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Entrance sign at Montana State Hospital at Warm Springs

Deficiencies were found in the care of geriatric patients at the Montana State Hospital, according to survey conducted in December by the Montana Department of Public Health and Human Services for the federal Centers for Medicare and Medicaid Services. 

Deficiencies in the treatment of geriatric patients were uncovered at the Montana State Hospital in Warm Springs late last year during a survey conducted by the Montana Department of Public Health and Human Services for the federal Centers for Medicare and Medicaid Services.

According to the survey, some patients’ rights “to receive care in a safe setting" and “to be free from all forms of abuse or harassment” were not met. The survey also found that standards for staffing and delivery of care were inadequate in some cases, that failure to meet standards for sanitary practices put patients at risk of infection and that hospital policy granting patients the right “to have staff assist you as needed” was not followed.

While surveyors did not require administrators to complete a formal plan of correction to address the issues, DPHHS officials say the department has already taken the necessary steps to correct the deficiencies and will work to prevent them from recurring.

But Bernadette Franks-Ongoy, executive of Disability Rights Montana, which filed the complaint that led to the survey, said investigators’ findings point to a “pretty severe set of issues” with how patients at the state hospital are cared for.

“They should be providing for the health and safety and minimum medical requirements for people in their care. This is a hospital,” said Becky Fleming-Siebenaler, an advocacy specialist at DRM, which provides federally mandated civil rights protection and advocacy for Montanans with disabilities. “They (patients) are there to be cared for. Then care for them appropriately and within the standards that are set.”

Surveyors sampled nine patients housed in the state hospital’s Spratt Unit, where primarily older men and women with long-term psychiatric disabilities and significant medical concerns are treated, and found various issues with their care.

One patient described staff’s treatment as “degrading” and resulted in her “crying” and “feeling hopeless” after she was reportedly was not provided with a catheter and physical therapy that had been ordered, and after her incontinence was discussed out loud, in front of other patients and staff. The same patient reported her foot “feels like it’s going to fall off” after she was not given range of motion exercises and that she was left in a soaked diaper, despite never having to wear one before. She also said she was not taken to use the bathroom at regular intervals.

Another patient was given only one bath during one 10-day period in October, no baths during a six-day period soon later the same month, and only five baths during all of November, according to facility records.

Another patient was not given a shave he requested ahead of a Christmas dinner.

When another patient’s ill-fitting shoes appeared to exacerbate an ulcer on his heel, he was given another pair of shoes that also didn’t fit and also appeared to hurt his ulcer.

Staff also reportedly cleansed stool from a female patient, rolled her over, touched her “clean gown,” “moved her bangs back from her face,” touched her oxygen tubing, left the patient’s room and helped transfer the patient to her wheelchair — all “with the contaminated gloves on.”  

Hospital employees interviewed as part of the report suggested to investigators that the deficiencies with patient care stemmed from problems with turnover and understaffing.

One staff member is quoted as saying, “(W)e have forty patients here and we have two RNs (registered nurses) to do treatments and take ... physician’s orders. They (RNs) rely on the psych tech to do their jobs.”

Another staff member connected recent turnover to the deficiencies, reportedly telling surveyors, “(T)his week there were people working that I hadn’t met before. Yesterday, the afternoon staff was almost all new.” According to the survey, the same staffer “stated that the nurses get pulled to other units. He stated the nurses are here from 7 a.m. to 7 p.m. He stated patients don’t always get toiled every two hours because some staff ‘don’t want to deal with it.’ He stated, ‘the last three days we have had more than enough people to do the job and no one is enforcing it.’”

The staff member who failed to remove the contaminated gloves reportedly said “they do not have sanitizer or gloves in the rooms.”

While surveyors sometimes require administrators to issue plans of correction detailing how they will fix problems identified in an investigation, the problems identified at the state hospital did not rise to that level.

“Like other healthcare facilities, the Montana State Hospital receives oversight from state and federal surveyors on an ongoing basis,” DPHHS Director Sheila Hogan said in an emailed statement. “This oversight and feedback are important because it helps to ensure we remain in compliance with all the various required state and federal regulations. As a result of the most recent survey, it was determined by the surveyors that a Plan of Correction was not required. Regardless, at the time of the survey, we were already aware of most of the issues identified, and have now taken steps to correct them.”

The December survey was conducted in response to a complaint DRM filed in November.

That complaint was motivated by a report the group received from a travel nurse who worked in the facility and reported to DRM “instances of inappropriate and abusive behavior of staff along with improper care of patients,” according to DRM’s complaint letter to DPHHS. According to the travel nurse’s report, staffers wheeled one patient “so abruptly that his neck snapped back and forth,” “shoved” and “took a swing” at an “elderly and frail” patient and scrubbed a patient “vigorously” despite being told “it hurts. The nurses also reported other issues to DRM, including “a significant amount of yelling” and the staff’s failure to share information with caregivers.

When Fleming-Siebenaler visited the facility on two occasions later in November, she “observed instances of staff yelling at patients, patients yelling for assistance without staff responding timely, and patients not engaged in any productive activities,” according to her complaint letter.

Despite such issues, Franks-Ongoy said, “I want to be clear, though, that some people who have gone there have gotten good treatment.”

But, she added, the problems indicate the state should do more to treat patients in Warm Springs.

“When the state takes on the role of providing care and treatment for people who need the care and treatment in this psychiatric facility, they need to be able to do it well,” Franks-Ongoy said. “And if they’re not going to do it well, they should be held accountable for not doing it well. And I think it’s really important that the policymakers that are funding the facility have a clear understanding of what’s really happening in that facility.”

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