Safety Checkup: State Hospital still needs work

Posted at 3:23 PM, Mar 02, 2016
and last updated 2016-03-02 20:53:11-05

The Arizona State Hospital is still failing to identify the root causes of many serious incidents involving lapses in patient safety and analyze whether those incidents could have been prevented, according to new documents obtained by ABC15.

The hospital has conducted a series of unofficial self-inspections called “technical assistance visits” since an ABC15 investigation exposed widespread problems at the state-run psychiatric facility.

The station’s reports also triggered a series of federal inspections, which forced the hospital to correct several major deficiencies or it would lose certification. One of the necessary corrections involved making sure the hospital properly reviewed and analyzed critical incidents.  

However, during a technical assistance report last month, officials noted a recent suicide highlighted the issue hasn’t been fixed.

“Patient verbalized falling in the (bathroom) after attempting to hang herself with a piece of a t-shirt,” according to the report. “The supervisor’s evaluation was that the patient was placed on close observation line of site as a nursing order. There is no documented evidence in the record of close observation/line of site. There is no documentation that a physician was notified and addressed the concern.”

So far, the hospital has conducted three of the technical assistance visits. Documents related to the visits were obtained by ABC15 through a public records request.  Read them below.

ASH Technical Assistance Visits by Dave Biscobing

The documents note improvement in some areas of the hospital. But they also identified other continued areas of concern, including inconsistent and incomplete documentation, gaps in patient observation, and issues with restraints and seclusion.

In response, health department Dr. Cara Christ also released the following statement:

“In order to ensure we provide a healthy environment for our patients and staff and remain in compliance with regulatory requirements, we are using unannounced technical assistance visits completed by our Division of Public Health Licensing Services team to identify areas where we can improve upon our current success. Under Dr. Bowen’s leadership, these visits have shown that the Arizona State Hospital has maintained substantial compliance and the results are used to proactively identify areas for further improvement, in order to meet our goal of exceeding our regulatory standards. We have seen incredible improvement at the state hospital over the past year and maintaining a safe and therapeutic environment for our patients and staff remains one of our top priorities.”

ABC15 also requested recent hospital worker compensation claims. The claims provide a look at what’s happening inside the hospital and how well, or poorly, staff members are managing and preventing incidents with patients.

However, the state health department denied the request even though it has released years of the claims to the station in the past. After a reporter highlighted the discrepancy, a health department spokesperson said the records would need to be requested from the Arizona Department of Administration.

In 2014, ABC15 successfully sued the health departmentto release hospital records. The lawsuit was filed against the health department's previous administration.

Contact ABC15 Investigator Dave Biscobing at