A patient grabbed her by the hair and repeatedly threw her into the doorframe. There was nothing the Oregon State Hospital employee could do to stop it from happening.
Fighting back tears, she recounted the attack to the Statesman Journal, saying because of hospital policies, she was not allowed to leave the patient’s side.
“So many of us have developed PTSD and anxiety,” she said. “After being there for about a year, you’re usually on medication for it.”
The Oregon State Hospital on Center Street in Salem is a psychiatric facility that currently serves about 549 patients with varying behavioral health conditions.
Multiple assaults on hospital staff are detailed in a more than 1,100-page investigative report the Statesman Journal obtained from Oregon OSHA. The report shows employees face daily violent altercations with patients and frequently are injured.
Staff members pointed to changing management policies and a more unpredictable population of patients awaiting treatment so they can aid and assist in their court cases. Experts said staffing shortages and the lingering impacts of COVID-19 contributed as well.
Many of the injuries have required staff to take time off work or work on limited duty, creating an even more dangerous environment for employees left to fill shifts. Through September of this year, there have been 729 lost time days when employees took full or partial time off due to injuries from patient assaults.
The genesis of the investigative report was an anonymous complaint by a hospital employee to Oregon OSHA in December 2019 about patient assaults resulting in staff injuries.
An Oregon Occupational Safety and Health Association (OSHA) inspection, ending in May 2020, resulted in two serious citations. Oregon OSHA found there was no hospital committee trained in accident investigation and there were no records of corrective actions being taken to prevent employee injury.
The state hospital has struggled to correct these violations. They did not establish a workplace violence prevention program until December 2021, and it did not begin meeting frequently until April when another anonymous employee complained: “Management does not implement any kind of solutions to mitigate these incidents and prevent workplace injuries from these attacks.”
That complaint prompted another Oregon OSHA investigation that ended in September. Investigators found the state hospital failed to investigate about 78% of the frequent “violent altercations between employees and patients.”
On Sept. 22, Oregon OSHA cited the hospital for three violations and issued a $54,180 fine. Hospital administrators have until Nov. 1 to submit a plan for correction and until Nov. 11 to pay the fines.
“We’ve got to do a better job of being able to support our staff,” Oregon Health Authority director Patrick Allen said during a Sept. 15 Oregon State Hospital Advisory Board meeting.
Employees say injuries are ‘repeated daily occurrences’
A door not latching properly, a lack of or no access to nursing stations in some units, “lots of people wandering the halls,” employees monitoring patients alone.
These are a few of the workplace hazards Oregon OSHA senior health compliance officer Linda Patterson noted in her report from her inspection and conversations with employees.
Multiple employees were quoted in the report saying injuries on the job are “repeated daily occurrences.”
In a six-month timeframe, from November 2021 to May 2022, more than 395 assaults occurred.
One incident cited in the report resulted in two head injuries:
Two patients began a verbal altercation. As a staff member went to intervene, one of the patients punched them in the stomach. Staff had to restrain the patient. Two other staff members were helping. One hit her head on the brick wall and the other hit her head on the ground. The patient began yelling racial slurs at one of the staff and spit in her face.
The patient was not “medication compliant” at the time of the assault, meaning they had been allowed to refuse to take medication for their behavioral health condition.
Some of the injuries sustained by staff include sprains, bruises, lacerations, burns, concussions, fractures, dislocations and head injuries.
A nurse sustained a cornea abrasion and was away from work for 22 days. A mental health therapist got a concussion and had facial bruising and lacerations. They were away from work for 45 days.
Another documented incident said a patient hit from behind the neck of staff and repeatedly hit on his face causing lacerations and bleeding. Staff remained conscious but was “out of sorts and pale.”
Staff injuries are classified as minor, moderate or severe.
Minor injuries are those that can be treated with at-home first aid, moderate injuries require emergency medical treatment but not hospitalization, and severe injuries result in hospitalization and long-term restriction of usual activities.
A changing patient population, new policies and a pandemic
In the past three years, the patient population at Oregon State Hospital has changed. The primary population is now aid and assist patients, or those who have criminal charges but are unable to aid in their own defense because of a behavioral condition and so have not yet gone to trial or been convicted.
Superintendent Dolores “Dolly” Matteucci , who reports to Allen, the director of the Oregon Health Authority, took over management of the hospital in March 2018, implementing new patient care policies.
As of September, more than 70% of the patients at the hospital in Salem were aid and assist, compared to slightly less than 50% in 2019, according to data provided by Oregon State Hospital.
The care of aid and assist individuals falls on the criminal justice system as they receive a psychiatric evaluation. If deemed unable to aid in their own defense, they must wait in county jails until a bed becomes available for them at the state hospital.
Patients come to the hospital from jail having received little to no behavioral health care, medication or therapeutic services.
These patients can have more behavioral issues and require more intense care. The investigation report said about a third of the aggressive events are due to half a dozen specific patients.
Aid and assist patients are three times as likely to have a restrictive event — briefly manually or mechanically restrained or isolation in a room where they cannot hurt themselves or others — compared to guilty except for insanity patients, according to OSH data.
Previously, patients who posed more behavioral issues were placed on what is called a 2:1 or a 1:1. One to two staff members would be assigned to a specific patient at all times so they could intervene before anyone got hurt.
Patients also are allowed to refuse medication and have access to things previously banned, such as taking meals and utensils to their rooms. Before, patients were patted down after meals.
“Patients’ rights trump my safety,” an employee told Patterson during her investigation.
Patients do not face consequences for violent actions and rewards are often given to de-escalate, employees told the investigator.
Many employees expressed a need for balance between patient rights and employee safety. They said they felt scared to intervene or make physical contact because of changing policies about patient rights.
“Management doesn’t do anything to stop the violence,” an employee said to Patterson.
