Incident reports from Oregon State Hospital provide a window into some of the chaos at the institution. (Salem Reporter graphic)

SALEM - Raph can’t remember how many times the patient punched him in the head.

It was just before 1 a.m. on July 5 when the patient, who had been in seclusion earlier that day, came to the medication window on his unit at Oregon State Hospital, asking for something to help him sleep.

The man, upset when the nurse first had to get a doctor’s approval, ran to the unit’s common area.

There, he came up on Raph from behind, hitting him in the head without warning. Trying to protect himself, Raph slumped down in his seat and put up his arms.

“I think about it, I replay it in my mind. I don’t want to say that I was traumatized by it. I mean, I was but not to PTSD levels,” said Raph, a mental health technician who asked to be identified by a nickname because he feared reprisal at work. 

He left the hospital in an ambulance and was diagnosed with a concussion, missing two weeks of work.

Employees and patients at the hospital are paying a steep price for the state’s inability to keep the hospital fully staffed, an investigation by Salem Reporter found.

Employees are being attacked on the job. They are being worked to exhaustion. They say they can no longer provide the care their patients need.

Many said they fear for their safety, and the safety of patients under their care.

“It’s a very real and very serious situation with acute physical violence ... We’re drowning,” said David Lynch, a mental health nurse at the hospital and the president of AFSCME Local 3295, the union representing state hospital nurses.

Members of the National Guard stand outside of Oregon State Hospital while on break from a training on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

The shortage of workers is so severe that hospital administrators called in the National Guard to work with patients in May. They said it was a temporary measure. But in September, military personnel returned as staffing problems persisted.

The churn of workers on hospital units in recent months has worsened patient care, employees said. Some clinicians report they’re doing little more than “babysitting” patients or say those under their care can’t get better when the people charged with helping them cycle in and out of units.

Disability Rights Oregon, a Portland nonprofit which has played a continuing role monitoring patient care at the Salem hospital, investigated. Jake Cornett, executive director of Disability Rights Oregon, wrote about the findings in a Sept. 27 letter to Gov. Kate Brown and Pat Allen, director of the Oregon Health Authority, which oversees the hospital.

“During our investigation into the conditions and treatment of people with mental illness during the pandemic, staff and providers paint a picture of a State Hospital in complete disarray and an agency that is unwilling or unable to confront just how bad things have gotten,” Cornett wrote.

The organization has yet to hear from Allen or the governor.

Elias Abrego takes the temperature of physician specialist Manisha Mittal at a COVID-19 check point at Oregon State Hospital on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

The chaos inside the hospital follows a decision at the start of the Covid pandemic to spread some of the institution’s least stable patients across the Salem campus, a move that workers say increased the risk of aggression and assault.

Administrators told Oregon’s workplace safety agency in the summer of 2020 that they would do more to investigate and prevent assaults inside the hospital. But more than a year after submitting their plan to correct the issues, hospital leaders have implemented few of the steps they outlined.

Hospital reports show employees continue to be injured.

“Her left eye was purple and blue in color and swollen. She could not open her eye completely. She reported that her pain level was 9 out of 10 … (Employee) had a tooth on the top row of her mouth that was broken when she was struck by (patient),” reads a July 3 incident report after a patient punched a licensed practical nurse in the face.

The nurse left the hospital by ambulance for hospital evaluation. The incident log recorded her injury as of “moderate” severity.

Salem Reporter obtained such reports from the hospital through a public records request.

Hospital leaders and officials at Oregon Health Authority say their decisions over the past year have been guided by a need to prevent Covid outbreaks inside the hospital.

They disputed employee assertions that violence has gotten worse, pointing to hospital data showing the overall number of staff injuries caused by patients has decreased each year since 2018, though they acknowledged such assaults have spread across more units of the hospital.

The number of approved worker’s compensation claims for injuries caused by patient interactions is also on the rise this year, hospital data shows, as are the number of patient injuries caused by other patients.

Leaders said they’re now working to provide more training on safety in hospital units with the largest increase in assaults and aggressive behavior. And they said mandated overtime is starting to fall as the Delta surge has waned and hospital administrators agreed to increase wages for many employees.

“We're hopeful that we're heading in the right direction,” said Sara Walker, the hospital’s interim chief medical officer.

Patient shifts

Raph wasn’t the only hospital employee who left work in an ambulance on July 5.

