State inspectors identified a series of lapses at the Oregon State Hospital’s campus in Junction City, including repeated failures to take steps to protect patients from physical harm.

The inquiry began when a Junction City patient walked away from an outing late last year, remaining at large for several weeks. But its scope grew as inspectors identified more problems. The resulting 134-page report paints a picture of a facility that routinely failed to safeguard patients even after unsafe conditions had been identified and documented.

The lapses put patients in danger from others who were being treated in the hospital, resulting in at least one alleged sexual assault and physical attacks, inspectors alleged, and staff also failed to protect patients from self-harm. Many of the patients are institutionalized through the criminal justice system.

“Those failures resulted in actual and potential physical and psychological harm to patients,” the report said.

The report puts the satellite campus in danger of losing its Medicare and Medicaid certification. According to the Oregon Health Authority, the state hospital receives in $18.7 million in Medicare and Medicaid over the state’s two-year budget cycle, but the Junction City facility expects to receive only $54,000 over that period.

The hospital has until Sunday to submit its plan for correcting the issues to the federal Centers for Medicare and Medicaid Services.

Overcrowding and understaffing have caused the state-run hospital’s main campus in Salem to turn away patients, a problem exacerbated by the pandemic. The hospital is required to treat patients who are accused of crimes but found unable to assist in their own trial or who have been found guilty except for insanity.

State hospital leaders have touted an expansion of the Junction City campus as a way to address the capacity issues by moving some of its most difficult long-term patients there. The new investigation outlines deficiencies that could undermine that plan.

Investigators found that administrators failed to identify and take steps to prevent future harm from some of the potential unsafe conditions identified. They also failed to provide timely investigations of patients’ reported grievances, the inspectors found.

The patient whose escape prompted the report ran away from a group during a December “urban hike,” the report said, and had brought a cellphone on the trip unbeknownst to staff.

The patient was authorized to have the phone on campus but not on off-campus outings, and the report found staff had failed to search for or ask about the cell phone. The patient remained at large until they were found in a town on the Oregon coast 25 days later.

Off-grounds outings continued without changes for weeks, the report said, and it outlined several other incidents in which staff failed to maintain direct supervision of patients on outings.

Another patient in July alleged they had been sexually assaulted by their roommate. The hospital reported the allegation to Oregon State Police but failed to conduct its own investigation and moved the alleged assailant to another room in the same unit.

“As of the date of this survey there was no documentation provided to reflect that the hospital had conducted a non-criminal investigation of the alleged sexual assault to identify how this was allowed to occur, to identify failures that may have contributed and to identify corrective actions to prevent recurrence,” the report said.

The report also documented physical attacks that left patients with visible injuries. One patient was hit repeatedly in the face in an attack that, according to a hospital staff report, “appeared to be unprovoked.” According to the state’s investigation, there “was no evidence of plans to prevent recurrence for these patients and other patients.”

The Junction City facility’s entanglement with the Salem hospital was among inspectors’ concerns. Even though the satellite facility is 65 miles from the Oregon State Hospital, they shared management. Inspectors said that the result was “a lack of clear leadership.”

Junction City campus staff also failed to develop individual treatment plans for each of five patients whose files investigators reviewed, according to the report.

The survey was conducted by regulators from the Oregon Health Authority, which also runs the state hospital.

In statements, Oregon State Hospital Superintendent Dolly Matteucci and Oregon Health Authority Director Patrick Allen pledged to address the findings.

“Our staff at the Oregon State Hospital want to provide the highest quality care to our patients so they can recover and return to live healthy and productive lives in their communities,” Matteucci said. “We look forward to addressing each of the administrative, documentation and supervision issues highlighted in this report.”

Disability Rights Oregon, an advocacy group whose lawsuit prompted a separate examination of hospital practices that’s expected later this year, said it was unaware of the federal investigation. KC Lewis, an attorney for the organization, said it was “deeply concerned” by the report’s findings.

“Losing funding would make it even more difficult to address OSH staffing issues,” Lewis said in a statement. “The findings highlight the urgent importance of building out a well-resourced and effective community-based mental health system. This raises very serious concerns for us.”

— Elliot Njus; enjus@oregonian.com

— Jayati Ramakrishnan; jramakrishnan@oregonian.com