychiatric rehabilitation. Some of the cases highlighted in the 48-page report include:
Nearly 400 cases of patient-against-patient assault over one year.
Infection control issues such mice in rooms, deaths from pneumonia and outbreaks of norovirus and scabies.
Patients injuring themselves, including multiple suicide attempts, while under staff observation.
Failure to follow common standards of care: A patient with a disorder that causes excessive thirst was left at the water fountain and gained 13 pounds in water weight in one day.
Patients being put in seclusion indefinitely: One patient had been in seclusion for a year with no other treatment when investigators arrived. Other issues included improper medication, failure to diagnose mental health conditions, improper use of restraints, nurses working excessive overtime and patients waiting for discharge for more than a year after being approved. The report sets out recommended changes but does not set timelines to complete them. It is the latest in a series of critical looks at the hospital. Multiple state-commissioned reports found major health and safety dangers there, primarily from the crumbling century-old facility in Salem. It was the setting for the 1975 film “One Flew Over the Cuckoo’s Nest.” The Oregon Legislature last year authorized $458 million to build two new state-operated hospitals by 2013: a 620-bed hospital in Salem and 360-bed facility in Junction City. The hospital also hired a new chief medical officer and additional staff. “It’s not the same hospital today that it was in 2006,” Goldberg said. A spokeswoman for Gov. Ted Kulongoski said the governor takes the findings seriously, but is pleased with progress made since the 2006 investigation. Others were more dismayed by the report. “It’s the worst report I’ve read in my entire life,” said Senate President Peter Courtney, D-Salem. “Every word was something else that was terrible. No standards, no progress … it goes on and on.” Courtney said he will create a a legislative oversight committee to monitor progress toward compliance with the Department of Justice’s recommendations. “In my opinion, this is the number one issue for Oregonians today,” he said. The National Alliance on Mental Illness of Oregon said it wants a comprehensive review of the entire mental health system so the 2009 Legislature will know how to respond. The Department of Human Services says it will request additional positions from the to improve patient care and safety. “This is a symptom of years of neglect to our entire mental health system,” Goldberg said.