Citizens Commission on Human Rights® of Colorado

The Centers for Medicare and Medicaid Services (CMS) has given the Colorado Mental Health Institute at Pueblo (CMHIP) until June 28 to correct serious deficiencies in the care of its patients or else lose its Medicare and Medicaid funding.

Acting on complaints of dangerous conditions, investigators from the Colorado Department of Public Health and Environment (CDPHE) made an unannounced inspection of the state psychiatric institution in February, as reported by the Pueblo Chieftain.

This inspection directly followed contact between CDPHE and the Citizens Commission on Human Rights of Colorado concerning the complaints of staff neglect at CMHIP that we had filed with CDPHE.  One of our complaints concerned staff neglect that led to the death of a patient.

The deficient practices found by the February inspection were so serious that CMHIP was slapped with the condition of “immediate jeopardy” by CMS, indicating that noncompliance with federal requirements “has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”

CMHIP submitted a plan of correction, which CMS accepted, and the condition of immediate jeopardy was removed.

However, “condition level” deficient practices remained, representing severe or critical health or safety breaches, which CMHIP was required to correct to qualify for CMS funding.

In a June 5 follow-up visit, CMS inspectors found that the deficiencies had not been adequately corrected and put the facility on a 23-day “termination track.”

CMHIP must comply with federal regulations to the satisfaction of CMS by June 28, or the 449-bed facility will no longer be certified to receive Medicare and Medicaid funding.

The publicly released CMS report from the February inspection cited noncompliance with standards for patient rights, nursing services, and quality assessment and performance improvement.

CMHIP failed to ensure that patients received timely examination by medical staff, that staff followed physician orders soon enough, and that recommended medical care and follow-up was provided, resulting in unsafe incidents and worsened medical conditions for patients.

CMS cited the failure of the nursing staff to notify the medical staff and provide ongoing evaluations when acute medical changes in a patient’s condition occurred.  This resulted in the delay of a physician assessing patients and in acute medical conditions for patients.

The facility also failed to analyze adverse patient events and take corrective actions to prevent reoccurrence of the errors.  The report specifically cited CMHIP’s failure to review the “unexplained” death of a patient, which left all patients in the facility at risk for a repeat of the same, uncorrected error.

The CMS report from the June 5 follow-up inspection has not yet been released by CMS.

Following the public revelations of substandard care of patients, CMHIP superintendent Ron Hale announced his resignation, effective July 9.

If you or someone you know has been harmed by treatment at the Colorado Mental Health Institute at Pueblo or any other mental health facility, we want to talk to you.  You can contact us by clicking here or by calling 303-789-5225.  All information will be kept strictly confidential.