A new audit found deficiencies in how Osawatomie State Hospital protects the safety of its staff, including a failure to take disciplinary action in several notable cases such as staff members who were accused of drinking on the job and supervisors who failed to respond appropriately to allegations of sexual harassment.
Legislative auditors report that the 116-bed psychiatric state hospital with a history of safety and security issues doesn’t have procedures in place to ensure physical security nor has it promoted a culture that encourages a safe workplace.
“We saw ample evidence that Osawatomie State Hospital officials can and should do a better job of managing the safety risks they can control,” the auditors wrote in their report.
“We saw evidence of inadequate physical security processes in multiple areas including door checks and tracking facility keys. We also saw staffing challenges with high turnover, numerous vacancies, and costly overtime,” the audit concluded.
“We saw evidence of workplace culture issues like not setting clear policy expectations, not collecting and using data to monitor staff safety risks, and not taking appropriate disciplinary actions when made aware of safety incidents,” audit said.
The auditors found in their report – released Monday – that the hospital’s management didn’t always hold staff accountable for the severity of their actions. Consider:
- A staff member was injured at work and appeared drunk. According to human resources notes, the individual should have been suspended. But the audit said the employee was not suspended because hospital management didn’t follow up fast enough. “This suggests that management sometimes does not respond to issues timely,” the audit said. The employee was accused of drinking on the job on two subsequent occasions. The staff member ultimately received a letter of reprimand. But the letter only addressed that the staff member was asleep while on duty, not that the staffer had been drinking at work.
- In one case, a staff member was accused of driving a patient in a vehicle while drunk. The staff member acknowledged drinking during lunch, the audit said. The initial proposed disciplinary action was termination. However, management suspended the staffer for five days because the staff member appeared to take responsibility for their actions. “This suggests lack of accountability and potential favoritism,” the audit said.
- In two cases, a supervisor failed to respond appropriately to reports of misconduct that included sexual harassment, the audit said. In one case, a human resources investigator found the supervisor failed to respond to or take disciplinary action about allegations of employee misconduct. The investigator substantiated the allegations, including that the accused staff member had engaged in sexual harassment. In a later case, an investigator found the same supervisor threw 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 engaging in favoritism,” the audit said.
The agency said in its response to the audit that human resources has completed a comprehensive staff transition, with all new team members receiving thorough training on the effective implementation of progressive discipline.
“Additionally, supervisors have undergone, and will continue to receive, ongoing training to equip them with the necessary tools, skills, and expectations to effectively manage and support their teams,” the hospital said in response.
While the audit found a number of deficiencies, the auditors said they have evidence suggesting that current management may be making some improvements.
They said the hospital’s current superintendent has demonstrated an interest in improving some of these problem areas through actions like reporting staff who did not meet expectations and committing to a comprehensive audit of facility keys.
The audit found the hospital identified at least 56 keys as stolen, including keys that give access to patient units.
The hospital identified many other keys, including eight grand master keys, as lost.
The auditors couldn’t say how many keys were lost because of the format of the data the hospital provided.
“These issues mean there’s a risk someone could gain unauthorized access to OSH buildings, or a patient could find keys and escape,” the audit said.
“We haven’t seen any evidence of these things happening, but we did review a few incidents in which staff or patients found misplaced keys,” the audit said.
In responding to the audit, the agency said all hospital staff will receive formal education at the time of hire on the expectations of handling keys assigned to them and the proper way to return keys when their employment ends.
Lawmakers who sit on the audit oversight committee were alarmed by some of the findings, include one where an employee was not fired after drinking on the job.
“I think we have some major problems, here,” said Republican state Sen. Caryn Tyson, chair of the audit committee. “This is quite disturbing.”
Republican state Rep. Shannon Francis, another member of the committee, echoed similar concerns about the audit.
“The findings in this report are concerning up and down the line,” Francis said.
This is not the first time that Osawatomie State Hospital has come under scrutiny.
In 2015, the Centers for Medicare and Medicaid Services revoked the hospital’s certification for repeated safety deficiencies, including insufficient nursing staff to perform necessary patient status checks and security staff not performing security checks.
A staff member was sexually assaulted by a patient in late 2015, which staff alleged was possibly due to lack of staff.
Tyson remarked about the high turnover at the facility, which the audit said was significantly higher than other Kansas hospitals for three years that were reviewed.
The turnover rate for state staff at Osawatomie averaged 37% annually from September 2021 through September 2024.
While all state agencies experience some turnover, Oaswatomie’s turnover rate is significantly higher than the turnover of 16% to 30% reported in a Kansas Hospital Association survey of 110 Kansas hospitals in 2024, the audit said.
When compared to other state hospitals, the vacancy rate for state staff was about 43% on September 1, 2023, and 39% on September 1, 2024.
It was similar to the vacancy rate the Department for Aging and Disability Services reported for Larned State Hospital at 45%, but much higher than Parsons State Hospital at 24%, the audit said.
High vacancy rates and turnover rates mean that Osawatomie must rely on contract staff and overtime to fill positions and meet their minimum staffing requirements, which drives up the cost to taxpayers.
Auditors roughly estimated that the hospital spent about $4.5 million more on contract costs and $2.2 million more on overtime costs in 2024 than it would have if it had sufficient state staffing.
The audit found that the hospital did not set clear expectations for how safety and security procedures should work.
“Throughout this audit, we found many instances where policies either do not exist or are outdated,” the auditors wrote. ” These issues suggest OSH management’s policy reviews aren’t timely or effective”
The auditors said they found areas where the hospital lacks policies which detail standard practices. For instance:
“The hospital doesn’t have policies or standard practices for how security staff should document their patrols of the OSH campus and buildings.”
“The hospital doesn’t have policies or standard practices for the types and amount of fire training security staff should receive.”
“The hospital doesn’t have policies or standard practices for the processes staff should use to retrieve keys from departing staff.”
“The hospital doesn’t have policies or standard practices for when progressive discipline of staff is warranted and what that discipline should look like.”
