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State hospital failed to prevent serious falls and deaths of COVID patients, inspection finds

A sign pointing to the entrances of the Montana State Hospital in Warm Springs, MT.
Courtesy Montana State Hospital
/
Montana State Hospital
A sign pointing to the entrances of the Montana State Hospital in Warm Springs, MT.

Federal inspectors found that the Montana State Hospital failed to prevent serious falls and didn’t implement COVID-19 mitigation strategies. Three COVID-19 patient infections resulted in death. The hospital has until March 13 to correct the issues or it could lose federal Medicare funding.

According to an inspection report obtained by MTPR, inspectors with the federal Centers for Medicare and Medicaid Services earlier this month found that one patient at the Montana State Hospital fell 13 times in little over a month. One fall led to a serious brain injury, and the patient died in the hospital three days later.

Inspectors also found that the hospital failed to implement precautions to prevent the spread of COVID-19. According to the CMS report, nearly 90 patients became ill, and three of those infections resulted in death.

The hospital was placed on “immediate jeopardy.” As a result, CMS sent a letter to state hospital administrators Friday saying they had 23 days to correct the issues or the hospital could lose Medicare funding.

Chairman of the Interim Children, Families, Health and Human Services Committee, Bozeman Democrat Ed Stafman, says the issues in the CMS report are a result of chronic staffing issues. He adds that the committee is considering holding a special to discuss the report’s findings.

During the committee’s last meeting in January, Montana Department of Public Health and Humans Services Director Adam Meier told lawmakers that the agency planned to hire a third-party consultant to assess the staffing and cultural issues at the state hospital. Some hospital workers at that same meeting said the current hospital administration has fostered a hostile work environment.

Democrat Mark Sweeney, whose district includes the state hospital in Warm Springs, says he’s heard from several workers about the current hospital administration.

“First and foremost, I think they need to install, even if it’s in a temporary basis, new management. That would be the first step,” Sweeney says.

DPHHS spokesperson Jon Ebelt said the state is working on a plan of correction, which is required to remove the immediate jeopardy status CMS placed on the Montana State Hospital. Ebelt said that the plan, the original CMS inspector report, and the state’s response be made public, but no timeline was provided.

Updated: February 24, 2022 at 7:26 AM MST
This story has been updated with a statement from DPHHS.
Aaron graduated from the University of Minnesota School of Journalism in 2015 after interning at Minnesota Public Radio. He landed his first reporting gig in Wrangell, Alaska where he enjoyed the remote Alaskan lifestyle and eventually moved back to the road system as the KBBI News Director in Homer, Alaska. He joined the MTPR team in 2019. Aaron now reports on all things in northwest Montana and statewide health care.
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