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RISKALERT  #1040 – Report Updated:  May 30, 2018

In a memo sent to top staff earlier in the week, “CMS identified a serious risk of harm to patients due to ligature risks
from the fire system in patient care areas of Building 21 ,” said the memo, which was obtained by public radio. Building 21 is where civil, or non-criminal, patients are treated on five different wards. Typically a ward has 30 patients. Western State Hospital is a Psychiatric Residential Treatment Center (PRTC) with over 800 beds.

A CMS finding of serious risk of harm is also known as an “immediate jeopardy.”  The memo also said that if the issue is not resolved, funding could be lost in 23 days.

Since 2015, Western State Hospital has been under scrutiny for serious repeat violations that inspectors said put patients and staff at risk. The litany of troubles included violent assaults on patients and staff, the 2016 escape of two high-risk patients and scores of unauthorized patient “walkaways.”

The safety violations were discovered by a team of 22 federal surveyors who were re-inspecting the hospital last week as part of a turnaround plan that is approaching the two-year mark. The sprawling hospital, which serves civil and forensic patients, must meet standards on 26 federal “Conditions of Participation” in order to continue receiving federal funding.

A “root cause” report in 2016 identified ineffective management, staff reductions and turnover leading to patients who felt “neglected” and a “culture of helplessness” among staff. A review by the Department of Corrections also found numerous security gaps including 25,000 master keys unaccounted for.

LESSONS LEARNED

1.   CMS requires all residential treatment facilities to maintain a safe physical environment, and any
identified risk situations should be addressed immediately to prevent loss of CMS reimbursement funds..

2.  Management must take the lead even in facilities related issues, instead of leaving the improved
   implementations up to lower level staff members.
   
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