Oregon State Hospital leaders describe corrective actions after sentinel events, report shorter seclusion and restraint durations
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Summary
State hospital officials told the Senate Judiciary committee about leadership changes, a plan of correction under CMS and Joint Commission oversight, and operational changes that reduced average seclusion duration from about 29 hours to roughly 5.5 hours and restraint duration from about 6.9 hours to 3.3 hours.
Officials from the Oregon Health Authority and the Oregon State Hospital briefed the committee on actions taken after recent sentinel events and described steps to improve patient safety and clinical oversight.
Dave Baden, Deputy Director for Policy and Programs at the Oregon Health Authority, said the governor—s office and OHA increased oversight after sentinel events and installed interim leadership at the hospital (interim superintendent and interim chief medical officer among other appointments). He described the hospital as the state—s highest level of psychiatric care and said the legislature has invested substantial general-fund resources.
Dr. Amit Bhavan, interim chief medical officer, detailed the hospital's plan of correction and operational changes aimed at reducing high-risk outcomes. Reforms included an extended seclusion/restraint consult team, updated nursing-assessment forms to clarify release criteria, improved post-fall assessment protocols, and faster access to physical and occupational therapy following falls.
Dr. Bhavan presented outcome metrics the hospital is tracking: average seclusion duration declined from about 29 hours (one year prior) to roughly 5.5 hours in the most recent month, and average restraint duration dropped from about 6.9 hours to about 3.3 hours. Hospital leaders said they continue weekly audits and are awaiting CMS revisits tied to the plan of correction.
Committee members asked about classification of manual versus mechanical restraints, reporting differences across facilities, whether wrongful restraint could be investigated as abuse, and the cadence of unannounced Joint Commission and CMS surveys. Hospital leaders said OTIS investigates abuse allegations, that the Joint Commission conducts triennial accreditation surveys (often broad in scope), and that CMS revisits plans of correction after surveys; a planned CMS revisit was delayed by a federal government shutdown.
What happens next: The hospital invited committee members for a site visit, will continue weekly audits and prepare for CMS re-survey, and has implemented training and new protocols intended to further reduce incidents and improve patient care.