On Amanda David’s last day working at the Oregon State Hospital, she sent an email to her boss.

David’s message to Superintendent Dolly Matteucci took the top executive to task for failing to address the burnout employees are feeling from frequent injuries, assaults on the job and a long-term staffing shortage.

But the Sept. 1 email also chastised the superintendent for allowing what Davis described as a toxic culture and alarming personnel issues that are driving away staff.

As she hit send, she blind-copied every other employee in the hospital. According to several staff members, the letter was deleted from the server hours later. Matteucci sent a message to staff in response to the note, acknowledging the strain of the past few months and urging them to come to her with complaints. But David said she never received a direct response from the superintendent.

David’s complaints echo the deep frustrations and fear of dozens of staff members who have recently filed complaints or called for a change to the hospital’s culture.

The Oregonian/OregonLive has spoken with six current and former employees and two patients in the past few weeks and reviewed dozens of documents related to staffing issues within Oregon State Hospital. Those people told the newsroom they are dealing with discrimination and harassment, such as a gay employee’s locker being painted pink, as well as hospital administrators’ failure to take their complaints seriously and a threat of retaliation if they speak up.

As the hospital grapples with an increasingly dissatisfied workforce, staff and mental health advocates are worried about potential effects on patients.

“It’s really raising very serious concerns,” said K.C. Lewis, Disability Rights Oregon’s managing attorney for mental health rights. “People who have been there a long time say it’s teetering on the brink of collapse.”

Since 2016, the Oregon Bureau of Labor and Industries has investigated 22 staff complaints classified as “civil rights” matters. Those include issues related to sexual misconduct, retaliation and discrimination based on disabilities or sexual orientation. They also include whistleblower complaints.

The agency deemed 14 complaints unsubstantiated and closed them. Several others were closed after being investigated by the federal Equal Employment Opportunity Commission, and two were withdrawn and later filed as lawsuits in state or federal court. Another is pending investigation.

The Oregon State Hospital’s Advisory Board took notice of the volume of complaints and wrote a letter to Matteucci on Sept. 28 detailing their concerns about reported incidents and calling for answers about how the hospital responds to such serious allegations.

In a video call with The Oregonian/OregonLive, Matteucci said she could not discuss open cases. But she said she was distressed by the complaints, and she and top administrators take the allegations seriously.

“In order for them to be healthiest, do their best work and provide the best patient care and services, they need to be safe,” Matteucci said. “And it needs to be physical and emotional safety.”

Matteucci said she trusts the system that currently exists for staff to lodge official complaints.

Hospital policies are supposed to protect people who report discrimination and harassment from retaliation. The policy states that any employee found to have engaged in retaliatory behavior may be disciplined or fired.

Kim Thoma, an administrative specialist and president of the union that represents many employees, said she has seen an increase in complaints, and worries about the toll it takes on staff’s health. But she hopes it’s a sign of more people speaking up.

“People are so exhausted and tired of this being the norm,” Thoma said. “And it’s not necessarily something that a training will fix.”

Fear of Retaliation

Staff report a persistent fear of retribution from hospital administration for reporting complaints — and several are now filing official grievances.

Brett Goodman said he experienced such a reaction when he reported a workplace incident this year.

Goodman, a worker in the hospital’s facilities department, filed a lawsuit in state circuit court in August alleging a hostile work environment based on sexual orientation. He seeks $5 million in damages.

In 2020, Goodman told a coworker that he was gay. After that conversation, Goodman said he noticed the colleague began behaving aggressively toward him.

Goodman told The Oregonian/OregonLive that the colleague, who was also a union steward, slapped, punched, kicked and shoved him, and at one point knocked coffee out of his hand. He also got another employee to paint Goodman’s locker pink, according to the lawsuit.

Goodman reported the incidents to his managers, but said he didn’t get a response. He then brought the concerns to the hospital’s human resources and several other agencies, including the Oregon State Police and the state labor bureau. Then he hired a lawyer.

In a court document filed Oct. 25, the state hospital responded, confirming other employees painted Goodman’s locker, which was documented by photo in the lawsuit.

Hospital representatives said they did not have enough knowledge about the allegations of physical assault or verbal abuse.

Goodman said other employees and hospital administrators have responded to his complaints with “complete silence.”

“Their silence and failure to denounce this behavior shows their incompetence and how blind they are to discrimination inside their own facility,” Goodman said.

David, the staff member who wrote the e-mail, filed a whistleblower complaint in April of this year, alleging she had been demoted for things she said as she reported sexual harassment. As of Nov. 22, she said she has yet to hear anything more about the status of her complaint.

Hired as a mental health technician in 2019, Davis was promoted after about six months. While working there, she said, one of her male colleagues commented that she got special treatment because she’s a woman, accompanied by sexual gestures. A few days later, she said, that colleague made a joke about rape.

David said she told the colleague to stop, then reported it to her boss, who wrote up the incident with human resources, which required the team go through sexual harassment training.

She said she hesitated to report the incident at first, because the person who made the comments was a long-term hospital employee.

A state hospital spokesperson declined to comment on the allegations.

While she was being interviewed about her complaints, David shared a comment she had made one day when she was upset during a private conversation with her manager.

