OSAWATOMIE, Kan. — A December publication by the Kansas Legislative Division of Post Audit found the Osawatomie State Hospital does not adequately meet the safety and security standards of its operating staff.

The audit was authorized April 24, 2024, to answer the legislative committee’s initial question:

Does Osawatomie State Hospital adequately ensure the safety and security of its staff?

To conduct the audit, employees were surveyed to better understand the environment at the hospital.

The legislative body visited the hospital and reviewed policy and incident reports with data available from January 2022 to September 2024.

Background

The state psychiatric facility operates two independent hospitals. Since 1863, the hospital has provided inpatient psychiatric and mental health treatment to patients 18 years and older.

Osawatomie State Hospital is entirely state-funded and is not certified by the Centers for Medicare and Medicaid Services (CMS).

OSH has a capacity for 116 patients. As of August 2024, it held 108.

Acute Care (AAC) held 39 patients with a 60-patient capacity, as of August 2024.

Numerous state agencies oversee the hospital and operate on a $59.6 million budget, 80% of which comes from the state general fund.

Osawatomie State Hospital, one of the largest employers in the county, has 533 authorized employment positions. Jobs range from full-time to part-time and include administrative, facilities and medical personnel.

Issues on hospital grounds

The report revealed Osawatomie State Hospital has a history of problems.

In 2015, OSH lost CMS certification due to repeated safety deficiencies, per the audit. The deficiencies included a lack of nursing staff to perform necessary patient check-ins and security staff not performing duties.

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The December 2024 audit also reported a staff member was sexually assaulted by a patient in late 2015, which employees alleged was attributed to a lack of staff.

OSH’s plan to resolve the 2015 issue was to better assess a patient’s risk of violence, increase training, remind staff to use personal safety alarms, and ensure that staffing levels were adequate.

Federal inspectors require renovations on light fixtures, door handles and windows to prevent patient suicide. Such areas should not physically allow for any item that hangs or attaches.

The report also stated staff safety and security pose challenges based on the population served. Staff consistently report patients are one of the biggest reasons they feel unsafe, a combination of verbal harassment and physical assault, per the audit.

Staff identified three main areas to determine whether OSH adequately ensures the safety and security of its staff: physical security, personnel and management culture.

WATCH | Osawatomie State Hospital: A History

The audit outlined OSH does not have adequate processes to ensure physical security.

On-site security staff does not have enough fire-trained staff to respond to campus fires because fire training hasn’t been conducted since March 2024. No policy exists describing fire training requirements for security staff.

The report also outlined a number of other concerns, including OSH does not ensure staff carry required personal safety alarms and doesn’t check if staff respond to alarms timely; facilities staff key tracking does not include complete and accurate accounting of keys; OSH has a process to monitor safety risks and noncompliance with policies but management hasn’t followed the process.

The audit finally reported that OSH management has not created a culture of reporting issues when they’re made aware, including professional boundaries or encouraging employees to speak up, per staff surveys.

Final findings

According to the audit, OSH staff turnover rates were high in the three years the audit committee reviewed data from September 2021 to September 2024.

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54% was the highest turnover of all active contracts from September 2023 through August 2024.

Roughly 95% of the state workforce at OSH, which is staff volunteered, worked overtime. In 2024, OSH dished out over 27,000 hours of overtime.

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The audit found the overall working environment and culture do not prioritize a safe workplace, noting management’s lack of clear expectations for safety and security processes.

Staff reported having mixed emotions about safety while at work.

KSHB 41 reached out to the Kansas Department for Aging and Disability Services (KDADS) for comment on the audit. Department spokesperson Cara Sloan issued this statement:

“The Kansas Department for Aging and Disability Services (KDADS) takes the safety and well-being of all its staff and residents seriously. We recognize the trust placed in us to care for some of Kansas’ most vulnerable individuals. That is why the agency promptly reviewed concerns and took steps to address the findings outlined in the Legislative Post Audit’s report regarding Osawatomie State Hospital (OSH).

“The report acknowledged the unique challenges and safety risks associated with operating a psychiatric hospital. Even with those realities, our actions reflect our unwavering dedication to improving conditions at OSH while fostering a culture of transparency, accountability, and continuous improvement. KDADS is committed to working collaboratively with state leaders, community stakeholders, and hospital staff to ensure we meet the highest standards of care and safety.

“We will continue to work with our staff and partners to address challenges head-on to build a stronger, safer environment for everyone at Osawatomie State Hospital.”

To read the full audit, click here.

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KSHB 41 reporter Ryan Gamboa covers Miami County in Kansas and Cass County in Missouri. Share your story idea with Ryan.