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Audit finds Kalamazoo Psychiatric Hospital lax on key safety issues

A picture of the Kalamazoo Psychiatric Hospital

A state audit of the Kalamazoo Psychiatric Hospital shows long-standing problems that could be affecting patient care.

The hospital failed to remove employees accused of patient abuse or neglect from patient contact in at least three investigations, according to the audit released this week by the Michigan Auditor General.

Hospital administrators said two of the three instances were caused by “miscommunication” between the hospital and the Office of Recipient Rights (ORR), which investigates claims of abuse, neglect or exploitation of a recipient of public mental health services.

Kalamazoo Psychiatric Hospital is one of three inpatient hospitals operated by the state for people with severe mental illness, or intellectual or developmental disabilities.

The audit indicates that several of the problems it found were recurrences of similar problems outlined in a previous 2011 performance audit of the hospital.  

The audit says the hospital needs to improve its process for handling allegations of patient abuse or neglect. It says when there are investigations into those complaints, the hospital often takes too long to respond. The audit reviewed 30 of 70 complaints “substantiated” by ORR between August 1, 2017 and July 31, 2019. More than half the time, the audit says the hospital didn’t respond to the ORR’s investigation findings in a timely manner.

The Michigan Department of Health and Human Services (MDHHS) says hospital staff will implement a tracking system to ensure timely responses to those investigations. MDHHS is required to develop a plan to comply with the recommendations of the audit and submit it to the State Budget Office for review.

There is a history of scandal at the hospital. In 2015, at least nine hospital staff-members were fired and 29 more suspended after an incident where a patient’s arm was broken. More than 50 staff members were either involved in the incident or witnesses.  

The audit also found the hospital frequently takes too long to file “incident reports” when something unusual happens to disrupt a patient’s normal routine or treatment. Such incidents could range from assaults on or by a patient, the use of restraints or seclusion on a patient, medication errors, and suspected crimes. The audit reviewed 40 of 4,376 incident reports over the same two year period. It said staff who witness such incidents often did not document their report by the end of their workshift, as required. Hospital staff failed to write patient progress reports 35% of the time.

The hospital “did not have controls to ensure that staff completed patient incident reports, notifications and assessments as required,” according to the audit, which it said could lead to, “potential negative impact[s] on the patient’s rights and well-being.”

An MDHHS spokesperson says the hospital implemented a new tracking system in October, 2019 to review all incident reports and update hospital administrators daily on incident reports that haven’t been completed.  

The audit also outlined problems with the hospital’s admissions procedures, finding that too many physical, psychiatric and nursing assessments for admitting patients weren’t being completed within the required 24-hour timeframe. The hospital says that it is in the process of implementing or has implemented reforms to ensure assessments are completed on-time.

The hospital says since January of 2019, the completion rate for physical assessments has risen to 87%, while nursing evaluations have increased to a 92% completion rate, and, according to the MDHHS spokesperson, psychiatric evaluations have risen to an 89% completion rate since January, 2019.

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