Montana psych hospital failed to properly investigate death

HELENA, Mont. (AP) — Employees at Montana's state psychiatric hospital failed to properly investigate the death of a patient who was reportedly told to go back to her room "and stop being dramatic," after she told staff she was having trouble catching her breath, a federal report said.

Investigators with the Centers for Medicare and Medicaid Services also found the Montana State Hospital in Warm Springs has inadequate staffing, resulting in a lack of patient supervision that led to 113 reported falls on one unit of the hospital from June 2021 through mid-September 2021.

Five deaths were reported in the Spratt Unit of the hospital in August, including the patient who died of "acute cardiovascular collapse" early on Aug. 14. An autopsy was not performed, the report stated.

A complaint about her death led to the CMS investigation, the Montana State News Bureau reported.

"Patients are dying from lack of care," an unidentified employee told investigators in late September.

The employee who investigated the patient's death asked staff who worked that night for written statements, but did not interview them about the woman's medical complaint, which was not logged in her chart, the report noted.

The in-house investigator said she reviewed video footage, but did not retain her notes about what she observed, and the video was not available for investigators to review because it had been accidentally recorded over, the report said.

Another staffer said she did not investigate why 30-minute checks that are required under hospital policy were not performed. The woman was found dead in her bed 45 minutes after being sent back to her room, the report said.

The facility "failed to thoroughly investigate the unexpected death to show that neglect did not occur," said the report, which will be discussed by members of the legislature's Children, Families, Health and Human Services Interim Committee on Jan. 21.

The report, posted online with other materials for the interim committee meeting, did not include the state hospital's plan to correct the deficiencies. Health department spokesperson Jon Ebelt did not respond to an email asking if the agency had made a response yet.

Inadequate staffing also led to reports of delayed hygienic care, inadequate documentation of medical and other issues, and failure to implement care plans, the CMS said in its report.

One patient was put back into bed after he fell in early August, suffering a fractured hip that was not diagnosed for five hours, the report said. The employees who put him back in bed waited nearly four hours before telling a nurse he had fallen and there was no documentation that the patient was given proper care after the fall, including a neurological check, the report said.

The unit was short a registered nurse and three direct care staff that night, the report said.

The Spratt Unit of the Montana State Hospital provides psychiatric and other medical care to elderly patients with dementia or severe mental illness. Its recommended staffing level is three nurses and nine direct care staff on daytime and evening shifts, with two nurses and nine direct care staff at night.

Investigators looked at staffing for shifts on the Spratt Unit for several days in August and September and at no time did it have more than five direct care staff working while the unit had between 25 and 33 patients. Typically, three patients needed one-to-one supervision, leaving just one or two direct care staff to help care for remaining patients.

The Montana State Hospital — located in a town of about 600 people about 23 miles (37 kilometers) northwest of Butte — is currently looking to hire three psychiatrists, 38 registered nurses, five nurse managers, and 91 psychiatric technicians, which are the direct care providers.

In November, the Department of Public Health and Human Services sought bids from a third party to fill a temporary management role at the state's medical facilities, including the Montana State Hospital, and to help stabilize the workforce and establish operation plans for the facilities. The deadline to submit bids has been extended to Jan. 26, Ebelt said Tuesday.