SALEM, Ore. — At Oregon's state-run psychiatric hospital, space is at a premium. The Oregon State Hospital has all but halted taking patients through the civil commitment process, funneled by capacity restrictions and court orders into prioritizing patients sent via the criminal justice system.
But recent scrutiny from the federal government on the Oregon State Hospital suggests that capacity isn't the only problem — security and patient safety have also been an issue, in large part due to procedures that either didn't exist or weren't being followed.
In a 102-page report, investigators from the federal Centers for Medicare and Medicaid Services laid out a pattern of violence and sexual assault among patients, with staff members failing to either intervene or follow up.
RELATED: Safety lapses contributed to patient assaults at Oregon State Hospital, federal report says
CMS investigators visited the hospital's main campus in Salem for about two weeks, between Feb. 28 and March 14 of this year. They also touched base with patients at the Oregon State Hospital facility in Junction City. Ultimately, they reported finding "systemic failures" that represent "a limited capacity on the part of the hospital to provide safe and adequate care."
"The governing body failed to ensure the provision of safe and appropriate care to patients in the hospital," the report states.
Allegations of patient abuse and neglect were not identified or investigated in a clear, complete or accurate way, the report found; indicating that OSH wasn't taking the necessary steps to ensure these incidents didn't happen again.
"The hospital failed to ensure each patient's right to provision of care in a safe setting, the right to freedom from all forms of abuse and neglect, and the right to prompt and appropriate response to grievances," the report continues. "Those failures resulted in actual and potential physical and psychological harm to patients."
The report found evidence of ongoing violence between patients, in some cases resulting in a patient ending up in the Emergency Room, with no plan in place to prevent those incidents from recurring.
CMS investigators also found that staff members had handed out condoms to patients, even though sexual contact is not allowed in OSH custody, and that sexual assaults occurred within the hospital.
Several disturbing incidents are documented in the report. In one case, a patient identified only as "Patient 23" was sitting in a courtyard when another person, "Patient 22," came up behind them and put them in a chokehold. Patient 22 hauled Patient 23 up and shook them until they lost consciousness, then threw them into a corner.
Staff members reportedly did not witness the assault, and Patient 23 was instead discovered by another patient.
The attacker, Patient 22, was supposed to have one-on-one supervision, but staff members weren't paying attention at the time. And according to the report, Patient 22 had made recent threats toward staff, inappropriately touching one of them.
Three days before the assault, Patient 22 had said that they were "homicidal," saying, "I feel like killing someone again, grab someone around the neck and strangle the f*** out of them."
The report also details how a patient, referred to as Patient 25, was moved to a new unit after becoming the victim of another patient's “hypersexual behavior.” Hospital staff concluded that Patient 25 was unable to give consent because of their mental state.
But after being moved to the new unit, Patient 25 reported being coerced into sex in the hospital's sensory room by yet another patient. When staff members went to investigate the sensory room, they found an open condom wrapper.
Patient 25 reported confusion about the fact that staff had handed out condoms, which staff said were for "self-care." During an unrelated press conference last week, a reporter asked Governor Tina Kotek about this part of the report.
"I don't know why they're handing out condoms, that was news to me," Kotek said. "We're going to ask them why that's happening, and we have been focused on improving the outcomes for individuals at the state hospital."
"As you know, it's mostly a population of folks who have been connected with the criminal justice system as aid and assist, and getting ready for their own defense," Kotek continued. "My primary concern is making sure what we're doing there is evidence-based, we're supporting the workforce to do it, and we're going to continue to monitor ... but that particular little fun footnote was a surprise and we'll be talking to them."
Oregon State Hospital has more than 1,000 cameras spread throughout the facility, but the CMS report noted that there were not enough people to monitor all of them, and that the cameras had blind spots. Investigators also found that staff members were not properly securing hospital doors, and did not seem fully aware of what was going on with patients.
The Oregon State Hospital said that there are always things that can be improved at the facility, but that they're dedicated to their patients. Friday marks their deadline to come up with a plan for improvements, which will need to be approved by the Centers for Medicare and Medicaid Services before another inspection.
In December, CMS threatened to pull $14 million in federal funding after a man charged with attempted murder escaped Oregon State Hospital custody and evaded police for two days. The hospital managed to keep that funding after putting in place new procedures for transporting patients.