Keys left in ignition allowed Oregon State Hospital patient escape, new report shows
The Oregon State Hospital has submitted a plan to the Centers for Medicare and Medicaid Services (CMS) for improving secure transport of patients to and from the hospital following a citation from CMS Friday ordering immediate action.
The need for safety improvements came to light following the recent hospital escape of Christopher Lee Pray, an “extremely dangerous” patient currently facing 21 charges, including attempted murder and assault.
Pray, who was in full restraints, was being returned to Oregon State Hospital following an emergency medical care visit to Salem Health the night of Aug. 31. Employees transporting Pray stepped out of the vehicle to assist him, leaving the keys in the ignition, according to a CMS report.
Pray took the opportunity to jump into the driver's seat and drive off. He was caught in Portland Sept. 2.
A CMS surveyor came to the hospital following the incident and cited Oregon State Hospital for issues related to safe transport of patients involved in the criminal justice system, specifically “aid and assist” and “guilty except for insanity” patients.
Aid and assist patients like Pray are facing criminal charges but have been found unable to aid their lawyers in their defense due to a mental illness. Guilty except for insanity patients have been convicted of a crime but were determined to have done so without intent or unknowingly due to a mental illness.
“Without a safe and secure transport process, these justice-involved patients are likely to suffer serious adverse outcomes by eloping from OSH, such as engaging in risky behavior that could lead to injury or death to themselves or others and remaining unmonitored in the community,” the corrective action plan submitted by the state hospital reads.
Corrective actions
The state hospital was given 23 days to make changes to address CMS findings. If it failed to do so, its eligibility to receive Medicare and Medicaid reimbursement would be terminated.
The corrective action plan submitted Wednesday includes the following actions for improving transport safety:
Using secure vehicles with barriers between the front and back seats to transport patients involved in the justice system.
Only allowing patients to enter and exit vehicles within enclosed garages.
Ensuring hospital staff has control of vehicle keys at all times.
Having employees involved in transport complete a departure and arrival trip checklist to ensure the above protocols have been followed.
Providing additional training to staff on new transport protocols.
The hospital confirmed it will have these changes completed by Sept. 27.
The plan now awaits approval from CMS, and a surveyor is expected to conduct another unannounced visit to ensure the state hospital is implementing actions outlined in the plan.
Sydney Wyatt covers healthcare inequities in the Mid-Willamette Valley for the Statesman Journal. Send comments, questions, and tips to her at SWyatt@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.
This article originally appeared on Salem Statesman Journal: Oregon State Hospital must make immediate safety improvements
