Arizona state mental hospital puts patients in danger according to federal inspectors

PHOENIX - Arizona’s state mental hospital puts patients in danger, has a dangerous shortage of staffing and lacks oversight, according to a recent federal inspection.

The Arizona State Hospital received the blistering report last month after inspectors with the Centers for Medicare and Medicaid Services, or CMS, visited the hospital in September.

Officials said the federal inspection was triggered by an ABC15 report on a patient’s death.         

During the visit, the CMS inspectors discovered “serious deficiencies” and are threatening to pull certification and millions in federal funding from the state hospital. They found the hospital does not have the "capacity to render adequate care" and the deficiencies discovered "adversely impact patient health and safety."

Officials with the Arizona Department of Health Services, which oversees the state hospital, have either ignored or declined repeated requests for an interview. State officials also did not respond to a public records request last week for the inspection report and the state’s response.

However, the ABC15 Investigators obtained the 46-page report from federal officials.

“Endangering” Patients’ Lives

In the inspection report, he’s listed as “patient #2.”

His real name is Christopher Paul Blackwell. He died just two weeks before his 24 th birthday.

“His voice is gone. He’s gone. And now, all I have left is a big old hole,” said Blackwell’s mother, Donna Baird.

Blackwell was a “1-to-1” patient at the Arizona State Hospital. That means he was supposed to be watched by one staff member around the clock to prevent him from swallowing dangerous objects. But Blackwell swallowed something dangerous at least five times in the past year, his autopsy shows.

The last time was on September 6.

Blackwell was taken from the state hospital to the emergency room at the Maricopa Medical Center. A CT scan showed that he had swallowed pieces of a broken CD.

According to federal inspectors, hospital “rules and regulations” dictate patients must be examined by a physician after returning from an outside facility. But a doctor at the state hospital admitted that Blackwell’s medical condition was never examined in the days after he returned.

On September 9, Blackwell collapsed. He died hours later. His autopsy would show he died from a “severe stomach infection.”

Federal inspectors wrote that the state hospital “failed to provide quality care” for Blackwell.  They also discovered that the hospital didn’t have any policies about when or how often patients should be re-examined.

Inspectors also found Blackwell wasn’t the only patient who didn’t receive proper monitoring, treatment and care.

In the past several months, inspectors discovered the state hospital failed to properly care for five other patients, who all required constant supervision.

For example, on July 13, a “1-to-1” patient was able to remove his protective helmet and bang his head repeatedly on the corner of a paper towel dispenser without anyone watching.

On the same day, a “suicidal” woman, who also required constant supervision, was able to take a sharp object, hide under a blanket and deeply cut herself, leaving a pool of blood. She also cut herself without supervision again two weeks later, records show.

Staffing Shortages

Federal inspectors also wrote that the hospital has “systemic problems” with nursing care. They found many times when the hospital failed to meet required levels of staffing.

It’s a problem the ABC15 Investigators first exposed in February.

“There are many, many days I will be on the floor alone, other staff will be on the floor alone,” said one insider, who asked to remain anonymous for fear of retaliation. Each hospital floor can have dozens of patients.

Insiders have also told ABC15 that due to low staffing levels patients have acted as security when other patients act out.

The report highlights several examples when staffing shortages led to patients hurting themselves or others. Inspectors found there was a “failure to ensure that the number of RN’s and other personnel met the facility’s pre-determined staffing requirements to provide for patients’ safety and care needs for 9 of 9 patients who sustained self-inflicted injury, assaulted others, or were assaulted by other patients.”

The hospital also failed to ensure that several patients like Blackwell  received the constant care and supervision they required and was prescribed by doctors, records show.

Lack of Oversight

In May, the state hospital hired temporary workers to fill in gaps left by staffing shortages.

But that’s where federal inspectors found another deficiency.

The temps were assigned to work with some of the most dangerous and need patients. But hospital officials assigned them without knowing if they were qualified or competent, records show.

Inspectors also wrote “the hospital was unable to provide any documented evidence of the supervision and evaluation” of the contracted employees.

 In four cases, inspectors found that temporary workers failed to properly monitor high-risk patients who then hurt themselves or others.

The hospital’s administrators were also criticized for not keeping adequate budget documents.

Millions of Dollars at Risk

If CMS pulls the Arizona State Hospital’s certification, the state will lose millions in federal Medicare reimbursements. The total is estimated to be more than $6 million a year. That money would have to be backfilled by state taxpayers.

The state has responded to the inspection and filed a plan of correction. According to their plan, several policies have changed or been created. The hospital is also hosting a job fair on Thursday.

State health director Will Humble has declined repeated requests for an interview. But a spokesperson sent ABC15 a statement:

“It’s common for hospital surveys to find areas that need improvement.  Immediately after the CMS visit, we initiated changes to address all issues that were raised and they’ve all been corrected.  CMS is reviewing our actions and we look forward to a positive report.”

CMS will be the final say to determine if the deficiencies have been fixed. If CMS decides the issues have been corrected, the hospital will not lose certification or funds. So far, a federal spokesperson said they are still reviewing the hospital’s response.

The state is also subject to a surprise follow-up inspection.

Contact ABC15 Investigative Reporter Dave Biscobing at and Investigative Producer Mark LaMet at

Print this article Back to Top