Legacy Good Samaritan Medical Center paid a $3,000 penalty for not taking all "reasonable means" to ensure employee safety in the wake of an armed hospital visitor's escalating threats against staff and then fatal shooting of a security guard.
An Oregon OSHA inspection of the hospital and interviews with nurses and doctors disclosed new details of how PoniaX Kane Calles intimidated and frightened people who were treating his girlfriend in the maternity ward.
One ob-gyn doctor told investigators that she had never "had a guest cause her terror to that degree."
Legacy Health paid the penalty and submitted a "corrective action" plan as required. It includes new written policies for how staff are to handle physical or verbal threats, sets out more defined steps to remove someone from a hospital and new mandatory training for nursing supervisors and comprehensive training for all staff.
Calles shot and killed security guard Bobby Smallwood, 44, on July 22, 2023, outside Good Samaritan's fifth-floor maternity unit. Smallwood's parents last week filed a $35 million suit against the hospital and Legacy Health, alleging negligence.
The state inspection found that hospital supervisors hadn't followed Legacy's "zero tolerance workplace violence policy" despite repeated complaints from nursing staff, a doctor and security that Calles "verbally and nonverbally intimidated, harassed, humiliated and threatened staff" over three days as his girlfriend was in labor and delivered a boy.
It also found the hospital failed to make sure staff knew how to respond to potential dangers or physically remove someone from its premises.
Two different nursing supervisors who responded to the maternity unit after staff had reported several instances of disruptive, threatening and violent behavior by Calles failed to have Calles removed from the hospital premises, the report found.
Nursing supervisor Ryan Lien received requests on July 20, 2023 from nurses and security guards who reported that Calles had pounded on the operating room doors the night before and objecting to the medical care provided as his girlfriend was undergoing a C-section to give birth to their boy, according to the state report. Lien had never received training on the hospital's written policy that called for "zero tolerance" of any workplace violence, the state report noted.
Another nursing supervisor the next day, Ross Buermann, received similar complaints from staff about Calles' continued hostility towards staff. He also had no training on the hospital's workplace violence policy and overruled the requests of multiple nurses and security guards to have Calles removed for his "hostile and threatening behavior," the OSHA inspection report said.
Calles was allowed to remain for two more days despite the series of staff complaints "all without the intervention of upper management," according to the report.
Calles "harassed healthcare staff, calling them nazis, racists and other vulgar terms," the report said. "He intimidated staff by yelling and posturing his body and/or fist in an aggressive manner. He threatened staff, saying he was going to sue them and later that if the healthcare team kept behaving the same way someone would be killed."
Calles also used "aggressive behavior/excessive belligerence, banging on locked operating room doors attempting to gain entry and getting into heated verbal arguments with staff," according to the report. "He repeatedly refused to provide information or cooperate with care for the newborn baby, and repeatedly prevented care from occurring."
Nurse Katie Trihub said Calles flew into an immediate rage when she entered his girlfriend's room at 8 a.m. Friday, July 21, 2023, claiming the nurse was trying to "slaughter" his girlfriend and that he was "man of the house," the state report said. Trihub submitted two reports online about Calles' behavior and another nurse pressed a security button/alarm to summon security.
When the lead security guard, Mary Morrissey, was asked to help remove Calles, she said her hands were tied because the nursing supervisor, Beurmann, disagreed and decided that he and a security guard would talk with Calles and establish boundaries for his behavior, according to the report.
Trihub even called her husband that day, telling him "she's not sure if she is coming home today," according to the state report. She decided she would not enter the mother's room alone and was afraid to write her name on a document for fear Calles would learn it, according to the report.
Trihub said she felt as if she "just has to take it" and that neither staff nor security had a firm understanding on how and when to remove someone from the hospital.
As for the online safety reports, she said she typically avoids submitting them because hospital officials don't appear to respond effectively or urgently.
Dr. Kristen Jensen, an obstetrician-gynecologist, said Calles awoke in his girlfriend's room agitated Friday when she entered. He was angered about the ID bracelet on his baby. She agreed to cut it off and replace it with a softer one and he told her, "If this keeps up someone is going to get killed," the report said.
Jensen told investigators she never had a hospital guest "cause her terror to that degree."
"Dr. Jensen said that it is frustrating because Legacy's zero tolerance policy was actually tolerating workplace violence," the report said.
Beurmann, the nursing supervisor on July 21, 2023, told state inspectors that he heard about Calles' disruptive behavior but didn't review any of the staff's written reports, learned of it mostly through "word of mouth" and had no idea that the nursing supervisor working the night before had issued Calles a final warning, the report said.
Instead, he decided to talk to Calles for about 20 to 30 minutes to assess his behavior and concluded Calles appeared "reasonable," according to the report.
Beurmann told a state investigator: "In an ideal state, there is zero tolerance, but in general the goal is to minimize workplace violence as much as possible, but there are not enough resources to ensure a zero-tolerance policy, and that it is more an ideal than a practice."
He also told investigators that he didn't interpret "zero tolerance" as meaning someone gets immediately kicked off the premises for exhibiting workplace violence but that the hospital must address the behavior.
Calles shot Smallwood the next morning, shortly after nursing and security staff found guns stashed in his girlfriend's room, learned Calles was believed to be carrying a gun and called police to respond. Calles fled out the front entrance of the hospital but was cornered by police in a van on a Gresham street later the same day. Police shot and killed Calles as he stepped from the van holding a gun, according to a grand jury transcript.
State OSHA civil penalties for serious violations that result in physical harm or death can range from $1,,153 to $16,138.
In the aftermath, Legacy Health created an "Immediate Safety Concern Help Chain Pathway" to spell out how to handle security issues.
It includes emergency phone numbers to call, staff roles and responsibilities, expected timelines for a response and a clear avenue to deal with insufficient responses, Angela R. Heckathorn, Legacy's environment of care director, wrote in to the state in June.
Good Samaritan employees also were "re-educated" on policies in place, including violence prevention, panic alarm procedure and patient screening and assessment, according to Heckathorn. Tabletop exercises and drills were also developed to conduct with the hospital's team of nursing supervisors.
Staff also called for metal detectors at every entrance, more security guards and more training on who has the authority to remove someone.
After the shooting, Legacy said it planned to install additional metal detectors; require bag searches at every hospital; equip more security officers with stun guns; and install bullet-slowing film to some interior glass and at main entrances.
Vicki Guinn, a Legacy Health spokesperson, declined to comment Monday on the OSHA investigation.