State hospital inspection reveals disturbing details

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.