An in-patient psychiatric hospital in Colorado Springs failed to provide a hazard-free workplace and destroyed video evidence attesting to employees’ claims of repeated violence within the facility, a federal investigation has found.

Cedar Springs Hospital and its parent company in Pennsylvania have been ordered by a federal administrative judge to pay the maximum fine allowed statutorily for “serious” violation of the Occupational Safety and Health Act of 1970.

The 110-bed treatment center for mentally ill children, teens and adults inadequately protected employees from “recognized hazards that are causing or are likely to cause death or serious physical harm,” according to a final report issued last month and obtained by The Gazette.

Employees reported suffering “serious injuries from workplace violence, including concussions, sprains, bruising and other injuries to the head and torso.”

The investigation by the U.S. Department of Labor’s Occupational Safety and Health Administration also found that the hospital destroyed relevant video evidence in “blatantly irresponsible behavior” and “failed to provide the worksite’s injury and illness records to an authorized representative within a reasonable time from the request.”

As a result, the Occupational Safety and Health Commission levied sanctions and another financial penalty, for a total of $15,000 in fines.

The nearly four-year case began in 2019. In June 2020, the hospital system contested the findings, alleging misconduct on the part of OSHA and challenging the commission’s scope of authority.

Those objections were rejected, with the report concluding, “Misconduct claims do not withstand scrutiny and are dismissed with prejudice. There was ample evidence to support the citations.”

Cedar Springs Hospital plans to appeal the OSHA ruling, Christina Reynoso, director of business development, said Tuesday.

Cedar Springs operates as a subsidiary of Psychiatric Solutions Hospital, which is a subsidiary of Universal Health Services Inc. The latter is a publicly traded company that includes the subsidiary, UHS of Delaware, in Pennsylvania, which provides management services to Cedar Springs and other behavioral health hospitals in the nation.

UHS-DE was named in the complaint from Colorado Springs and has lost other judgments before the commission, including workplace-violence cases against Suncoast Behavioral Health Center, a psychiatric facility in Bradenton, Fla., and at Fuller Hospital in Attleboro, Mass. The company recently was cited for labor violations at Centennial Hills Hospital Medical Center in Las Vegas, Nev.

Former Cedar Springs employee Luke Peil of Colorado Springs was among several workers included in the complaint, which came about after a whistleblower reported to OSHA repeated incidents of violence within the facility.

“It was not unusual for workers to be struck by patients. Workers were punched, bitten, kicked, scratched and had hair pulled. Such assaults frequently occurred, with many injuries resulting from the violence,” the commission’s report states. Some episodes resulted in head and eye injuries, and “a high number of injuries serious enough to require lengthy days away from work and restricted duty.”

While the nearly 160-page report acknowledges that “There is no existing … OSHA standard for preventing workplace violence in health care,” it states that workplace violence hazards can be sufficiently mitigated.

However, mitigation at Cedar Springs during the inspection that began in November 2019 and continued into 2020 was “inadequate and failed to reduce the hazard to the extent feasible,” the report said.

Cedar Springs’ OSHA logs showed that workplace violence accounted for 73% of recorded injuries.

Peil said while he worked at Cedar Springs as a mental health technician from 2018 to 2021, he witnessed patients physically attacking other patients and staff in the eight-unit facility.

“So, I was consistently called in on codes,” he said. “We had to almost always physically deescalate the situation at that point.”

Orderlies such as Peil also served as security detail, he said, as there were no official security officers.

It was not unusual for patients to find ways to enter nurses’ stations, where they jumped on desks, bit, hit and kicked staff, and stole office supplies, the report states.

Employees mentioned understaffing as a continuing problem.

“There were times when they’d have two techs and one nurse for 30 kids,” Peil said. “It’s impossible for two people to monitor all of those patients and keep them safe.”

Charge nurse Melissa Drawdy told investigators that having one nurse and one mental health specialist working on a unit with 12-14 patients was inadequate to maintain staff safety.

Administrators were aware of injuries occurring particularly when staff were alone with patients in care units, the report noted. The Colorado Department of Public Health and Environment found in 2018 that Cedar Springs workers were left alone and injuries were occurring often from a lack of employees.

In 2019, a supervisor instructed staff to call police when a patient, after attempting to “elope,” began “bashing a worker’s head onto the concrete outside of the care unit,” the report said.

OSHA investigators also found dangerous materials and contraband being brought into the facility, including a large butcher knife. The majority of patients arrive via ambulance and taken directly to a care unit, where there were no metal detectors at the start of the OSHA investigation.

The need to yell for help — because phones were only available at the nurses’ stations and two-way radio communication was limited — after verbal deescalation failed and physical restraint became necessary — were noted, as well.

Missing video would have backed either administrators’ claims that calling out for assistance was sufficient, with a typical response time of 42 seconds, or, as workers claimed, it would take “several minutes” to receive help on an incident that involved worker injuries.

Over four days during the investigation, a highly aggressive patient was restrained 14 times after choking an employee, punching another on the chest and body, forcing open a window, throwing hot chocolate at several staff, kicking a housekeeper, and punching and head-butting other workers.

Among the hospital’s policies, immediate notification of the administrator on call was required for patient injuries but not worker injuries, the report said. 

The citation recommends “feasible and effective” improvements to abate the hazardous conditions, including reconfiguring nurse stations to prevent patients from entering them; providing communication devices and silent alert signals for employees; better identifying and securing contraband; conducting debriefings after violent episodes; staffing for changes in acuity and caseload; and designating specific staff with specialized training as security guards.

Peil said he now suffers from post-traumatic stress disorder and anxieties he attributes to having worked at Cedar Springs.

In fact, he said the experience was so traumatic it drove him to another industry: information technology.

“The administration didn’t care about its employees or patients’ safety,” Peil said. “It seemed like they had a different priority than the people working there. Their priority seemed to be cutting corners and making money.

“I hope things are safer there now, because they weren’t willing to make changes on their own.”

The Cedar Springs Hospital in Colorado Springs includes eight units with 110 beds for children, teens and adults who seek treatment for mental illnesses.  

Courtesy photo