Editor’s note: The KHI News Service conducted a months-long investigation into what led federal officials to deem Osawatomie State Hospital as a facility too dangerous for Medicare patients and whether officials can rebuild the hospital for a successful future. This is the third story in a series.
Administrators at Osawatomie State Hospital worked to maintain a delicate balance in 2011 as they struggled to cope with rising demand for care and funding that hadn’t kept up.
OSH superintendents had credited the facility’s experienced workforce for pulling it through lean times before, but that key source of stability soon would be diminished.
Click here for a list of key sources interviewed for this series of stories about Osawatomie State Hospital.
Kansas reduced its state hospital beds in the 1990s as part of an effort to treat more people with mental health issues in their communities. Lawmakers believed community-based treatment would be both more affordable and more humane for people with all but the most severe conditions.
But the Legislature and multiple administrations failed to fund community mental health centers at levels necessary to make the reform plan work, even in good fiscal times, and the situation only worsened when the Great Recession hit. Budget cuts for community mental health centers meant that state hospitals like OSH had less support even as the number of people in need of psychiatric treatment increased.
Federal officials in 2006 had found OSH patients weren’t getting appropriate care. But by 2011, concerns at OSH mostly had to do with overcrowding and strained budgets. That would change, however, when early retirement incentives triggered a spate of staff departures.
Retirements increase workload
In an effort to keep a campaign promise to downsize state government, newly inaugurated Republican Gov. Sam Brownback offered early retirement incentives to hospital employees who had worked for the state for at least 10 years.
Rebecca Proctor, executive director of the Kansas Organization of State Employees, said too many employees took the offer at OSH, and the hospital lost some of its most experienced staff.
“It’s very difficult to replace that knowledge, No. 1, and No. 2, it’s difficult to replace that level of staffing,” she said.
The workers who left weren’t quickly replaced. In February 2012, the Kansas Legislature’s House Appropriations Committee heard that OSH had 55 fewer workers than the previous year although its patient counts remained above capacity.
The retirements had increased the workload on remaining employees, causing more to leave, Proctor said. Concerns about working conditions at OSH had come up from time to time since she joined KOSE in 2008, she said, but they increased greatly starting in 2011.
“There has always been a vacancy rate,” she said. “They’re never fully staffed. But the shortages weren’t crippling” before the retirements.
Steve Ashcraft, who was superintendent of OSH from 2011 to 2013, said recruitment and retention were issues at the state’s mental health hospitals long before his tenure. The work is challenging, the pay isn’t always competitive with private medical facilities and the labor pool is limited in the rural areas where the hospitals are located, he said.
“It’s always going to be a challenge when you have that mix,” he said.
The last across-the-board pay increase for state employees, including OSH staff, was in 2009. A lack of pay increases led to other OSH staff departures, which then caused more hospital employees to quit due to the burden of increased overtime, Proctor said. Morale suffered among experienced employees when they saw new employees being hired for about the same amount they were earning, she said.
“It’s a really tough job. It takes a special person to do this job day in and day out,” Proctor said. “It also became difficult to (hire) staff when people don’t see that there’s going to be improvement in their pay or working conditions.”
Former OSH Superintendent Greg Valentine, who was fired in 2011 for what he says were political reasons and now is superintendent of a psychiatric hospital in Delaware, said policy changes during his final months at the hospital made staffing even more difficult. Officials at the Department of Social and Rehabilitation Services told him that he needed to get their approval before filling open positions, which sometimes delayed hiring by several months.
Staffing hadn’t fallen to unsafe levels, he said, but the trend was troubling.
“I think there may have been a desire to show some savings at the state level,” he said. “I thought, ‘If this continues, we’re going to have some serious problems.’ I could see it happening.”
At the same time, the work wasn’t getting any easier.
When Valentine left, Wes Cole took over as interim superintendent for a few months. Cole, who had worked at the hospital for 38 years, said providing care became more difficult with an increasing number of patients who often had more severe mental health conditions. The combination led to more assaults on staff, he said.
“It created a problem for providing quality care, and it created a problem for staffing,” he said. “I think it was more of a dangerous situation. When you have to focus on keeping people safe, you can’t focus as much on treatment.”
