From the Salem Statesman Journal, November 6, 2010

For the second time in less than a month, the Oregon State Hospital has been fined for workplace safety violations.

Oregon Occupational Safety and Health Division levied a $1,250 penalty against the Salem psychiatric facility on Oct. 29, records show. It came on the heels of a $3,750 fine OR-OSHA imposed against the hospital in a separate case on Oct. 7.

The Salem psychiatric facility intends to challenge the regulatory agency’s findings by pursuing appeals in both cases, hospital Superintendent Greg Roberts said Friday.

In the first case, the hospital was cited for safety violations after regulators found self-defense training was inadequate for employees dealing with violent patients. Regulators also determined that the hospital had been tardy in providing training for staffers to use shields as “a tool to protect employees from projectiles, riots and to approach patients in order to secure them.”

Roberts said the hospital’s appeal in that case is set for a hearing with OR-OSHA on Nov. 22.

In the latest case, regulators found safety violations in connection with an August incident in which two security staffers received injuries after they were called to transport a mental patient from a transitional-program cottage to a secure hospital unit.

The two staffers reportedly were assaulted by the patient at the cottage and in the transport vehicle. Both employees received hospital treatment for their injuries.

The OR-OSHA citation issued in connection with the incident says the hospital:

-Did not have adequate security staff on duty to perform the transfer.

-Did not have a contingency plan in place “in case the patient was resistant to transfer.”

-Did not have a plan or policy for searching the patient for weapons and other contraband after he was transported to a maximum-security ward.

The regulatory agency also found that the hospital lacked a standard policy or procedure for transporting patients from transitional cottages to other units at the mental hospital.

Roberts said the hospital “fully disagrees with the findings in the report.”

In part, he said, the hospital intends to challenge OR-OSHA’s assertion that the facility lacked a policy or procedure for transporting patients from the cottages.

“There is a transfer policy, there always has been a transfer policy,” Roberts said. “We actually ended up clarifying the policy or modifying it, I think, in pretty minor fashion following the incident.”

Roberts assumed leadership of the hospital Sept. 20, about a month after the incident.

Another point of contention between OR-OSHA and the hospital focuses on the regulatory agency’s assertion that the hospital lacked enough security staff to perform the transfer.

“From what I know of the incident, it looks like there were plenty of staff,” Roberts said. “Three security staff and five staff from the cottages were present. So that’s eight staff. Once the patient became agitated, three more (staff members came to the scene). So that’s 11 staff. I don’t understand how they’re saying there was not adequate security staff.

“I don’t know what information the OR-OSHA person had, but from the statement of the findings it doesn’t match with anything I have.”

Six cottages are located on the southwest portion of the hospital campus. They make up a 36-bed transitional program for criminally committed patients who are on track to leave the hospital.

OR-OSHA launched an investigation into the incident on Sept. 3. The inquiry was prompted by a hospital employee’s complaint.

An OR-OSHA inspector who looked into the complaint gave this account of the incident in field notes summarizing the case:

At about 9 p.m. on Aug. 17, two security employees on duty during the swing shift and their supervisor responded to Cottage 4 to meet with a nurse.

“The nurse simply said they were doing an arranged transfer and led them to the cottage. The patient was in the living room. They told him they were transferring him back to the 50 Building.” (The 50 Building houses medium-security patients).

The security staffers were not briefed on the patient’s history, which included acts of aggression, nor was any plan made in advance to have additional staff on standby.

Inside the cottage, the patient lashed out at the security employees: “After gathering items, the patient made a statement to the effect of ‘This all you got? You are going to need more than this to take me,’ and he turned and began choking the officer. The other officer attempted to pull his hand free, while the supervisor grabbed the patient’s other arm momentarily, then let go.

“The patient began head-butting the officer, and the second officer grabbed him around the legs and pulled them all to the ground.”

As other patients watched, one resident “began egging on” the assaultive patient.

Amid the fracas, one security officer yelled for bystanders to summon help. Cottage employees began arriving at the scene, “but no one stepped in to help contain the patient.”

About 10 minutes after the security staffer pleaded for assistance, additional hospital employees responded to the cottage. They came from the 50 Building, which is located on the north portion of the hospital campus.

The patient’s outburst finally was quelled.

A short time later, a decision was made to transport the patient to a maximum-security ward in a hospital security car.

During the transport, “the patient kicked out the window of the vehicle,” tried to escape and “committed additional assaults” on the two staffers.

After the patient arrived at the maximum-security ward, he was placed in a restraint bed and “patted down” during a cursory check for weapons.

“He did not get a thorough search, as is the protocol for those coming into the ward initially.”

Because the patient had a history of contraband violations, the failure to conduct a rigorous search “posed a serious safety risk” to staff on the high-security unit.

Based on the inspector’s findings, the OR-OSHA citation rapped the hospital for lack of safety planning, policies and procedures. The citation also concluded that there was “little communication between the doctor, nurse, security and house staff to ensure security was adequately prepared for the transfer.”