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Inspectors investigate patient death, staffing issues at Montana State Hospital

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An employee at the Montana State Hospital told investigators “care is not getting done and patients are dying from a lack of care" following an unannounced late September inspection of the facility after a complaint made by someone employed there.

The survey, completed Sept. 30, was done by inspectors for the Centers for Medicare and Medicaid Services after a complaint made by an employee at the state hospital in Warm Springs, the only public psychiatric hospital in the state. The report details findings of dramatically insufficient staffing — in one case an employee said she thought a patient's death could have been prevented if not for being short-staffed.

Inspectors wrote that based on interviews and records, the hospital failed to thoroughly investigate the death to show that neglect did not play a role.

Also detailed are falls by patients who the report found did not have proper care or supervision. Inspectors interviewed employees and reviewed scheduling records that showed at one point a lack of workers left one direct care staff member responsible for 28 patients. 

A story in early December from the Montana State News Bureau revealed that 40% of positions at the hospital were vacant. Numbers provided by the state health department show a massive increase in its reliance on traveling staff over the last two years alone: 22 traveling staff worked at the facility in 2019 compared with 136 in 2021.

Montana State Hospital

One of the older buildings on the campus of the Montana State Hospital at Warm Springs.

In that story, state health department spokesperson Jon Ebelt said during the COVID-19 pandemic, “MSH began to experience an increase in the number of staff openings due to a variety of factors, such as the need for child care, personal medical reasons and increased competition in the labor market for the same or similar positions.”

That story said the state hospital did undergo a CMS inspection in September triggered by a complaint, but Ebelt said the review found the hospital in compliance with no need for corrective action. Ebelt did not provide the complaint or subsequent inspection report when requested then. The Montana State News Bureau asked about the Sept. 30 survey in a Monday email to the state health department but did not receive clarification before press time.

A copy of the Sept. 30 survey was posted to the website for an interim legislative committee set to discuss the topic later this month.

On Nov. 29, the state health department, which operates the hospital, put out a request for proposal seeking a third party to fill a “temporary management” role at the state’s medical facilities, including the hospital, and to help stabilize the workforce.

In the December story, department Director Adam Meier issued a statement:

“I applaud the commitment and dedication our facility staff bring to their jobs on a daily basis, and we must do all we can to support them and the hundreds of Montanans these facilities serve. I am fully aware of the concerns that have been raised and the challenges that we face. That is why we issued the (request for proposal) to take a comprehensive and thorough review of the operational structure of all facilities DPHHS oversees. This review will help us make informed and thoughtful decisions going forward. The department is eager to move forward with this project and implement recommendations as appropriate.”

Patient death

The survey found the hospital failed to thoroughly investigate an unexpected patient death and was unable to show the death was not caused by neglect.

On Aug. 13, 2021, the patient on the Spratt Unit, the hospital's geriatric wing, told nursing staff she was unable to catch her breath, according to the survey.

“The nursing staff were alleged to have told (the patient) to ‘return to your room and stop being dramatic,’’' according to the survey. The patient was reportedly found in her room dead 45 minutes later.

In an interview Sept. 27, a staff member who worked with the patient the day before she died told inspectors she thought her death could have been prevented, according to the survey.

Montana State Hospital

The entrance for visitors in one of the buildings located on the campus of the Montana State Hospital at Warm Springs.

“We were very short staffed that day,” the staff member said.

The inspectors reviewed a document produced by the hospital titled “Abuse Investigation - Final Summary,” dated Aug. 26. That document said the patient was found unresponsive in her room at 1:15 a.m. on Aug. 14. CPR was performed but was not successful.

Video footage reviewed by staff showed the patient went into her room at 10:22 p.m. Staff did checks at 11 p.m., 11:40 p.m. and then at 1:15 a.m. when the patient was found unresponsive. The patient was supposed to be checked on every 30 minutes, but three of those checks were not completed and it was not clear why that didn't happen.

At one point the patient’s roommate said the patient got out of her bed, walked to the window and stated she “couldn’t breath(e),” according to the survey.

Inspectors spoke with one staffer who said said she “peeked in” on the patient that night and reported the patient seemed OK, but said “I was not paying that much attention.”

Another staffer interviewed by inspectors said she hadn’t investigated why the patient didn’t have 30-minute checks the night she died, but said the high number of patients in the hospital that night made it difficult for employees.

That worker told inspectors there were four patients who required 1-on-1 care, meaning there was just one staff member left to do patient checks and one staff member to do patient care.

In another interview, a different staff member said the patient who died “did complain a lot,” inspectors wrote, “and she could see where nurses might not take her seriously.”

When inspectors interviewed the staff member assigned as the in-house investigator after the death, that staffer said she’d reviewed the video footage and had the staff on duty that night and early morning write statements regarding the events leading up to the patient’s death.

