Audit Highlights Security Flaws at State Hospital

By Tim Carpenter, Kansas Reflector

TOPEKA — Inadequate physical security systems, erosion of workplace culture and persistently high staff turnover jeopardizes the safety of Osawatomie State Hospital employees serving adults with acute mental illness, a state audit said.

The assessment by the Kansas Legislature’s auditing agency, released to a joint House and Senate committee, highlighted clusters of security shortcomings on the hospital campus. The Osawatomie complex has 175 beds for patients and an authorized staff of 530.

Members of the Legislature’s bipartisan auditing committee said they were concerned by security threats documented in the 50-page evaluation.

“The findings of this report are concerning up and down the line,” said Rep. Shannon Francis, a Republican from Liberal.

Sen. Caryn Tyson, a Parker Republican who chairs the auditing committee, told Scott Brunner, deputy secretary for state hospitals and facilities at the Kansas Department for Aging and Disability Services, that he was responsible for correcting the staff safety problem.

“These hospitals are needed. There is great demand,” Tyson said. “I just hope we can get this under control. I say we, but it’s you. The Legislature can jump up and down and scream all day, but the bottom line is you have to perform.”

She said the audit was ordered by the Legislature in response to former OSH employees who said “they were in danger” while at work and “felt so much in harm’s way” that they resigned.

Troubled history

OSH was established in 1863 in Miami County to provide care for individuals 18 years or older. It is one of two state-run facilities — the other is Larned State Hospital — striving to provide inpatient mental health services. OSH patients can be unpredictable, aggressive and violent. Many are held at the hospital under court order. Auditors said they reviewed hospital security camera footage of patients attacking staff without warning.

OSH, with capacity of 116, isn’t certified by the federal Centers for Medicare and Medicaid Services. It operates without federal funding. In 2015, OSH lost CMS certification due to safety deficiencies tied to insufficient nursing and security personnel. A separate facility on the OSH property, Adair Acute Care, is CMS certified and funded and delivers crisis services with 60 beds. The OSH complex has 25 buildings, including housing, administration, physical exercise, laundry and other facilities. It employed 28 security staff, auditors said.

Staff consistently reported to auditors that patient conduct was the leading reason employees felt unsafe at work. “Staff reported being verbally and physically harassed and physically assaulted by patients,” the report said.

The audit concluded OSH didn’t “have adequate processes to ensure physical security” of personnel working among a “high-risk, vulnerable population.”

Auditors surveyed 1,220 people who worked at OSH or AAC from 2020 to 2024. That information, and individual phone calls or emails to auditors, offered a sense conditions at OSH could be improving. The report noted some staff felt discouraged about reporting problems to supervisors due to fear of retaliation or a sense that coming forward wouldn’t make a difference.

“The audit captured that same kind of concern you’ve heard about retaliations,” said Brunner, a deputy secretary at KDADS. “Quite frankly, we hear similar kinds of reports in all four state hospital campuses. That part is not unusual.”

Keystone cops?

Auditors said administrators of OSH indicated they had limited options when dealing with especially violent hospital patients. Aggressive men could be transferred to Larned State Hospital or law enforcement could be called to arrest allegedly violent patients.

“However,” the report said, “both are only temporary ways of managing the situation with patients often returning to OSH after Larned or law enforcement’s involvement.”

The audit said OSH didn’t require staff members to wear personal safety alarms and made no effort to determine whether authorized personnel responded to alarms in a timely way. The hospital’s personal alarm systems hadn’t undergone testing since 2021, the report said.

The audit said OSH was uanble to make a complete and accurate accounting of building keys. OSH didn’t have a method for retrieving keys from departing staff. OSH said it could say at least 56 keys, including keys to patient units, had been stolen. Auditors discovered some employees had grand master keys to multiple facilities that they didn’t need or weren’t authorized to possess.

Security staff patrols of the OSH campus were found to be incomplete and inadequate, said auditor Mohri Exline, who briefed legislators Monday on the report.

Auditors documented 61 security patrols, but 48% appeared to be “implausible or questionable” based on how long officers said the patrol lasted. Officers asserted the task of physically verifying building doors were locked took between 8 minutes and 75 minutes. A mock patrol performed by security staff for auditors indicated it required one officer 30 minutes to patrol one section of OSH’s campus.

OSH’s security cameras weren’t monitored in real time, the audit said. Instead, footage was used retroactively to review specific incidents.

Auditors said security personnel didn’t have enough people trained to respond to fires, in part, because that training hadn’t occurred at the hospital since March. As of September, 37% of OSH’s security staff hadn’t received fire training. OSH informed auditors security personnel were removed from fire-response duties in October, and the hospital would rely on Osawatomie’s fire department.

Staff discipline

The report indicated OSH turnover, including among contract labor, likely contributed to security challenges due to a high vacancy rate and the steady introduction of new employees. Turnover from September 2023 to August 2024 among contract staff was 54% at OSH. Turnover for state employees at OSH averaged 37% from September 2021 to September 2024. By contrast, the Kansas Hospital Association said average turnover at 110 Kansas hospitals averaged 16% to 30% in 2023.

“High vacancy rates, turnover rates and overtime also increase risks to staff safety and likely compound the physical security issues we identified,” the audit said.

Meanwhile, the audit concluded OSH management hadn’t promoted a culture that prioritized adherence to guidelines and development of a safe workplace. OSH administrators failed to set clear expectations for employees on security issues, and hadn’t collected data to better identify and fix problems.

Auditors said OSH leadership repeatedly failed to take reasonable disciplinary action, including one incident involving an apparently intoxicated staff member who was injured at work.

A separate incident involved an inebriated staff member who drove a patient in a vehicle. The initial proposed disciplinary action was termination, but OSH management instead suspended the staff member for five days.

The audit delved into two instances in which an OSH supervisor failed to respond appropriately to reports of alleged sexual harassment. In one case, auditors said, a human resources investigator found evidence of harassment but the supervisor didn’t order disciplinary action.

“In a subsequent case,” the report said, “an investigator found the same supervisor had thrown a welcome-back party for an employee who was on leave for sexual harassment and was planning a welcome-back party for another employee who was also placed on leave for sexual harassment. This implies that supervisors sometimes are not adequately holding staff accountable and may be engaged in favoritism.”