Oregon State Hospital plans changes to prevent deaths like one in April

Oregon State Hospital plans to train medical staff to immediately check the vital signs of new patients and respond to life-threatening emergencies with adequate equipment.

The changes are part of the hospital’s proposed plan of correction to fix violations that federal inspectors flagged when they investigated the circumstances surrounding the April 18 death of Skye Baskin, 27. Hospital staff failed to immediately check the vitals of Baskin after he arrived from the Douglas County Jail on misdemeanor charges of disorderly conduct and resisting arrest. He was declared dead 69 minutes after his arrival, records show.

The state hospital submitted the plan, released to the Capital Chronicle through a public records request, on Friday, May 31, to the federal Centers for Medicare and Medicaid Services.

The Oregon Health Authority, which runs the state’s secure psychiatric facility in Salem, is waiting for the federal agency to approve the plan.

The hospital’s proposal includes:

Reviewing and updating protocols for admitting new patients to include screening them for potential medical emergencies.Tracking and organizing medical emergency equipment used for code-blue events when a patient’s life is in danger. Inspectors found the equipment was unorganized.Auditing medical equipment as well as regular code blue emergency drills for hospital staff to practice life-saving procedures.

Hospital officials told the federal agency they can correct the problems by July, the plan said.

The case is the latest in a string of incidents for Oregon State Hospital that have drawn scrutiny from federal regulators.

Last year, a patient escaped from the state hospital in a van, driving it down a highway in a high-speed chase. In that case, the hospital updated its security policies to secure vehicle keys.

Earlier this year, inspectors investigating a patient-on-patient assault found blind spots in the security camera system, which allowed the assault to unfold in which one patient lifted another up by the neck and shook that person in the air. For 34 seconds, no one was aware of the attack.

Separately, Oregon State Police have confirmed they are investigating the death of a patient who died of a suspected fentanyl poisoning .

Baskin’s death

The federal report on Baskin’s death found that, rather than immediately checking his vital signs upon his arrival, hospital staff listened to Douglas County deputies tell them he routinely was unresponsive.

His eyes were closed when hospital staff snapped his photo as part of the intake procedure, records show. A nurse checked Baskin’s vital signs only after he was put in a wheelchair and wheeled to his room with his head hung down and body unresponsive.

The report said the hospital’s failure to immediately assess Baskin created an unsafe environment that “likely contributed” to his harm and death.

While Baskin was in jail, his defense attorney Angelina Hollingsworth told the court her client was unresponsive during a jail visit and asked for the misdemeanor charges to be dismissed because he was in jail for more than a month and no local programs were available to help him. Instead, the judge sent him to Oregon State Hospital, which treats defendants so they can aid in their defense.

Baskin spent about six weeks in the Douglas County Jail. Police arrested him after he was wandering along a highway in and out of traffic.

Oregon State Police are investigating the death, as they do for any unattended death at the state hospital.

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