Surveyors with The Joint Commission noted serious threats to patient safety at Oregon State Hospital during a recent visit, placing the psychiatric facility’s accreditation status at risk, according to local news reports.
The accrediting body was on site to review conditions at the Salem-based facility March 24 and March 25, following an unexpected patient death that occurred March 18. Surveyors found issues with how often staff check in on patients who are in seclusion, as well as problems with the safety of the seclusion space itself, according to a letter The Joint Commission sent to Sara Walker, MD, the hospital’s interim superintendent, which was cited in reports from The Statesman Journal and Oregon Live.
The facility has taken corrective actions, including establishing a code blue team; staff training and falls and responding to codes; and the creation of a seclusion response team. Joint Commission surveyors will conduct a follow-up survey April 17 to determine whether sufficient improvements have been made to reaffirm accreditation status, which is currently in “preliminary denial,” according to the review letter.
Surveyors with CMS also began a review at the hospital March 26, which is also in response to the recent patient death.
The facility has faced scrutiny for a series of patient-safety incidents over the past several years. In 2024, it received two immediate jeopardy warnings related to a patient’s death and a patient who escaped during transfer.