“I explained that I had been disrespected in a meeting, and I told him I had more management experience in my pinky than the whole team,” David said. “I told him, ‘just because I don’t have two balls doesn’t make my experience less valid.’”

David said she apologized to her boss for those comments. But a couple of months later, she said she was demoted for being unprofessional, and placed on probation. She said that when she sought to be promoted again, the hiring team told her that due to disciplinary action, management said she was not ready for a promotion.

She was disgusted that an investigation into a colleague’s sexual comments ended with retaliation against her.

“I went through interview after interview,” she said. “I just assumed I was blackballed.”

Failure to investigate or respond

Several employees who spoke with The Oregonian/OregonLive said the hospital was slow to react or failed to investigate their complaints.

Gregory Charles, a longtime hospital security guard, filed a tort claim in September. Charles, who is Black, said that during a meeting this June, a supervisor was reading a report about a patient using a racist slur against a staff member. The employee who made the report repeatedly urged the supervisor to use the full word. Charles’ report said that the supervisor did not use the word, but did not discipline or address the employee’s behavior.

“While I and other African-American staff must daily tolerate patients using the (slur), it is unacceptable for staff to incite a supervisor to use that word,” Charles wrote in the tort claim. “Yet, the hospital tolerated such conduct and refused to do anything about it.”

Charles said in his claim that he had been subjected to “ongoing racially discriminatory and harassing conduct at work,” such as being given negative performance reviews last year based on his performance from several years ago. He’s also concerned his supervisor has not evaluated his white coworkers as harshly.

It’s the latest in a series of complaints from Charles. He has been fired and rehired twice by the hospital in a decade, each time filing a grievance contesting the firing and being reinstated. In 2018, arbitrators found that the hospital fired Charles without just cause and ruled he should be rehired and reimbursed for lost wages.

Charles said in those cases, he was accused of misconduct, including taking unauthorized breaks and failing to assist coworkers with certain duties. But he and his lawyer alleged that several white coworkers were accused of the same things, and did not face the retaliation that he did.

In a Sept. 28 letter to Matteucci, the hospital’s advisory board raised alarms about several incidents they said highlighted such concerns.

The incidents included a transgender woman patient being placed on a maximum-security, all-male unit after refusing to take her medication. The move caused the patient to struggle and begin assaulting people, according to staff reports. There was also a report of a Black patient who was placed in an empty COVID-19 unit due to his violent history. When the unit began filling up with COVID-19 patients, the man was not moved, even though he had tested negative, according to staff.

The advisory board also asked Matteucci to respond to reports that a Black nurse was told by a hospital employee that they didn’t think she was a nurse because they “see her kind around here all the time and they aren’t actually nurses.”

When the nurse reported the incident to human resources, the board said, she got an email saying “do you know what can of worms you’re opening?”

The board wrote that the reports of patients and staff being put in unsafe situations is “distressing.” Failure to provide a safe environment for staff makes it harder to protect patients, the advisory board wrote.

Matteucci said she’s asked the Oregon Health Authority’s Office of Equity and Inclusion to review those incidents. The investigation into the discriminatory comment to the nurse is now active, she said.

Meanwhile, the advocacy group Disability Rights Oregon has been making at least weekly unannounced visits to the hospital because of hospital employees’ and patients’ concerns.

“No one feels comfortable going to administration, and there’s a culture of not being able to raise concerns there,” said Lewis, the advocacy group’s lawyer. He added that the Disability Rights employee who visits weekly “says things are as bad as he’s ever seen them.”

Lewis described a “culture of constant crisis,” which makes it difficult to truly address concerns of discrimination or harassment.

Matteucci said she believes the culture of the hospital has been affected by the pandemic, with staff not as able to foster direct relationships as they used to be. She said that lack of interaction leads to less confidence between staff and leadership.

She added that it takes time to address those challenges.

“When there is an allegation of retaliation, it is investigated,” she said. “It doesn’t necessarily mean you feel good or get the answer you want. But reconciling those past and current challenges and moving forward together is the piece that takes time.”

Staffing problems persist

Meanwhile, the hospital continues to deal with major staffing shortages and resignations.

In a Nov. 17 presentation to the Oregon House Committee on Behavioral Health, Matteucci described the unique stress of working at a psychiatric hospital, along with a national healthcare worker shortage.

She presented data about the current vacancies at the hospital’s Salem campus, which has about 1,500 employees when fully staffed. At the Salem campus, the hospital currently has about 13% of its nursing positions vacant, including a quarter of its licensed practical nurse positions. Nearly 22% of all psychiatric care positions remain open, and 39% of the behavioral health specialist roles are vacant, according to hospital data. Overall, about 12% of the hospital’s staff jobs are currently not filled.

Resignations have also increased, with the hospital seeing an average of 27.4 “voluntary separations” per month between January and September of this year. That’s nearly 10 more per month, on average, for all of 2020, and the highest monthly average over the past 5 years.

Matteucci noted that staff don’t have to give a reason for their resignation. Of those who did this year, 12.4% said they were leaving because of dissatisfaction with the job or management. The majority of others said they were leaving for family or career reasons.

But stories from hospital staff suggest that there are more troubling causes behind the departures.

“After I sent that email, I’ve had a lot of people reach out to me and tell me about their experience,” David said. “But they didn’t want to file anything, because they retaliate.”

—Jayati Ramakrishnan