Audit: Reporting, abuse procedures lagging at Kalamazoo Psychiatric Hospital

Beth LeBlanc
The Detroit News

Kalamazoo Psychiatric Hospital failed to complete reports on deaths and serious injuries in a timely manner and did not remove at least three accused employees from having contact with patients during abuse or neglect investigations, according to the Office of Auditor General.

The hospital also failed to closely monitor the access individuals had to confidential data and failed to complete timely assessments of new patients, according to the report released Tuesday

The 183-bed hospital provides behavioral health services to adults with mental illness in 34 counties in southwest and West Michigan, including individuals awaiting a psychiatric evaluation to determine competence to stand trial and those found to be not guilty by reason of insanity.

Kalamazoo Psychiatric Hospital

The audit of the facility — which included records between Aug. 1, 2017, and July 31, 2019 — found issues with the hospital's patient care services but found its pharmaceutical controls were “effective.”

"We take the audit findings made by our Office of the Auditor General very seriously and have already begun to take actions to improve the hospital’s patient care and services with great urgency," said Bob Wheaton, a spokesman for the Michigan Department of Health and Human Services. 

The performance audit of the hospital found conditions related to delayed documentation, delayed assessments and access controls. 

The hospital is required to complete admission assessments within 24 hours of admission, but more than half of the 40 cases reviewed had not had a psychiatric assessment within that time period, according to the audit.

Another 17 had not received a physical assessment within 24 hours and four had not received a nursing assessment within that time period.

The hospital, according to the audit, thought the assessments were supposed to be completed within 48 hours.

Since the time period in which the audit was conducted, the hospital increased physical assessments to a completion rate of 87%, nursing evaluations to 92% and psychiatric evaluation to comply with what’s required under law, the hospital told auditors.

The audit also found the hospital failed to remove from patient contact employees involved in three of the 19 abuse or neglect complaints reviewed by auditors. Two of the failures resulted from miscommunication with the state, according to the hospital, but the third instance occurred “because of a shortage of psychiatrists at the time.” 

For 17 abuse or neglect complaints, the hospital did not reply to the Office of Recipient Rates within the legal 10-day window and instead averaged delays of 32 days.

The hospital said it would work with the Office of Recipient Rights to ensure timely responses. 

In addition, auditors examined 40 of the 4,376 incident reports filed between Aug. 1, 2017 and July 31, 2019 for unusual incidents including assaults, medical errors, restraint of a patient or incidents suspected to be criminal. 

Of the 40 cases reviewed, 27 reports failed to include timely documentation from all staff witnesses, 11 did not include documentation showing guardians or state regulators were notified, and two did not include documentation of patient injury assessments. The hospital agreed to review internal processes to ensure compliance with state laws that require more timely documentation. 

Separately, for four of the seven “sentinel events” — an unexpected patient death or injury — that occurred between Aug. 1, 2017 and July 31, 2019, the hospital was unable to find documentation that it notified the Michigan Department of Health and Human Services. The hospital said it called the department, but didn't document the call.

In other instances, the hospital failed to notify in a timely manner regulators and committees that would review the events. 

Auditors  encouraged the hospital to institute better controls over the keys to patient units, medication rooms, offices and cabinets, noting that 25 of the 40 employees reviewed had 115 keys that were not assigned to them. Additionally, none of the 108 keys located in two patient units, including to unit cabinets and patient lockers, were listed in a database.

The hospital has since transitioned to a new key tracking system, according to the audit. 

The hospital agreed to periodically review user access within its electronic health record system after the audit found it had not done so regularly for its 531 active users.