Alaska State Ombudsman Kate Burkhart has concluded an investigation of three allegations related to patient safety and use of seclusion and restraint at Alaska Psychiatric Institute (API). The Ombudsman made eleven recommendations to the Department of Health and Social Services (DHSS) and API to address the problems investigated.
Between January 1, 2015 and December 31, 2018, the Ombudsman received 42 complaints specifically about API. Nearly one-third of those complaints alleged maltreatment or neglect of patients. In December 2017, the Ombudsman received a complaint that a member of API staff had assaulted a patient. On June 20, 2018, the Ombudsman received a series of allegations about the way API staff were treating patients.
The Ombudsman initiated an investigation upon her own motion under AS 24.55.120 on June 20, 2018. The Ombudsman investigated three allegations:
- API does not take reasonable and necessary action to prevent and/or mitigate the risk of harm to patients from use of force by API staff.
- API does not take reasonable and necessary action to prevent and/or mitigate the risk of harm to patients due to violence by other patients.
- API does not consistently comply with AS 47.30.825(d) or 42 CFR §482.13(e) in the use of seclusion and restraint.
Based on a preponderance of the evidence collected in the course of the investigation, along with the surveys by the Centers for Medicare and Medicaid Services and the workplace safety investigation by attorney Bill Evans, the Ombudsman found all three allegations are justified. The Ombudsman made recommendations for improvements in API operations to prevent violence toward patients and reduce the use of seclusion and restraint.
Read the executive summary of the report here.
Read the full public report of the investigation, findings, and recommendations here.