Federal report says Larned hospital staff failed to keep patients safe and secure

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TOPEKA — A federal report on the escape of a dangerous patient from the Larned State Hospital says the state put patients in “immediate jeopardy” by failing to ensure their safety and security.

A survey conducted by the Centers for Medicare and Medicaid Services discovered the patient was able to escape in January because a nurse’s aide left the door to the secure area unlocked, and staff members responsible for checking on him every 15 minutes documented that he was in his bed for hours after he was gone.

Isaac Watts, a 43-year-old who was detained on charges of kidnapping, attempted murder and domestic battery, was under enhanced surveillance when he walked out the door in a straightjacket. He was considered a threat to himself and others.

At the time, the Kansas Department for Aging and Disability Services announced it was conducting a security audit of the chronically understaffed hospital. The escape was the second within six months.

Cara Sloan-Ramos, spokeswoman for KDADS, didn’t respond to email messages seeking comment on the status of the security audit or the CMS report about the Jan. 3 escape.

Larned State Hospital in western Kansas provides court-ordered mental health evaluations for individuals awaiting trial, as well as treatment for sexual predators. The facility has been short-staffed for at least a decade because of low wages, the rural setting, and the dangers of working in an environment where staff are physically and sexually assaulted.

Last month, the American Civil Liberties Union of Kansas and the National Police Accountability Project sued the state over long wait lists for mental health treatment. The ACLU said the hospital only fills about half of its beds because it lacks the staffing to cover shifts, and more than 100 people are currently on the waiting list.

CMS from Jan. 7 to Jan. 19 conducted an investigation into the escape by Watts. The  federal oversight agency provided a copy of the report in response to a request from Kansas Reflector.

“Based on interview, record review, and policy review, the hospital failed to protect and promote each patient’s rights by failing to provide a safe and secure environment,” the report said. “The cumulative effects of this deficient practice resulted in an immediate jeopardy situation.”

By CMS standards, an “immediate jeopardy situation” is when “noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.”

Video showed a certified nursing assistant unlocked an emergency exit door to the hospital’s Crisis Stabilization Unit at 2:03 a.m. Jan. 3. Patients discovered the unlocked door after noon. Watts could be seen pushing the door open at three times throughout the afternoon. He eloped at 9 p.m. and was captured the next day in Garden City.

During a Jan. 14 interview, the CNA said she opened the fire exit door “just to make sure the key worked.” She said she thought she locked the door after opening it but couldn’t remember if she pushed the door afterward to make sure it was secured.

“She did not want to answer any further questions and ended the call,” the CMS report said.

Trained staff are responsible for making sure each patient is accounted for at least every 30 minutes. When sleeping, the staff must see the patient’s skin and observe the chest rise and fall. They were supposed to check on Watts more frequently because he was suicidal.

The hospital’s Special Protection Flow Sheet showed a mental health technician documented Watts was in his room, calm and laying down from 9:15 p.m. to 9:45 p.m., after he was already gone. Another CNA documented Watts was in his room, calm, eyes closed, with visible respirations from 10 p.m. to 10:45 p.m. Another mental health technician discovered Watts was missing — after he documented Watts was in his room from 11 p.m. to 11:45 p.m.

“We were notified that a door was found unlocked,” the staff member said. “When doing patient checks, we open the door to the patient’s room if the door is closed and look in to see what they are doing. We do not have to wake them up or pull the covers back, that’s a good way to get hurt or hit … but have to observe that a person is actually there by visualizing a body part or breathing. I thought maybe there was something up that night because when I did my first check, I didn’t hear him snoring. I guess maybe I wasn’t paying attention that night. As soon as the security guard said the door was open, I went into his room and pulled back the covers, and he wasn’t there.”

A hospital program director acknowledged that staff failed to follow policy, but the hospital couldn’t provide evidence that staff had been trained on patient checks.

The hospital in February terminated contracts with the CNA who left the door unlocked, and the CNA and first technician who inaccurately documented Watts was still in bed. The other technician was reassigned and given additional training.

A review of the hospital’s Safety and Security Department Shift Log showed that only four of 60 perimeter checks were completed during the 7 a.m. to 3 p.m. shift between Dec. 3 and Jan. 2. Only 37 of 60 perimeter checks were completed during the 11 p.m. to 7 a.m. shift.

The three security officers who were assigned to check the perimeter on Jan. 3 all failed to check for unlocked doors. The hospital failed to provide evidence of training or corrective actions taken for security staff.

CMS accepted a plan proposed by KDADS and the hospital Jan. 19 to address the security failures. The plan includes more intensive patient checks, training and documentation. Leadership must check that all doors are secure each shift. Security officers have to report door checks by radio and email, and senior officials will conduct daily random audits. The hospital also was looking into door alarm systems.

Kansas Reflector is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Kansas Reflector maintains editorial independence. Contact Editor Sherman Smith for questions: info@kansasreflector.com. Follow Kansas Reflector on Facebook and Twitter.

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