Around 10 p.m., the patient who attacked Raph told a nurse he planned to “go after” another nurse who had given him a “look,” according to hospital incident reports.

Nurse leaders made plans to transfer the employee to another unit. But as the nurse was walking to the break room to gather his belongings, the patient ran toward that nurse and another worker.

“The patient pushed his way into the room and hit the orienting RN multiple times in the face,” the report said. One employee injured her left shoulder while subduing the patient. One worker was taken to the hospital by ambulance.

Hospital employees attribute such assaults to the choice by hospital administrators early in the pandemic to spread some of the institution’s least stable patients to units ill-equipped to care for them.

A sign on a door into a screening area at Oregon State Hospital on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

State officials have struggled for years to find ways to care for Oregon’s most seriously mentally ill residents at the hospital. 

Since 2017, the hospital has seen a sharp uptick in patients admitted to the hospital who are facing criminal charges and determined to be unable to aid and assist in their own defense because of a mental illness or disability. 

Such “aid and assist” patients now comprise 72% of the roughly 500 patients in the Salem hospital, and the number of those civilly committed for mental health treatment has lagged. The hospital’s mission is to treat those patients to a point where they can understand the criminal charges against them and make decisions in court proceedings.

Hospital nurses and mental health workers interviewed by Salem Reporter stressed that most patients in the hospital aren’t violent or aggressive.

Those that display such behavior often do so early after arriving at the hospital, when they’re in an unfamiliar environment and health providers are still determining how to best treat them.

Before the pandemic, a majority of patients who were new to the hospital and adjusting, or prone to aggression, were typically housed in the Harbors section of the hospital - six units with 112 beds, designated for stabilizing patients who were new to the facility, unpredictable or aggressive.

Employees refer to Harbors as “maximum security.”

All rooms in the unit are singles, rather than the double occupancy rooms common in other areas of the hospital. Staff-to-patient ratios were higher, and nursing stations have protective thick glass around them so it’s more difficult for patients to get in.

But when the Covid pandemic began, the hospital needed a place to quarantine new patients and monitor them. The goal was to ensure that anyone coming into the hospital with Covid wouldn’t spread the virus.

“Our patients move around a lot, they interact with each other a lot. And the risk of an outbreak that potentially spreads to hundreds of people is a significant concern to us,” Walker said.

Oregon State Hospital on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

The Harbors units were the best quarantine space, Walker said, because of the single rooms.

Hospital administrators turned four of the six units into Covid quarantine. That meant dozens of patients who would normally spend longer being stabilized were transferred throughout the hospital.

The result, employees said, was that they had to care for less predictable, less stable patients without additional training and in spaces that weren’t designed for patients who are sometimes violent.

That’s had a particular impact on hospital units that previously housed mostly patients found guilty except for insanity, who typically have longer hospital stays and are more stable.

“I can’t keep the patients safe, I can’t keep the staff safe and I definitely can’t keep myself safe,” said one veteran nurse who works on Bird 3, a unit that previously housed mostly guilty except for insanity patients.

She’s worked at the hospital for almost two decades and said now is the first time she’s feared for her life and safety at work.

Like other employees, she declined to be identified by her name for fear of retaliation from hospital managers.

Activity coordinator Elias Abrego works a COVID-19 screening check point at Oregon State Hospital on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

Walker acknowledged that the decision to move patients across the hospital has been most challenging for employees who were used to lower acuity patients in Bird and Bridges units. She said the hospital added staff and training to compensate for the shifts.

“We did expect that we would need to be focusing on helping our staff develop skills in working with a more highly acute population and navigating that milieu,” she said.

“We also expected a benefit to staff safety from a Covid standpoint,” said Pat Allen, Oregon Health Authority director. 

Walker said the hospital did not make physical modifications to units suddenly housing more unstable patients.

She said the units that patients transferred to were already designed to handle aggressive behavior and such changes weren’t necessary. The Bird units, for example, have three hallways and more activity rooms “so patients who don’t get along well have an easier time staying apart from each other,” Walker said in an email.

Lynch, the nurse union president, said the staffing shortages have become an escalating problem, where remaining employees become increasingly overworked and thus more likely to be injured.

“They aren’t used to this level of violence, and when that happens and you don’t have enough people to respond or able to respond in a safe way, the amount of time people are off work because of injuries is longer,” he said.

