Corrective measures underway at Oregon State Hospitals following April escape of patient


Shane Ersland


Members of the Oregon State Hospital Advisory Board discussed on Thursday improvements that are underway at the two state psychiatric hospitals—in Salem and Junction Cityfollowing the escape of a patient in April.


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Derek Wehr, Deputy Superintendent of the Oregon State Hospital’s (OSH) Salem Campus, discussed corrective measures that are underway during Thursday’s OSH Advisory Board meeting. Proposed improvements follow the escape of Thaddeus Ziemlak, a patient at the Junction City campus. The psychiatric patient escaped from an outing at Eugene’s Alton Baker Park on April 14th at around 4 pm. Law enforcement officers took him into custody the next morning.

CMS conducted an investigation after the incident and issued a 134-page report outlining corrective measures it mandates the hospital to take.

“We’re confident we’ll be able to complete all corrections on time and they’ll lead to improvements in patient care,” Wehr said. “There is overlap when you think about procedures. We want to make improvements on both campuses.”

All corrective actions will be complete on or before June 14th, Wehr said. 

“We have several dedicated teams who are working on this,” he said. “I don’t see any barriers that would prevent us from meeting the timeline.”

Wehr did not discuss specific corrective measures, noting the size of the report.

“It is 134 pages; it would be challenging to go through every single item,” he said. 

Several corrections are related to the process in which patients are allowed to enter various communities and how patient escape situations are evaluated, in order to prevent them from occurring in the future, Wehr said.

Wehr was asked if any of the report’s proposed corrective measures are related to staffing, and what the current staffing statuses are at both campuses.

“The nature of the report is not related to staffing issues,” he said. “We are still challenged by the current workforce limitations all hospitals and health care systems are facing as far as trying to fill vacancies.”

Patient outings have been prohibited at the Junction City campus since Ziemlak’s escape. But Wehr said outings are important activities for patients and actions are being taken to allow outings to resume.

“I, personally, and the leadership team at the state hospital, think community outings are extremely important,” he said. “We don’t want people to come to the state hospital and live their lives here. We want them to get out into the community and recover. It’s important for them to have time in the community.

The off-grounds outings will not be on hold for a substantial amount of time. But we need to take a step back and make sure we have processes and procedures in place to make sure patients, staff and communities are all safe. We’re trying to do that work very quickly. There are some things we need to have in place before we can feel comfortable with outings again.”

Wehr was asked if alternative indoor activities were in place for patients while outings are unavailable.

“On both campuses, we have alternatives in place to address that need,” he said.

Several risk review considerations are made when determining whether a patient should be allowed to go on outings, Wehr said. Those include a comprehensive look at the patient’s medical record from their stays at Oregon hospitals and other facilities they have been placed in, he said.

“There is a robust risk review process that every patient who has privileges goes through,” Wehr said. “We want to make that process even more robust. There are also processes that happen the day of the outing. We’re looking at all of those things to make sure we have a solid, safe way for patients to get out in the community.”

Wehr was asked if patients who are considered to be high risk should require monitoring from extra staff when on outings.

“When we have off-grounds and on-grounds outings start again on the Junction City campus, you’ll see those elements,” he said. “We’re looking at having a higher staffing ratio and one-to-one or two-to-one staff-to-patient ratios.”