Report alleges overstaffing
Despite the increasing tensions, Ashcraft, who took over for Cole, said the hospital continued to pass inspections. State officials apparently thought the situation was under control, because in 2013 they hired a consulting firm to explore whether some state hospital beds could be repurposed.
The report by the Buckley Group, a consulting firm based in Englewood, Colo., said the state could save $3 million by providing only short-term acute care at OSH and other types of care in communities.
But for that to happen, the report said, the state and the community mental health centers in OSH’s 46-county catchment area would need to substantially increase “residential and community-based resources for the chronically mentally ill.”
The consultants also said that OSH was overstaffed compared to industry benchmarks, although it seemed anything but to hospital employees. Direct-care staff frequently worked “forced” overtime, according to KOSE.
“Louise,” a long-term employee who worked in nursing at OSH and asked not to be identified, said state officials became more reluctant to allow needed hiring after the Buckley report was published.
As the state considered whether it could get by with less staffing at OSH, the patient count kept climbing. In July 2014 the hospital hit a record patient census of 254, despite being licensed for 206 patients. That day wasn’t an aberration. The average for the year also was well above capacity.
The overcrowding caught the attention of the State Fire Marshal’s Office, which said the conditions were unsafe because extra beds added to patient rooms would make it more difficult to reach exits in an emergency.
Federal officials also weren’t pleased. The Centers for Medicare and Medicaid Services threatened to pull Medicare payments from OSH, but the Kansas Department for Aging and Disability Services avoided the financial hit by ordering staff to complete regular “fire watch” checks in patient rooms.
Mistakes lead to patient’s death
Up to that point, no one had found evidence of harm to patients. That changed starting in late 2014, when federal inspectors cited OSH for patient care problems that resulted in one patient dying and another losing a toe.
An October 2014 report said one patient had to have a toe amputated due to gangrene and another was hospitalized with a blood clot. In both cases, it appeared staff had neglected to provide adequate care or forgotten to give medications. According to the inspection, a staff member said the patient with the blood clot “fell through the cracks after the third or fourth day.”
Federal inspectors also blamed understaffing for contributing to a patient’s death in January 2015. The patient had been prescribed an antidepressant and an antipsychotic, and reported feelings of constipation, which is a common side effect of both drugs. He also was prescribed laxatives to ease the constipation, but nursing staff didn’t adjust his treatment over the next four days, allowing his symptoms to become dangerous.
The patient was found unresponsive, with an “extremely distended” abdomen and breath that “smelled of feces.” He was taken to a hospital, where he died less than three hours later. The death was attributed to sepsis, when multiple organs fail due to complications of an infection.
OSH employees told federal inspectors they were short-staffed in the days leading up to the patient’s death and that some staff had been moved to assist with other units.
“The hospital failed to plan appropriately and provide staff in adequate numbers, according to the unit’s patient census, to ensure nursing staff responded to each individual patient’s nursing needs in a safe and effective manner around the clock,” the inspection said.
It added that the “deficient practice” led to the patient’s death “and had the potential to cause harm to all patients due to inadequate staffing.”
The deficiencies cited in the report came as no surprise to some frontline workers.
“Louise,” the long-time nursing employee, said the hospital’s decision not to staff a medical clinic also played a role. Nurses on the units had to provide both medical and psychiatric care to patients with complicated needs, she said, and the increased workload made mistakes more likely.
“It’s a little difficult to know what physical problems they’re having when they’re having mental problems too,” she said. “But … if there are sick people on the unit, (nurses) have to know what to do.”
Mistakes like those that led to the patient’s death shouldn’t happen at a well-run psychiatric facility, said Steve Feinstein, who was superintendent of OSH from 1994 to 1998.
“It’s inconceivable to me that if you had a competent medical and nursing staff that this could have happened,” he said. “Where was quality control?”
Employees report forced overtime
After the patient’s death, OSH leaders pledged to require more training, increase staffing, hire a consultant to help improve nursing care and employ nurses on a contract basis to reduce staff overtime.
At a public meeting in March 2015, however, staff openly complained that they still had to work overtime without warning. Some said they had witnessed employees reprimanded or fired for objecting to policies and working conditions that they thought put patients in jeopardy.
Edwina Bastion, a retired nurse who had worked at OSH for 41 years, told KDADS officials that poor working conditions and management practices were driving away staff the hospital needed.
