A patient at Washington state’s largest psychiatric hospital received a new feeding tube but wasn’t monitored for pain medications, vital signs or wound care.
Another didn’t receive doctor-ordered treatment for head, eye and toe injuries, while a patient prescribed an oxygen test every half-hour after an asthma attack was only checked a few times.
U.S. officials held a surprise inspection last month at the state-run Western State Hospital, which cares for Washington’s most seriously mentally ill and dangerous patients, and found so many glaring health and safety violations that they stripped the facility of its certification and cut its federal funding — about $53 million annually.
The hospital for years has been plagued by problems ranging from assaults on health care workers to escapes by violent patients, including a man accused of torturing a woman to death who was loose for two days in 2016. Past U.S. inspections also found a lack of trained or qualified staff, fear of retaliation from managers and a focus on bureaucracy over staff safety.
The state vowed to fix violations, and the Centers for Medicare and Medicaid Services kept offering more chances. The agency that ensures facilities receiving federal funds are in compliance with health and safety standards has now ended ties, cutting off about 20 percent of the hospital’s budget.
Washington state has vowed to come up with funds to cover the gap, but losing the hospital’s certification will likely make it harder to hire and keep staff.
The U.S. report released late Tuesday reveals that in addition to patient care violations, inspectors found the facility is still a fire hazard. Some fire doors don’t latch properly, fire walls aren’t maintained and some sprinklers don’t work, inspectors said.
The hospital also failed to identify and remove materials that could be used by patients to strangle themselves or others, the report said.
Cheryl Strange, head of the state Department of Social and Health Services, which runs the hospital, said her agency was analyzing the federal report on the new inspection to determine what changes are needed.
“We are a better hospital than we were in June 2016, and we will continue working to improve the mental health system in our state,” Strange said in a statement.
But U.S. officials noted some of the violations were found in previous inspections.
The hospital was cited twice, in 2015 and again in 2017, for problems with the sprinkler system, fire alarms and fire drills. It was cited in six different reviews going back to 2015 for failing to develop a plan to ensure tracking of patients’ entire medical and nursing-care needs, the report said.
When inspectors reviewed hospital records, they found nurses don’t always provide care ordered by a doctor. Nurses didn’t complete blood work and neurological assessments, monitor blood glucose levels and do other checks. Staff didn’t maintain treatment plans for 10 of 22 patients reviewed, federal officials said.
“Failure to develop care plans to address patient care may lead to patient harm and failure to appropriately treat a medical condition,” the report said.
One female patient was transferred from another ward for acting out sexually, with her treatment plan saying, “She does struggle a little more with appropriate boundaries with others and does need reminders.”
Her record contained incidents in the weeks that followed including having sexual intercourse with another patient, taking her clothes off in front of a peer and trying to have sex with a patient on the patio. But nurses failed to update her treatment plan to reflect her increasingly sexually aggressive behavior.
The plan said she was taking her medications, but records also said she was flushing them down the toilet.
The hospital also didn’t take patients out of restraints as soon as possible — the case for two of six patients reviewed. One was restrained for almost four hours on different days, even though his behavior was labeled “not agitated” for almost two hours during those periods.
A nurse told U.S. officials that staffers will monitor restrained patients at hourly intervals and release them when appropriate but that the patient should have been freed sooner based on the finding that he wasn’t agitated.
“Failure to remove patients from restraints at the earliest possible time puts patients at risk for psychological harm, loss of dignity and loss of personal freedom,” the report said.
The hospital also failed to ensure escorts were available to take patients to medical appointments, forcing the cancellation of 31 dental appointments in April, and didn’t respond properly to patient grievances.
In two instances, patients called the hospital’s abuse/neglect line in early May with concerns about physician care and receiving funds related to a family death. U.S. inspectors found no documentation to show the complaints were addressed.
Inspectors also found problems with refrigeration of food and laboratory specimens and the condition of the hospital, noting a torn mattress, cracked restroom tiles and chipped drywall in a patient’s room.
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