Lack Of Security Checks, Patient Violence Create A ‘Perfect Storm’ At Osawatomie State Hospital

Aug 4, 2016

Years of problems at Osawatomie State Hospital reached a crisis point in the fall of 2015, when the sexual assault of a hospital employee by a patient triggered two failed inspections and the loss of federal funding.

Kansas had relied more on OSH after it reduced the number of state hospital beds in the 1990s. The idea was to put more money into community mental health services, but that hadn’t happened since the early 2000s — and those services actually lost money during the Great Recession

The problems for OSH became worse in 2011, when the state used early retirement incentives to trim the hospital’s workforce but lost too many experienced employees. It all added up to fewer employees at OSH trying to take care of more patients with stagnant resources.

Inspectors from the federal Centers for Medicare and Medicaid Services found problems with treatment, patient safety and understaffing at OSH in 2014 and 2015. In one case, understaffing contributed to a patient’s death.

Still, they were willing to give the state more time to remedy the problems.

Lack of security checks

For a while, it appeared OSH was making progress. The hospital consistently stayed at or below capacity for the first time in years in 2015 because of an admissions moratorium. Renovations prompted by federal inspections were gradually removing safety hazards and funding stayed stable, though it remained below pre-recession levels

But the reprieve didn’t last. After the October 2015 assault of an OSH employee, inspectors discovered that some security and nursing employees weren’t fulfilling their duties, putting patients and staff at risk

According to a report from federal inspectors, a mental health technician was taking gowns to a male patient’s room during the night shift on Oct. 27, 2015, when the patient grabbed her, covered her mouth and sexually assaulted her. Two patients who were in the hall at the time said they heard screaming, went to the room and shoved the male patient, who had a history of domestic violence, off the worker.

When inspectors investigated the attack, they found security staff had falsified records to indicate they were performing regular checks, when in fact they weren’t. In interviews, three administrative staff members said they had been told that security employees weren’t performing checks, and a fourth said the hospital didn’t have enough nursing staff to adequately supervise the units.

[View the November 2015 CMS inspection report after sexual assault of OSH employee]

According to the report, an administrative employee “revealed they had received reports from the hospital’s supervisory staff, prior to (the employee) being attacked, that they had concerns with security rounds staff incorrectly performing the required 10-minute security rounds. Some of the concerns were that security round staff are standing around talking with (mental health technician) staff, not performing their rounds, and leaving the unit before their replacement arrives.”

Inspectors also noted that the lack of supervision placed patients who might be suicidal at greater risk, because they had unsupervised access to bathroom fixtures that could be used for hanging.

“The cumulative effect of the systemic failure to supervise the provision of care, to perform required safety checks and to protect suicidal patients from hanging risks placed all patients receiving services at risk for harm,” the inspection said.

A letter from CMS, dated Nov. 27, noted it could cut off Medicare payments to OSH immediately due to its “ongoing non-compliance” but wouldn’t do so because of the hospital’s importance to an already strained mental health system. CMS officials gave the hospital one more chance to salvage its federal funding.

That chance lasted less than a month.

[View the December 2015 Kansas Plan of Correction]

The ‘perfect storm’

During a follow-up inspection in December 2015, CMS found more incidents where both staff and patients weren’t protected from violent and inappropriate behavior.

The inspectors found that a male patient with a conviction for criminal sodomy had been placed in a wing of the hospital with mostly female patients.

Female patients reported that the male patient touched them inappropriately, and he had what apparently was consensual sex with a female patient who had a history of suicide attempts, self-injury and attacks on other patients.

A staff member told the inspector that employees had raised concerns about placing the male patient with a history of sexual violence in a female wing, where a number of patients with severe needs were being treated.

“The case mix in this unit is loaded so heavy with high-risk patients that it is the ‘perfect storm,’” an OSH employee told inspectors.

[View the December 2015 CMS inspection report finding continuing violence at OSH]

Despite the concerns expressed by staff, neither patient was moved until their sexual encounter was discovered.

The inspector also said staff hadn’t taken steps to calm another male patient who had shown signs of agitation and potential violence before he punched and kicked staff members and stabbed another patient with a plastic utensil.

One staff member said other staff didn’t respond when a patient tried to hit him or her, and the nurse on duty “rolled her eyes” when the staff member spoke up, according to the inspection.

The incidents convinced federal officials that the hospital wasn’t doing enough to maintain a safe environment for staff and patients. CMS decertified OSH in December 2015, costing the hospital about $1 million in monthly payments for Medicare-eligible and uninsured patients. 

[See the December 2015 CMS termination letter to OSH]

‘Systemic failure’

CMS called the violence at OSH, and staff’s response to it, evidence of “systemic failure.” The hospital’s former superintendents largely agree.

Don Jordan.
Credit Heartland Health Monitor/File photo

Don Jordan, who was superintendent of OSH from 2002 to 2005 and secretary of the Department of Social and Rehabilitation Services from 2006 to 2011, said psychiatric hospitals will never be free of violence, but the inspections indicate employees ignored basic safety protocols.

Worse, the final inspection report showed that direct-care employees weren’t doing required checks on patients, he said.

“When you can watch a unit for an hour and nobody does their job, that’s the problem,” he said. “If that’s not a systemic failure, I don’t know what is.”

Some former leaders of psychiatric hospitals placed the blame for the violent incidents at the top — with hospital and state leaders.

Steve Feinstein, who was superintendent at OSH from 1994 to 1998, described the inspection findings as “absolutely shocking.” The problems suggest a disconnect between the hospital’s leadership and front-line staff, he said, and a need for managers who have to the authority to identify and fix issues.

“If those things had been found in a private hospital, people would have been fired right at the very top,” he said. “Some of these nursing problems are so egregious it’s almost unbelievable they happened in this day and age.”

Steve Ashcraft, superintendent of OSH from 2011 to 2013, defended current superintendent John Worley, who took over in August 2015. He laid blame on the state, however, for hiring people who lacked experience with mental health patients for leadership positions at a psychiatric hospital.

Worley “is very competent, but he’s an anomaly,” he said. “He can’t do everything himself.”

"If those things had been found in a private hospital, people would have been fired right at the very top. Some of these nursing problems are so egregious it's almost unbelievable they happened in this day and age." - Steve Feinstein, Osawatomie State Hospital superintendent from 1994 to 1998

The problems involving violence and a lack of oversight may have had more to do with a lack of stability among leadership than any particular superintendent’s actions, some suggested. OSH had four superintendents from 2011 to 2015, not counting Wes Cole’s brief interim stint.

Stability is critical in psychiatric facilities, so front-line staff can focus on observing the patients for signs of trouble, said Walt Menninger, former CEO of the Menninger Clinic, which was based in Topeka until 2003.

“You want an environment that is fairly stable, so ideally the person working on the line with the patient … can focus on that job with 90, 95 percent of their attention,” he said. “If there is a problem with a higher level … if you have to divert some of your attention to wonder what is happening up there, you’re going to miss signals down here.”

Next: While significant improvements are under way at Osawatomie State Hospital, experts say Kansas needs to examine its mental health system as a whole to avoid a future crisis.

Megan Hart is a reporter for KHI News Service in Topeka, a partner in the Heartland Health Monitor team. You can reach her on Twitter @meganhartMC