State mental hospital could lose Medicare agreement for dangerous patient’s escape

PORTLAND, Ore. (KOIN) — Oregon State Hospital, a public mental hospital in Salem, is at risk of having its Medicare agreement with the Centers for Medicare and Medicaid Services terminated in 90 days after an “extremely dangerous” patient charged with “serious violent crimes” escaped custody using a hospital transportation van on Aug. 30, 12 hours after they were admitted to the hospital, a report by the CMS states.

The patient, 39-year-old Christopher Lee Pray, was able to escape from hospital staff after employees left him in the van with the keys still in the ignition. Despite making previous comments to the employees about his plans to escape, Pray was still put in a situation where he was able to commandeer the van and flee from authorities at speeds in excess of 100 mph, the report reads.

“The patient, who was [wearing restraints], unbuckled their seatbelt, slid between the two front seats into the driver's seat and sped away,” the report reads. “Both staff members were standing outside the vehicle when this occurred. The security staff member attempted to stop the patient by reaching inside the vehicle and sustained an abrasion to their elbow. Hospital staff called 911, reported the incident, and during law enforcement pursuit of the patient, the vehicle reached speeds of up to 100 mph.”

Pray was found up to his neck in mud in a Portland slough days later. Firefighters were initially called to the scene for a report of a dead body in the slough. However, after arriving on scene, firefighters discovered that Pray was still alive. Firefighters pulled Pray from the mud and he was taken to the hospital for medical treatment.

CMS investigators attributed the man’s escape to the Oregon State Hospital’s failure to develop policies, procedures or training to prevent this type of escape from occurring. After completing its report between September and October 2023, the federal agency concluded that there are severe deficiencies within the hospital, which placed the health or safety of its patients or workers in “immediate jeopardy.” CMS officials deemed the issue a “Level 4 Deficiency” — the most severe level of noncompliance. 

In order to avoid having its Medicare agreement terminated, Oregon State Hospital is required to take “immediate corrective action” to develop a plan to correct the issues by Dec. 21. If Oregon State Hospital fails to correct the issues, CMS will end the agreement on March, 10, 2024. 

OSH Superintendent Dolly Matteucci said that the hospital is actively working to resolve the issues.

“The safety of patients, staff and the public is our number one priority at Oregon State Hospital and we are taking immediate measures to ensure we meet the CMS requirements and continue to keep patients, staff and the public safe and secure,” Matteucci said.

However, in the report, CMS officials state that the hospital was initially reluctant to aid the federal agency in its investigation. 

“On [Sept. 15], the surveyor conducted a meeting with the survey manager to review the findings for potential [serious safety issues] as survey findings revealed that no actions had been taken to prevent patients requiring similar secure transport and supervision for medical outings from accessing transport vehicle keys and eloping,” the report reads. “The hospital's failure to fully cooperate slowed this [serious safety issue] determination but did not impact the underlying recommendation.”

In a press release issued on Dec. 12, the Oregon Health Authority said that many of the report’s findings are already being addressed and that the hospital held a workgroup Tuesday to develop additional solutions to the problems outlined in the report. The workgroup included representatives with the hospital’s nurses, health care workers, security, officers, tech workers and public relations standards and compliance departments.