Workplace Safety Inquiry Doesn’t Fault Oregon State Hospital

Written by Alan Gustafson, Statesman Journal, May 5, 2011

The Oregon State Hospital won’t face any sanctions in connection with a workplace safety inspection prompted by a patient attack that seriously injured a longtime hospital employee.

Oregon’s Occupational Safety and Health Division found no violations of workplace safety regulations during its review of the assault.

That conclusion troubles hospital security employee Rich Dean, who still is sidelined by injuries he suffered in the patient’s attack, which occurred more than five months ago.

Interviewed this week, Dean took issue with aspects of the recently concluded OSHA investigation.

“It seems a little light. It doesn’t seem like all the facts were analyzed,” he said.

Dean recounted several security lapses that he said were “glossed over” by workplace safety regulators.

“I don’t know why OSHA would find that everything was as it should be because clearly it wasn’t,” he said. “For lack of a better way to put it, it was a comedy of errors over there.”

The assault took place Nov. 22, during the first day of patient evaluations conducted in the Harbors section of the new psychiatric hospital in Salem.

Dean suffered a broken ankle, a torn rotator cuff, a fractured eye socket and other injuries when he was punched and kicked in the face by a Multnomah County jail inmate, who became violent at the end of a mental evaluation.

In finding no grounds for issuing a citation against the hospital, Oregon OSHA listed 13 “findings and justifications” that factored into the decision, according to inspection documents released this week to the Statesman Journal.

Among them:

-There had been no previous assaults on hospital employees by jail inmates undergoing mental evaluations.

-The hospital conducted security and safety assessments for employees before the November incident.

-It had emergency procedures in place for summoning assistance before the incident.

-It provided assault prevention training for security staffers.

-The hospital reported the accident to Oregon OSHA within the required time for notification of an overnight hospitalization.

The inmate who committed the assault, Samuel Lehtinen, had been moved from the Multnomah County jail to the Salem psychiatric facility for an evaluation to determine whether he was mentally competent to aid and assist in his legal defense on pending criminal charges.

Lehtinen had a history of assault, including a previous attack on a mental-health employee.

His assaultive history was noted in records reviewed by a state hospital clinician, Brooke Howard, who was assigned to evaluate Lehtinen, according to an Oregon OSHA report, titled “Accident Synopsis.”

Taken to the hospital from the jail, Lehtinen arrived for the evaluation wearing belly chains, leg irons and handcuffs.

Howard reportedly agreed to have the handcuffs removed because “she felt the inmate needed full use of his hands” to complete tests conducted for the evaluation.

Lehtinen was “composed” for most of the two-hour evaluation, according to the report.

However, he did not cooperate with Howard, refusing to answer her questions.

The inmate reportedly became agitated when the therapist decided to conclude the evaluation.

“When Dr. Howard asked the inmate if there was anything else she could share with the court, the inmate responded by picking up a plastic water pitcher and threw it,” the report says.

The pitcher sailed between Howard and the inmate’s defense attorney, hitting a wall.

The clinician and the attorney ran out of the room.

Dean and two fellow security employees reportedly were monitoring the incident via security cameras in a nearby room.

All three rushed to the evaluation room, where Lehtinen lunged at Dean and began punching him. As they fell to the floor, the two other security employees piled on top of them.

Dean suffered a broken ankle in the melee. As he tried to get away, the inmate kicked him in the face.

From another room, Howard made a distress call to the hospital’s communications center. Five additional security staffers responded, arriving at the Harbors evaluation room about three minutes later.

The group subdued the inmate and placed him back in restraints.

Dean was taken to Salem Hospital for treatment.

In this week’s interview, Dean highlighted several lapses that should have drawn more attention from workplace safety regulators.

For starters, Dean said his wife, Olga, also a security employee at the state hospital, warned security director Karen Garcia that the security presence in Harbors wasn’t adequate for the first day of evaluations.

Dean said his wife issued a “prophetic warning” to the security chief a couple of hours before the assault. “Listen, this is the first day over there in the new place,” he said, recounting his wife’s words. “You’ve got three evaluations that are going on. You’ve got Rich over there monitoring the gates (and two other security workers) over there. You really think that’s enough?”

According to Dean’s account, the security director “basically blew off” the warning.

At the time of the assault, Dean said, the emergency alarm system, sometimes called a panic button, was not yet operating in Harbors.

“We had no means to push a button and get staff in that direct area,” he said. “It’s fine now, but it wasn’t up and running at the time.”

Dean also questioned why he wasn’t made aware of the inmate’s history of assaultive behavior.

And he cast doubt on the methods used by the two security coworkers who “dog-piled” on top of him and the inmate.

“There’s nowhere in the training that speaks to dog-piling as a means to secure an individual, and that’s exactly what happened,” he said. “That’s why I got hurt. Just before I got him to the ground, my two co-workers jumped on top of me, creating that extra weight. That snapped my ankle and drove my right shoulder hard into the floor, and that tore my rotator cuff. In addition, it left this inmate with a free hand and he just pummeled my left eye.”

Unable to walk, Dean said he tried to slip away from the fracas, only to suffer a final injury.

“As I was scooting away, (the co-workers) let go of one of his legs and he kicked me in the eye and broke my eye socket in about four places,” he said.

Dean said he’s still recuperating from shoulder surgery and expects to return to his job in about a month., (503) 399-6709, or follow at