Employees had numerous complaints about management relations with staff and expressed dissatisfaction with superintendent Matteucci’s management style.
“Superintendent, know how to do your job,” one staff member was quoted as saying in the report.
Staff told the investigator they did not feel comfortable going to management for fear of retaliation or losing their jobs. They want to feel supported after injury, but many feel management does not care about them. Some said they worked without reporting they were injured because they worried for their co-workers’ safety if they were out recuperating.
“The mentality is, if I’m not here, more people are going to be hurt,” a staff member told Patterson during the investigation.
Other OSH policies changed during the pandemic.
During 2020 the state hospital was focused on keeping patients and employees safe from contracting COVID-19, prior to the release of vaccines. The workplace safety team, cited in the 2019 investigation as critical for incident investigation and violence prevention, instead primarily focused on responding to the COVID-19 pandemic.
‘Just like another day of work’
In 2021, there were 1,103 lost time days where employees took full or partial time off because of injuries sustained from patient assaults.
Employees said at times, they were left with very few people in a unit full of patients. They said units were rarely staffed appropriately.
|Oregon State Hospital lost time daysfrom patient assaults by year|
|2019||1,829 days lost|
|2020||1,567 days lost|
|2021||1,103 days lost|
|2022 (Jan. – Sept.)||729 days lost|
The investigation detailed one incident in which an employee sustained a severe laceration, bone fracture and head injury after being left alone in her unit.
“0 other staff present during the assault,” the report says.
A patient began punching her in the head, which required her to use self-defense to get the patient to stop. She had to get away to seek help, leaving the patient alone. “She was teary-eyed and appeared to be disoriented, stating she was ‘in shock’,” the report says.
Staff said they do not believe anything changes after incidents that result in injury; they just go back to work and are rarely given information on how to prevent it from happening again.
“It was just like another day of work,” a staff member told Patterson, speaking of their return after being injured on the job.
Not all patient-to-staff aggression events result in injury. Those that do often lead to a claim filed with State Accident Insurance Fund (SAIF).
SAIF benefits can include medical care, wages for lost time, compensation for permanent injury and vocational benefits, such as training programs for those unable to return to their job.
“We hope to help them prevent claims altogether,” Kathy Gehring, vice president of claims at SAIF, said.
SAIF also works with agencies to help them minimize risk in the workplace by providing recommendations for improving workplace safety.
SAIF declined to tell the Statesman Journal the total amount of compensation claims paid for hospital employees from 2019 to present.
Tackling the challenges, state agencies intervene
Oregon OSHA’s initial inspection of the Oregon State Hospital in 2019, which resulted in two serious violations, found the hospital needed better accident investigation training and corrective action to prevent patient-to-staff aggression.
During the second inspection this year, Patterson asked if the workplace violence prevention program had conducted patient assault investigations. She was told, “Not yet.”
The hospital also has a Central Safety Committee and Critical Incident Review Panel, but they were not conducting consistent patient assault investigations or providing recommendations for improving safety conditions for employees, the investigation found.
Investigation of incidents that result in employee lost time injuries, or injuries that leave workers unable to perform their daily duties for at least one day, is legally required by House Bill 2022, which has been in effect since 2008.
Investigating makes it possible for the hospital to implement better assault prevention strategies and identify patients who are a high risk for violent behaviors.
“When responding to an individual patient act of aggression, the clinical team will meet with the patient and make changes to the treatment care plan,” State Hospital spokesperson Amber Shoebridge said. “However, these are not always well documented, and OSH misses the opportunity to do system-wide interventions and improvements.”
The hospital’s safety department is working on a plan of correction aimed at limiting recurring incidents, Shoebridge said.
“OSH is also working on a new process to better capture incidents and gather more information in real” time, she said.
SAIF also has safety consultants who can make recommendations about OSHA compliance. SAIF can intervene and help the hospital come up with a plan of action for preventing workplace violence.
A spokesperson said SAIF could not comment on individual policy holders such as the state hospital.
Pamela Ahr, chief safety officer of SAIF and former safety consultant, said: “As a safety consultant, any claim is too much.”
A big part of working with SAIF policyholders is building a trusting relationship, Ahr said.
“We would always try to intervene when people are getting injured, but it’s a partnership,” Ahr said. “The agency has to welcome us.”
Change at an agency, Ahr said, requires taking small steps.
“Every baby step we are able to get with a policyholder, we celebrate,” she said.
SAIF does not have to inform OSHA about non-compliance, instead focusing on getting agencies in compliance before OSHA steps in.
They monitor claims and look at potential hazards and try to determine how they can help reduce or prevent those hazards.
Required action and recommendations
Oregon OSHA provided requirements and recommendations for action in the inspection report that includes:
- Conducting periodic workplace safety assessments.
- Providing assault prevention and protection training for all employees.
- Keeping track of all employee assaults as well as identification of the causes and consequences of these incidents.
- Ensuring all employees know how and where to report injuries and incidents.
- Involving more employees in safety assessments.
- Providing additional and extensive training on prolific patient care.
- Securing psychological counseling for employees who have experienced or witnessed assault.
OHA director Allen said in the Sept. 15 State Hospital Advisory Board meeting that he plans to personally engage with improving workplace safety at the state hospital.
“We really do take staff safety incredibly seriously,” Allen said.
Sydney Wyatt covers healthcare inequities in the Mid-Willamette Valley for the Statesman Journal. Send comments, questions, and tips to her atSWyatt@gannett.com, (503) 399-6613, or on Twitter@sydney_elise44
The Statesman Journal’s coverage of healthcare inequities is funded in part by the M.J. Murdock Charitable Trust, which seeks to strengthen the cultural, social, educational, and spiritual base of the Pacific Northwest through capacity-building investments in the nonprofit sector.