In this April 2017 photo, a security officer stands on steps at the entrance to Western State Hospital in Lakewood, Washington. (AP Photo/Elaine Thompson, File)

In this April 2017 photo, a security officer stands on steps at the entrance to Western State Hospital in Lakewood, Washington. (AP Photo/Elaine Thompson, File)

State hospital inspection reveals disturbing details

Glaring health violations, safety hazards, weird patient behavior and lost records, to name a few.

By Martha Bellisle / Associated Press

SEATTLE — One patient who had just received a new feeding tube wasn’t monitored for pain medications, vital signs or wound cleaning.

Another who was supposed to be treated for head, eye and toe wounds didn’t receive his doctor-ordered care.

And a patient who suffered an asthma attack was supposed to get an oxygen saturation test every half hour, but was only checked a few times.

When the Centers for Medicare and Medicaid Services held a surprise inspection at Washington state’s largest psychiatric hospital last month, they found so many glaring health and safety violations they stripped the facility of its certification and cut its federal funds — about $53 million annually.

The agency’s newly released report reveals that in addition to patient-care violations, inspectors discovered the facility continues to be a fire hazard. Some fire doors don’t latch properly, fire walls aren’t maintained and some sprinklers don’t work, the surveyors found.

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, secretary for the Department of Social and Health Services, which runs the hospital, said they’re analyzing the federal agency’s findings 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 CMS noted some of the violations found in the recent inspection were cited during previous surveys, but were still happening.

The hospital was cited twice, in 2015 and again in 2017, for problems with the facility’s sprinkler system, fire alarms and fire drills. It was cited in six different surveys going back to 2015 for failing to develop a plan to make sure the patients’ entire medical and nursing-care needs were tracked, the report said.

When inspectors reviewed hospital records, they found nurses don’t always provide care that had been ordered by a physician. Nurses didn’t complete doctor-ordered blood work, neurological assessments, monitor blood glucose levels and other checks. Staff didn’t maintain treatment plans for 10 of 22 patients reviewed, surveyors 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 and her treatment plan said “she does struggle a little more with appropriate boundaries with others and does need reminders.”

But her record contained a list of incidents in the weeks that followed that included having sexual intercourse with another patient, taking her clothes off in front of one of her peers, attempting to have sex with a patient on the patio and other sexually aggressive behavior. Nurses failed to update her treatment plan to reflect her increasingly aggressive behavior.

The patient’s treatment plan said she was taking her medications, but records also said she was flushing them down the toilet.

The staff didn’t make sure there were escorts available to take patients to medical appointments. One patient missed an optometry appointment because the escort “lost his keys,” the report said. And in April, there were 31 canceled patient dental appointments because of a lack of escorts.

The hospital failed to respond properly to grievances filed by patients.

One patient called the hospital’s abuse/neglect call line on May 3 with concerns about physician care. The operator forwarded the complaint to a risk management team for investigation, but the surveyor found no documentation to show the team had discussed the issue and addressed it with the patient.

Another patient called the neglect/abuse line on May 8 with concerns about receiving funds related to the death of parents, and again, the surveyors couldn’t find reports to show the complaint was addressed.

The hospital failed to implement its seclusion and restraint policies and didn’t take patients off restraints as soon as possible. That was the case for two of six patients reviewed.

One patient was restrained for almost four hours on different days, even though the patient’s behavior was labeled “not agitated” for almost two hours during those periods. The nurse told the surveyor staff will monitor restrained patients at hourly intervals and release them when appropriate, but based on the finding the patient wasn’t agitated, he should have been released sooner.

“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 violations went beyond patient care.

Inspectors found problems with the hospital’s refrigeration of food and laboratory specimens, and discovered a torn mattress in one bedroom, cracked tiles in a restroom, and five-feet of chipped drywall below a window in a patient’s room.

Talk to us

More in Northwest

Joshua Freed
Ex-Bothell mayor accused of misleading real estate investors

One Snohomish couple sued Joshua Freed after losing a $300,000 investment in a development project.

Rate of COVID-19 cases is on the rise in Washington state

Hospitalizations are still low but are beginning to increase, according to statewide data.

An egg-producing chicken is in a pasture at Wilcox Family Farms, Thursday, April 9, 2020, in Roy, Wash. Eggs have been one item that can be hard to find on grocery store shelves during the outbreak of the coronavirus, even though the closure of restaurants and large corporate kitchens has led to a decreased demand for food service egg products. (AP Photo/Ted S. Warren)
State asks live poultry sales to end because of bird flu

The 30-day closure is not mandatory. There are still no reported infections in Snohomish County.

