Legacy Good Samaritan Medical Center has paid a $3,000 penalty for failing to take all “reasonable measures” to ensure employee safety following an armed hospital visitor’s escalating threats to staff and then fatality. shooting a security guard.

An Oregon OSHA inspection of the hospital and interviews with nurses and doctors revealed new details about how PonyX Kane Calles intimidated and scared people treating their girlfriend in maternity.

An ob-gyn told investigators he had “never had a guest terrorize him to this degree.”

Legacy Health paid the penalty and submitted a “corrective action” plan as required. It includes new written policies on how staff should 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 the fifth-floor Good Samaritan maternity hospital. Smallwood’s parents filed the lawsuit last week a $35 million suit against the hospital and Legacy Health, alleging negligence.

The state inspection found that hospital supervisors failed to follow Legacy’s “zero-tolerance workplace violence policy,” despite repeated complaints from medical staff, a doctor and security that Calles had “intimidated, harassed, humiliated and threatened staff verbally and non-verbally’ for three days. the girlfriend was in labor and gave birth to a boy.

It also found the hospital failed to ensure staff knew how to respond to potential danger or physically remove someone from its premises.

Two different supervisors who responded to the maternity ward after staff reported multiple instances of disruptive, threatening and violent behavior by Calles did not remove Calles from the hospital premises, the report said.

Nursing Supervisor Ryan Lien received calls on July 20, 2023 from nurses and security guards who reported that Calles had pounded on the operating room doors the night before and objected to medical care being provided as his girlfriend was undergoing a C-section for to give birth to their boy, according to the state report. Lien never received training on the hospital’s written policy that called for “zero tolerance” for any workplace violence, the report states.

Another nursing supervisor the next day, Ross Buermann, received similar complaints from staff about Calles’ continued hostility toward staff. He also had no training on the hospital’s workplace violence policy and rejected requests from several nurses and security guards to remove Calles for his “hostile and threatening behavior,” the inspection report said OSHA.

Calles was allowed to stay two more days despite a series of staff complaints “all without senior management intervention,” according to the report.

Calles “harassed the medical staff, calling them Nazis, racists and other vulgar terms,” ​​the report said. “He intimidated staff by shouting and holding his body and/or his fist in an aggressive manner. He threatened the staff, saying he would sue them and later that if the nursing team continued to behave in the same way, someone would be killed.”

Calles also used “excessive aggressive/belligerent behavior, banging on locked operating room doors trying to get in and engaging in heated verbal arguments with staff,” according to the report. “He repeatedly refused to provide information or cooperate with the newborn’s care and repeatedly prevented care.”

Nurse Katie Trihub said Calles immediately became enraged when he entered his girlfriend’s room at 8 a.m. Friday, July 21, 2023, claiming the nurse was trying to “butcher” his girlfriend and that he was “the man of the house,” the state. the report said. Trihub submitted two reports online about Calles’ behavior and another nurse pressed a security button/alarm to call security.

When 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 an agent security will speak with Calles and set limits on his behavior, according to the report.

Trihub even called her husband that day, telling him she was “not sure if she’s coming home today,” according to the state report. She decided she would not go into her mother’s room alone and was afraid to write her name on a document for fear Calles would find out, according to the report.

Trihub said she felt she “just had to take it” and that neither staff nor security had a firm understanding of how and when to remove someone from the hospital.

As for online safety reports, she said she usually avoids submitting them because hospital officials don’t seem to respond efficiently or promptly.

Dr. Kristen Jensen, an OB/GYN, said Calles woke up in his girlfriend’s room agitated Friday when she entered. He was upset about the ID bracelet on his child. She agreed to cut it off and replace it with a softer one, and he told her, “If this keeps up, someone’s going to get killed,” the report said.

Jensen told investigators he had never had a hospital guest “terrorize him to this degree.”

“Dr. Jensen said it was frustrating because Legacy’s zero-tolerance policy actually condoned workplace violence,” the report said.

Beurmann, the nursing supervisor on July 21, 2023, told state inspectors that he had heard about Calles’ disruptive behavior but had not reviewed any of the written staff reports, learned about 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 speak with Calles for about 20 to 30 minutes to assess his demeanor and concluded that Calles seemed “reasonable,” according to the report.

Beurmann told a state investigator: “In an ideal state, there is zero tolerance, but generally the goal is to minimize workplace violence as much as possible, but there are not enough resources to ensure a zero tolerance policy zero and that it is more an ideal than a practice.”

He also told investigators that he did not interpret “zero tolerance” to mean that someone is immediately kicked out of the facility for exhibiting violence in the workplace, but that the hospital must address such behavior.

Calles shot Smallwood the next morning, shortly after custodial and security staff found weapons hidden in his girlfriend’s room, learned that Calles was believed to be carrying a gun and called the police to respond. Calles fled from the hospital’s front entrance, but was cornered by police in a van on a Gresham street later that day. Police shot and killed Calles as he exited the van holding a gun, according to a grand jury transcript.

State OSHA civil penalties for serious violations that result in physical injury or death can range from $1,153 to $16,138.

Later, Legacy Health created a “Helpline Pathway for Immediate Safety Issues” to explain how to handle safety issues.

It includes emergency phone numbers to call, staff roles and responsibilities, expected timeframes for a response and a clear path to dealing with insufficient responses, Angela R. Heckathorn, Legacy’s director of care environment, wrote in June.

Good Samaritan employees were also “re-educated” on policies in place, including violence prevention, the panic alarm procedure and patient screening and assessment, according to Heckathorn. Exercises and table exercises were also developed to be carried out with the hospital supervisor team.

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; request baggage searches at each hospital; equip more security officers with stun guns; and install bullet retarding film on some interior glass and at the main entrances.

Vicki Guinn, a spokeswoman for Legacy Health, declined to comment Monday on OSHA’s investigation.

— Maxine Bernstein covers federal courts and criminal justice. Contact her at 503-221-8212, [email protected], follow her on X @maxoregonianor on LinkedIn.

Our journalism needs your support. Subscribe today to OregonLive.com.