Units are often so short-staffed that employees don’t have time to attend training that could help improve safety or debrief after an incident, he said.

The constant cycling of staff, new hires, and temporary placements also means patients are less likely to be working with the same people consistently – something employees, patient rights organizations and hospital administrators say is key to preventing aggression and aiding treatment.

Employees suddenly working with a different group of patients say they don’t have the tools they need.

The nurse on Bird 3 said she and other providers were given flashcards to explain to patients the role of a judge and district attorney, but no other training on the legal obligations or skills such patients needed.

“We’re supposed to be helping them get ready to go to trial,” she said. “We were not taught what they need to know … We were told to ad lib it and we would figure it out. We haven’t figured it out,” she said.

Hospital spokeswoman Aria Seligmann said that’s untrue. She said a team of three experts on the process met with leaders on Bird units to “provide specialized training.”

“This team has offered continued mentorship and support to the Bird team throughout their transition,” Seligmann wrote in an email.

Walker said in the process of moving patients around, hospital administrators tried to move “aid and assist” patients to units where staff had experience with competency restoration. Bird units had some of those patients prior to the pandemic, she said.

“We've tried to target those to units where the teams are accustomed to working with patients in that population, because they understand how the system works and the discharge processes,” Walker said.

Assault investigations

In late 2019, Oregon’s Occupational Safety and Health Administration inspected the hospital after an employee filed a complaint about frequent assaults by patients and a lack of management response to address the problem.

Employees told a state inspector that the hospital’s security employees were sometimes unavailable or slow to respond to emergency calls. Some detailed serious injuries, including broken bones, caused by patients and said there was no investigation or follow-up by the hospital.

READ IT: OSHA inspection report

Oregon OSHA cited the hospital in June 2020, saying its safety committee members had not been trained in accident investigation, did not have written records of recommended corrective actions to prevent assaults and did not review all accidents and incidents. 

The committee, the report said, was only reviewing statistics about injury causes and worker’s compensation claims.

The agency described the violations as “serious” and fined the hospital $2,000.

In response, hospital administrators said they would create two subcommittees, one in Salem and one at the state hospital in Junction City, to review all accidents and staff safety incidents, including assaults by patients.

“Each month these sub-committees will report the details of their findings and recommendations to the full Safety Committee, soliciting feedback and gaining agreement to move them forward to management for response,” wrote Kirsten Hewlett, the hospital’s interim director of safety and security, in a correction plan dated June 17, 2020. 

The accompanying letter to OSHA said the subcommittees and their new processes would be up and running by October 2020.

But Salem Reporter found that 10 months later the hospital had largely failed to implement the corrections it promised.

Members of the National Guard stand outside of Oregon State Hospital while on break from a training on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

In response to a records request from Salem Reporter, Oregon State Hospital said on Aug. 4 it was still finalizing the subcommittees and could not produce any records of meetings held, safety recommendations or responses from management to prevent assaults.

“The membership has not been finalized; therefore, the work for the subcommittees has not started and protocols have not been built. This work has been delayed due to the pandemic and the hospital’s overall COVID-19 response,” Jeanne Windham, Oregon Health Authority public records officer, wrote in an email.

Seligmann said the subcommittees began meeting Oct. 5.

Walker could not detail any recommendations made to reduce the violence against employees. 

She said such decisions are usually made by clinicians and the safety committee was still reviewing total numbers on employee injuries, not individual incidents.

Weekly, she said “administrative leadership of the hospital get together and talk about what's going on in each of the programs, really kind of identifying what are the hotspots patients or units that need more clinical resources or attention.”

That meeting has been occurring for several years, she said. 

“More recently, we've added a consideration of where can our Safe Together trainers spend some extra time this week, units struggling most with acuity of patient aggression in particular, to help support the staff,” she said.

Walker and Allen pointed to hospital data showing the number of assaults by patients toward staff has fallen since a 2018 peak, even as the number of patients in the hospital has remained about the same.

That year, the hospital documented 896 “patient to staff aggression events.” So far in 2021, patients have assaulted hospital employees 421 times through Sept. 30 - an average of 47 times per month.

But other hospital data suggest the problem of violence and aggression hasn’t decreased.

Incidents of patients assaulting other patients are on the rise.

