HELENA – Montana’s state psychiatric hospital has until March 13 to correct serious deficiencies in patient safety that likely contributed to the deaths of four patients, or face the loss of federal funding, the Centers for Medicare and Medicaid Services said.
One patient died after repeated falls at the Montana State Hospital in Warm Springs while failure to contain a COVID-19 outbreak led to 87 patients contracting the respiratory virus. COVID-19 contributed to the deaths of three patients, CMS said after its Feb. 8-10 on-site visit.
In a Feb. 18 letter, CMS wrote that deficiencies in patient care constitute an immediate and serious threat to the health and safety of patients at the hospital, the Montana State News Bureau reported.
The state hospital, which treats adults with serious mental illness, is working on its plan to correct the shortfalls. The plan will be publicly available after the Centers for Medicare and Medicaid Services approves it, health department spokesperson Jon Ebelt said Thursday.
The CMS report first addresses the case of a 74-year-old dementia patient who fell 13 times in less than two months before hitting her head in a fall at 3:40 p.m. on Jan. 27. She told a staffer her head hurt at 5:30 p.m. and then “quickly became unresponsive,” the report said.
Staff were unable to get in touch with a doctor or other supervisor until 6:15 p.m. when the doctor called the hospital in nearby Anaconda and emergency responders were dispatched. The patient left the state hospital about three hours after she fell. She died three days later.
Patient records showed the one-to-one staffing that was initially ordered as part of her treatment plan was removed, that her care plan did not include interventions to prevent falls and that a recommendation she be provided with eyeglasses was not followed. Staff had sometimes decreased her assessed risk of falling right after she fell, CMS said in its report.
The report also recounts an outbreak of COVID-19 that started with a staff member on Dec. 28. The first patient tested positive on Jan. 4.
From Jan. 4 trough Feb. 8, the outbreak affected 87 of 107 patients and 95 staff, including staff members who were interviewed by CMS inspectors shortly before being diagnosed, the report said.
The hospital did not follow Centers for Disease Control and Prevention infection prevention requirements by failing to isolate patients with COVID-19 from those who did not have the respiratory virus, and by allowing staff to work with both COVID-19 positive and patients who were not sick — sometimes on the same shift. Staff were not always wearing adequate Personal Protective Equipment to prevent transmission of the coronavirus, CMS investigators said.
“The cumulative effects of these deficient practices placed patients at risk of serious injury and/or death,” the CMS report stated.
An 80-year-old dementia patient who tested positive for COVID-19 on Jan. 13 died on Feb. 4, while a 75-year-old patient who tested positive on Jan. 14 died on Jan. 26. COVID-19 contributed to the deaths of both patients, the report said.
One of the COVID-19 deaths, involving a 70-year-old woman, happened in October 2021, prior to the larger outbreak.
The hospital does not have an approved policy for preventing the spread of COVID-19, staff told CMS investigators.
The nurse manager on the Spratt Unit, which primarily cares for dementia patients, said on Feb. 8 that all but one patient had tested positive for COVID-19 over the previous month, the report said. Patients with and without COVID-19 were being treated on the unit, the nurse manager said.
The February CMS visit followed one in September that concluded hospital staff failed to properly investigate the August 2021 death of another 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.
The September report also found the hospital was inadequately staffed, resulting in 113 reported falls on one unit of the hospital from June 2021 through mid-September 2021.
The Montana State Hospital is in Warm Springs, a town of about 600 people about 23 miles (37 kilometers) northwest of Butte.
The state Department of Public Health and Human Services is looking for a contractor to temporarily manage all of the state’s health care facilities, with a focus on the state hospital, to address the shortfalls. The $2.2 million contract is expected to be awarded in March, Ebelt said.