The in-house investigator didn't interview staff specifically about the complaint saying the patient couldn't breathe and was told to go to bed. And the video from that night and early morning was no longer available for inspectors to watch because it was accidentally recorded over; the in-house investigator said she didn’t keep her handwritten notes about the video footage.

Another staffer told investigators that at some point on the night the patient died, that staffer gave the patient a laxative after she reported constipation. When the patient later said she had a headache, the staffer told the patient to go back to bed and said she “tucked her in.” The staff member said if she had to make a “wild guess,” that happened around 9 p.m.

When inspectors reviewed the patient’s medical records, they found there was no nursing progress note or assessment of the patient’s health concerns made the night she died. The patient's last nursing progress note was dated nine weeks earlier on July 24.

A “Death Review” report generated by the hospital listed the cause of death as acute cardiovascular collapse. There wasn’t an autopsy.

Lack of staffing

In an interview Sept. 28, a staff member told inspectors the facility had been struggling with staffing for the last few months and had been taking steps to get the resources they needed.

Montana State Hospital

The entrance to the campus of the Montana State Hospital at Warm Springs.

“Beyond that, he stated, we have done the best we could,” the inspectors wrote.

Inspectors found the hospital’s staff had discussed the need for 1-on-1 supervision for some patients, and noted while it affected how many staff were available for other jobs, it was necessary for those who continued to fall despite other intervention efforts.

When inspectors reviewed a log of falls at the hospital, they found 113 reported from June through Sept. 16 for the Spratt Unit.

A review of minutes from a meeting Nov. 14 found “possible contributors to the 29 falls in August could be new staff on the unit, and the high acuity on the Spratt Unit," the survey said.

One hospital employee said the staffing department sent out a daily assignment sheet the employee told investigators misrepresented the staffing situations.

“It is not accurate — they do not take into account our 1:1s and those patients are no longer listed on the schedule. It makes the schedule look pretty,” the employee said.

In yet another interview, a different employee said that low staffing levels meant “the nursing chart notes have fallen off, and we are not able to assess patients in a nursing note. I do not feel patients and staff are safe.”

The staff member who told investigators that patients were dying from a lack of care also said the Spratt Unit had five deaths in August. The staffer said he emailed the director of nursing about the situation with 1-on-1 care “but we still do not get help.”

“The staff here also have to set up for meals and clean up after meals. Six patients need assist with meals, when the census is 40, patients go unchanged - pee and poop,” the staffer told inspectors.

Another staffer reported the situation “can be scary.”

“We have four treatment-resistant patients and they know when we are short staffed, and there is no one to help if those patients get combative,” the staffer said.

In one case, inspectors found a day when only one nurse was scheduled for a day shift in a wing of the hospital; that staffer reported that there was not a registered nurse that day.

Patients suffer from falls

The 19-page survey noted several patients who fell repeatedly, often when they were not supervised.

"The facility failed to ensure adequate numbers of nursing staff were available on the Spratt Unit to provide care, supervision and one-to-one supervision for patients, resulting in multiple falls and falls with injury," the report reads.

In one case, an email dated Aug. 3 sent at 2:10 a.m. found one patient on the Spratt Unit was found on the floor with his pants around his knees. Two certified nursing assistants picked him up, changed his clothes and put him back to bed. A staff nurse was not told about the fall until 5:56 a.m. A staffer who checked on the patient at 7:14 a.m. found that one of the patient’s hips looked twice the size of the other, according to the survey.

That patient was supposed to have checks every 15 minutes, but there was not documentation to show the hospital was doing that. A review of the patient's records showed he had a history of falls and was currently at risk for falls.

After a medical consultation that morning, the patient was transferred to the hospital with a left hip fracture.

“There was no documentation that proper care was given to the patient after the fall,” the survey states.

A review of the staffing schedule showed the unit was short one registered nurse and three psych techs or certified nursing assistants the morning of the fall.

When inspectors interviewed one staffer, they learned at one point the Spratt Unit had one nurse and three direct care staff for 30 patients. Two of those patients required 1-on-1 staffing, which left one direct care staff for the other 28 patients. In another example provided to inspectors, a staffer said they’d heard certified nurses aides report they had to operate a Hoyer lift used to move patients, which requires two people to run, by themselves.

Random reviews of daily staffing assignments for August found those kind of staffing levels happened frequently.

The survey did not include responses from the state Department of Public Health and Human Services saying how they planned to address the findings. 

The Legislature's interim Children, Families, Heath and Human Services Committee is set to meet Jan. 20-21.

— Reporter Seaborn Larson contributed to this story.


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State reporter

State Bureau reporter for Lee Newspapers of Montana.

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