(Graphic by Rachel Alexander/Salem Reporter)

(Graphic by Rachel Alexander/Salem Reporter)

In 2019, those assaults happened about once a day. In 2020, the rate increased, and the hospital recorded eight patients severely injured by other patients - the highest total in at least a decade.

By the end of September 2021, patients had attacked other patients 385 times in 2021, averaging 43 incidents per month. Five of those resulted in severe injury.

Hospital records contain other indicators of the extent of the crisis.

“Code Green” calls, which indicate a behavioral emergency, have climbed since 2019, averaging three per day in 2020, and four per day in 2021 through the end of July.

The number of accepted worker’s compensation claims for staff injuries caused by patient interactions is also up.

Those claims can be for injury resulting from an assault, or injury caused by exertion while restraining or subduing a patient.

In 2019, SAIF accepted 145 hospital employee claims caused by patient interactions. In 2020, that number rose to 252. In the first seven months of 2021, hospital employees had 205 claims accepted.

Short staffing

The result, for hospital employees, is exhaustion and a sense of helplessness.

Mandated overtime, where employees are required to work extra hours so the hospital can maintain legally required staffing ratios, spiked in mid-June, then fell to almost none in July as National Guard soldiers began working on units.

When the Guard left at the end of the month, mandates again increased. On Aug. 14, employees across the Salem hospital were required to work 361 hours of overtime. Mandated overtime that week climbed to an average of 162 hours per day.

Employees said mandates mean working up to 16 hours in a day, sometimes several days in a row.

Raph, the mental health technician who suffered a concussion, said after his return to work, his doctor wrote a note saying he couldn’t work more than 12 hours in a day.

“I had to do something,” he said. “People were getting mandated literally three or four days in a row.”

In response, hospital leaders said they’ve taken steps to secure both temporary and permanent employees and improve retention. They said those steps have already reduced mandated overtime in October.

National Guard soldiers will be on duty through the end of 2021 under a new contract. On Oct. 8, hospital Superintendent Dolly Matteucci said in an email to staff that about 40 more National Guard soldiers would begin training later in the month.

National Guard Col. Ron Smith, task force commander for Oregon State Hospital, on Thursday, Sept. 23, 2021. (Amanda Loman/Salem Reporter)

Several found the deployment rewarding enough they applied for permanent positions at the hospital, said Col. Ron Smith, the task force commander for the hospital assignment. Eight who initially deployed to the hospital in July volunteered to return in September for a second deployment.

Smith said aside from one incident where a patient assaulted a Guard member in July, deployed soldiers have stayed safe on the units, though a few have had “minor scuffles” with patients.

Matteucci said 58 temporary agency nurses and mental health technicians were scheduled to begin work the week of Oct. 8, with 10 more still in training. Those contracts expire at the end of the year.

Hospital and OHA leaders also inked a deal with two employee unions to temporarily raise hourly weekend pay for nurses by $31 per hour, mental health technicians by $18 per hour and custodians and food service workers by $13. Those figures are on top of regular hourly pay.

That’s expected to cost the state $9 million by the end of January.

Seligmann said union leaders and hospital managers are working on a 2022 proposal to the Oregon Legislature for more staff. They’re also working to reduce the time needed to hire new employees and adding training classes so new hires can begin work sooner.

Still, employees and patient advocates said there is insufficient urgency to fix staffing problems.

In the first six months of the year, 137 hospital nurses and mental health technicians quit their jobs, compared to 176 resignations for all of 2020.

Cornett, the Disability Rights Oregon director, said the hospital leaders’ lack of urgency over staffing shortages risks grinding to a halt the state’s entire system for criminal defendants with mental illnesses.

“If OSH continues to lose staff and is not able to increase its capacity to meet the needs of Oregonians with serious mental illness – or worse, if the hospital is forced to reduce capacity – you risk presiding over a systemwide breakdown,” he said in the letter to the governor.

One resigning mental health technician, Amanda David, emailed to the hospital’s entire staff her resignation letter on Sept. 1, addressing her comments to Matteucci.

“Thank you for showing me and others that we are just a ... number,” David wrote. “Not only is the floor extremely short staffed, the individuals in security are working countless doubles because they too are also extremely short staffed … You and your team are putting us and patients in danger and you’ve known about this for months with no real improvement. Band-Aid fixes are just not good enough anymore.”

Contact reporter Rachel Alexander: [email protected] or 503-575-1241.