US agency issues safety notice at Washington state hospital

AP News
Posted: Feb 26, 2016 10:56 PM

SEATTLE (AP) — As Washington state's largest psychiatric hospital faces a deadline to fix safety problems or lose millions of federal funds, federal inspectors issued an "immediate jeopardy" notice saying the facility failed to protect patients from harm.

Inspectors with the Centers for Medicare & Medicaid Services issued the notice Thursday after saying a patient at Western State Hospital was given the wrong medication. The notice reflects a crisis situation in which the health and safety of people at the hospital are at risk. Hospital CEO Ron Adler notified staff about the situation in an email acquired by The Associated Press on Friday.

The 800-bed facility received multiple warnings from federal regulators in 2015, including six immediate jeopardy notices in November. It had until Tuesday to fix those problems or face losing millions of dollars in federal funds. But late Friday, CMS sent a letter to Adler saying they were extending the termination date until April 1.

Inspectors were at the facility this week to ensure changes were made after pervious violations were found. They interviewed staff, inspected documents related to the use of seclusion and restraints, and checked on the hospital's infection control systems, among other probes, according to notices sent to staff through the week.

On Thursday, the survey team issued the jeopardy notice, Adler said in the email.

"The hospital failed to ensure that staff members followed hospital policy, procedures and standards of practice for patient identification prior to medication administration and procedures," the notice said. "This posed a serious risk of harm to patients."

Julie Bannester, spokeswoman for CMS, said the agency has no comment on the notice at this time because the survey is still in progress.

Adler declined to discuss the CMS notice with The Associated Press and referred questions to the Department of Social and Health Services, Behavioral Health Administration, which runs the facility.

Carla Reyes, the agency's assistant secretary, responded by releasing a statement that thanked the staff for reporting the incident and said they're working to fix the problem. She said the hospital administers 9,500 doses of medication each day, but on Wednesday, a patient was given the wrong drugs.

"We continue to make improvements in all areas of patient care and safety," Reyes said. "Hospital staff are evaluating root causes for this situation and working together to identify solutions that will result in safer patients and improved quality of care."

The hospital's safety policy requires nurses to confirm that the patient is correctly identified using at least two methods that could include a photo ID, asking the patient to identify himself and provide a date of birth, or have another staff member confirm the patient's name, according to Adler's note. The nurse must also ensure they're giving the right drug in the right dose.

Both houses of the Legislature have added funds for mental health and the psychiatric hospital in the upcoming budget, but some lawmakers have lost confidence in the way Western State Hospital is being run.

On Wednesday, the House Judiciary Committee approved a bill that aims to improve oversight of state hospitals. It would create a Legislative State Hospital Authority that would serve as a consultant to the Legislature on funding and policy issues related to the facilities. It also would form a joint select committee on hospital oversight. House Bill 2453 has been sent to House Appropriations.

The Legislature and Gov. Jay Inslee added funds to the hospital's budget to provide an increase in salaries for staff. The department has said its inability to hire and retain staff is the root cause of the hospital's problems.

But some doctors and nurses have told The Associated Press the problems stem from bad decisions made by the hospital's administration and many fear retaliation if they try to speak out about what they say is a mismanaged system. The agency has denied retaliating against staff.


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