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Montana State Hospital: four deaths in five months

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Posted at 4:44 PM, Feb 25, 2022
and last updated 2022-02-25 18:51:39-05

The Montana State Hospital received an “Immediate Jeopardy” citation on Feb. 9, after a federal investigation found the hospital failed to follow federal guidelines, contributing to the death of four patients. Without corrective action, the hospital will lose its federal funding.

The Centers for Medicare & Medicaid Services report, completed in early February, said the hospital in Warm Springs failed to prevent falls and did not have an adequate COVID plan in place during an outbreak in the facility. The findings forced CMS to place the hospital on “Immediate Jeopardy” status on February 9.

The report was obtained and first reported by the Montana State News Bureau.

The four deaths outlined in the report happened between October 4, 2021, and February 4, 2022. Three of the deaths resulted from the hospital’s inability to control a COVID outbreak and the other from its failure to implement safety measures to prevent a patient from falling 13 times, with the last fall being fatal.

February’s investigation is the second federal investigation of the hospital in recent months. A September CMS investigation revealed that dangerously low staffing levels contributed to 113 patient falls between June and August 2021.

The Montana Department of Public Health & Human Services, which oversees the hospital, has put together a plan of correction to address the shortcomings identified in the CMS report, spokesperson Jon Ebelt said in an email. The plan is pending CMS approval. The department is also offering $2.2 million for a private contractor to review operations at the hospital and other state-run health facilities, despite pushback from lawmakers.

According to the Montana State News Bureau, the hospital has until March 13 to bring the hospital into compliance with federal guidelines. If it fails, CMS will end the hospital’s Medicare provider agreement.

During a February 9 interview, the facility’s infection prevention specialist told CMS investigators the hospital had neglected to put together a COVID prevention plan.

“Prior to August, the facility did not have an Infection Control plan, policies, or a strong infection prevention and control program. Currently, the facility does not have an Infection Control Plan, Risk Assessment or COVID-19 Pandemic Plan that has been approved or went through committee for approval, we only have rough drafts,” the specialist said.

According to the report, between January 4 and February 8, 87 of the hospital’s 107 patients at the time and 95 staff members tested positive for COVID. According to a February 22 census, the hospital is currently serving 238 patients.

Along with planning shortfalls, the report showed that hospital staff were simultaneously working in COVID and non-COVID units within the hospital, and that COVID-free patients were sometimes lodged with patients who had tested positive for the infection.

“We didn’t have the capability to stop admissions, and we had to continue to take COVID-19 positive patients. The Bravo Unit with eight beds is the designated COVID-19 (unit), however, we could not hold all of them on the Bravo Unit. We have not been able to keep dedicated staff on the nursing units where there are COVID-19 positive patients and staff are working on multiple units,” the hospital’s Director of Nurses told CMS on February 10.

In another interview on the same day, the hospital’s Chief Operating Officer said he was not aware that employees were working in positive and non-positive units simultaneously.

“There was no rationale for why all units had COVID-19 positive patients when the Bravo unit was the designated COVID-19 unit. There was no policy or procedures for new admissions and length of time or criteria for a transitional unit for patients to be monitored for COVID-19 and then transferred to the assigned unit,” the report said.

The report also outlined the hospital’s shortcomings in preventing falls.

A 73-year-old dementia patient, identified by the Montana State News Bureau as Kathy Toavs, fell 13 times in two months, with the last fall on January 27 causing subdural and other hematomas. According to the report, Toavs died on January 30.

The report says the hospital failed Toavs in not implementing safety measures to prevent frequent falls, not completing mandated post-fall assessments and stripping her of one-on-one staff supervision as dictated by her treatment plan.

And Toavs was not the only one. According to the report, between January 1 and February 9, 41 of 107 patients fell, including another patient who had to be sent to the emergency room of Community Memorial Hospital of Anaconda on Feb. 6 after a fall caused a laceration to the head.

On Thursday, the Children, Families, Health, and Human Services Interim Committee announced a special meeting on March 4 to learn more about the Immediate Jeopardy citation. The same committee met in January. At the meeting, hospital employees lamented poor patient care and dangerous working conditions at the hospital.


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