King County Superior Court Judge Roger  Rogoff stands in court, Monday, Oct. 10, 2016, in Seattle. Rogoff announced Monday that a settlement had been reached in a lawsuit brought by survivors and family members of people killed in a 2014 Oso, Wash., landslide against the state of Washington and a timber company that logged an area above the site of the slide. (AP Photo/Ted S. Warren)
Former judge to head office probing Washington police shootings

The state’s new independent office will review cases where police use deadly force.

Whatcom County Superior Court Judge Raquel Montoya-Lewis, wearing an eagle feather honoring her Native American heritage, smiles as she speaks with media members after being named to the state Supreme Court Wednesday, Dec. 4, 2019, in Olympia, Wash. Montoya-Lewis was appointed to the bench by Washington Gov. Jay Inslee, who said she will be the first Native American justice to serve on the state's highest court. Montoya-Lewis, an enrolled member of the Pueblo of Isleta and a descendant of the Pueblo of Laguna Indian tribes, will be sworn in next month to fulfill the remaining year of Chief Justice Mary Fairhurst's term, and the seat will be open for election in 2020. (AP Photo/Elaine Thompson)
State Supreme Court Justice Montoya-Lewis on medical leave

Officials with the court didn’t release additional details, citing the justice’s desire for privacy.

Police: Arby’s manager in Washington peed in milkshake mix

He said he did it for sexual gratification, and he’s “almost sure” he threw the tainted bag away.

Andrew Cain Kristovich (Snohomish County Sheriff's Office)
Oregon fugitive with Snohomish County ties arrested in Nevada

Andrew Cain Kristovich escaped from a federal prison camp in April. He was considered armed and dangerous.

FILE - In this Monday, March 1, 2021 file photo, The first Alaska Airlines passenger flight on a Boeing 737-9 Max airplane takes off on a flight to San Diego from Seattle-Tacoma International Airport in Seattle. A Boeing pilot involved in testing the 737 Max jetliner was indicted Thursday, Oct. 14,2021 by a federal grand jury on charges of deceiving safety regulators who were evaluating the plane, which was later involved in two deadly crashes. (AP Photo/Ted S. Warren, File)
Alaska Airlines to keep canceling flights at high level for weeks

Flight cancellations since April will continue. The chaos has been damaging for Seattle’s hometown airline.

FILE - Washington Attorney General Bob Ferguson speaks March 23, 2022, at the Capitol in Olympia, Wash. Months into a complex trial over their role in flooding Washington with highly addictive painkillers, the nation's three largest opioid distributors have agreed to pay the state $518 million. Ferguson announced the deal Tuesday, May 3, 2022. (AP Photo/Ted S. Warren, File)
DNA from 372 state sex offenders added to national database

Officials have been unable to collect samples from some offenders, including three in Snohomish County.

FILE - Randy Weaver, the object of the Ruby Ridge siege, visits with the media at the main FBI roadblock outside the Freemen compound in Montana on April 27, 1996. Weaver, patriarch of a family that were involved in an 11-day Idaho standoff in 1992 with federal agents that left three people dead and served as a spark for the growth of anti-government extremists, has died at the age of 74. His death was announced Thursday, May 12, 2022, in a Facebook post by daughter Sara Weaver, who lives near Kalispell, Montana. (AP Photo/Jim Mone, File)
Randy Weaver, participant in Ruby Ridge standoff, dies at 74

The 11-day standoff in the Idaho Panhandle mountains transfixed the nation in August of 1992.

Barbara Williams, center, holds an umbrella for her mother, tribal chair Cecile Hansen, right, as they prepare to join other members of the Duwamish Indian Tribe in performing an "honor song" Wednesday, Feb. 27, 2008 near a location in Seattle where bones were found during construction activities near the Pike Place Market. The song was performed because the tribe felt at the time that the remains could have been from an ancient member of the tribe, but city authorities said later in the day that the remains appeared to have been from a small animal. (AP Photo/Ted S. Warren)
Duwamish Tribe sues again for federal recognition

Tthe lawsuit demands the court set aside the denial of recognition in 2015 by the Obama administration.

A pod of transient orcas, known as T124As, surfacing near Tacoma. (Craig Craker/Orca Network)
Sightings of mammal-eating orcas increasing in Puget Sound

The killer whales enjoy a diet of harbor seals, sea lions, porpoises and the occasional bird or squid.