“If you had happy nurses, you wouldn’t have the problems you’re having now,” she said at the March 2015 meeting. “They don’t feel like they’re communicated with.”
“It’s inconceivable to me that if you had a competent medical and nursing staff that this could have happened. Where was quality control?”- Steve Feinstein, Osawatomie State Hospital superintendent from 1994 to 1998
Inspectors continued to flag staffing problems at OSH in July 2015. They noted units often had only one registered nurse on duty, and each nurse had to deal with as many as 30 patients with challenging needs.
In one example an inspector noted, all 30 patients in a unit under the care of a single nurse had been identified as potentially violent. In addition, six needed to be checked every 30 minutes and three required constant supervision.
One registered nurse told inspectors, “I often stay two to three hours after my shift ends to get everything done.”
Mental health technicians also told inspectors they were overworked because their peers often left for better-paying jobs. One technician said he or she didn’t want to work a double shift that day but was “afraid” to say no.
“They will write you up if you refuse, and if you refuse many times, you’ll get fired,” the technician said. “They don’t have enough staff. This place is a revolving door.”
Employees at psychiatric hospitals shouldn’t be working overtime frequently, because they become exhausted and don’t notice signs of trouble, said Walter Menninger, former president and CEO of the Menninger Clinic, which operated in Topeka until 2003.
“People want to do a good job,” he said. “But if you feel overwhelmed or you get burnt out, you’ll miss things.”
OSH downsizes for renovations
Inspections also found problems with patient housing in early 2015. Rooms had fixtures that patients could potentially use to hang themselves. There also were indications that patients had pulled water fountains from the wall and inserted objects into electrical outlets in attempts to generate sparks to light cigarette butts they found outside.
Federal inspectors demanded extensive renovations to address the safety issues but allowed the hospital to continue operating with one unit off-line at a time. OSH lowered its capacity in May 2015 by 60 patients, to 146, to allow for the renovations.
KDADS officials urged community mental health centers to work with OSH to divert patients who could be treated elsewhere. It didn’t work entirely as planned, however. Community hospitals reported they had to hold patients needing psychiatric treatment for multiple days before a bed would open at OSH.
The inspection report also said that OSH employees weren’t dealing well with patients who resisted treatment. An employee told an inspector that in 2014 the hospital discontinued a program aimed at encouraging patients to attend group therapy sessions. Inspectors found little evidence that patients who chose not to attend sessions received other meaningful treatment, “potentially delaying their improvement.”
“Although the treatment plans for these patients included multiple group therapies, patients regularly and repeatedly did not attend groups,” a July 2015 inspection said. “They spent many hours without structured activity and occupied most of their time sleeping or wandering around the hallways.”
Hospitals can’t force patients to attend therapy, but they can offer incentives, said Don Jordan, who was superintendent of OSH from 2002 to 2005 and SRS secretary from 2006 to 2010. At times, they were able to get everyone on a unit to participate because staff made it a point of emphasis, he said.
The inspector also observed an employee who struggled while leading a group therapy session. Patients had side conversations or arguments, and one became agitated and then started dancing, singing and laughing but wasn’t removed from the room.
The director of psychology said the employee was relatively new, but “due to not having a significant number of group leaders, this person has been assigned to conduct some groups.”
“This failure results in fragmented treatment for patients and supports negative, rather than positive, social behaviors,” the inspector noted.
Mark Ready, who did staff training at OSH before retiring in in 2012, said some of the problems came from a decreased emphasis on preparation toward the end of his career. For most of the time he worked at OSH, new mental health aides had to go through a two-month class about mental illness and patient behaviors before they went to work, he said.
Later, it shifted to only three or four days of classroom training, with the idea that staff would learn while working the units — a situation that put unprepared employees at risk and increased the number who quit after a short time on the job, Ready said.
That just isn’t enough time to prepare people to work with patients who have serious mental illnesses, said “Louise,” the long-term nursing employee.
“Unless you’ve been around it, unless you have the background on it, unless you’ve had the good training, you don’t know” how to treat those patients, she said.
As the summer of 2015 ended, the problems at OSH were getting worse. Staff numbers remained low, and the state hadn’t addressed the long-standing problem of underfunding community resources. Still, federal officials put off their decision on whether to pull payments from the hospital until November, to allow OSH the time to finish renovations and address other problems.