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Colorado Mental Health Institute News for Colorado

State Psychiatric Facility in Pueblo Facing Loss of Medicare and Medicaid Funds Over Dangerously Deficient Practices

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.

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Colorado Mental Health Institute News for Colorado

Patient’s Death at Colorado Mental Health Institute at Pueblo Due To Staff Neglect

A state investigation has concluded that staff neglect was the cause of the choking incident last September at the Colorado Mental Health Institute at Pueblo (CMHIP) that caused brain damage leading to a patient’s death, according to the occurrence summary report recently released by the Colorado Department of Public Health and Environment (CDPHE).

The forensic pathologist who subsequently performed the autopsy on the decedent concluded that the brain damage was the cause of death.

The male patient in his 60s lacked bottom teeth and had a dietary restriction that required his food to be cut into small pieces.  After being served whole food by CMHIP staff, he collapsed when it lodged in his throat and obstructed his breathing.  Staff reportedly attempted, but failed to dislodge the food with the Heimlich maneuver, and then performed CPR, but the patient remained unresponsive.

He was rushed to a local hospital, where he was placed on life support, but his condition never improved.  Eight days later the support services were discontinued and he was pronounced dead.

The autopsy report states the cause of death was brain damage due to the lack of oxygen from choking on food.

Three CMHIP staff members were suspended during the state investigation.  Following CDPHE’s finding of staff neglect, one staff member was fired, one resigned, and one received corrective action that included additional training and supervision.

An accelerated response to the incident by CDPHE was triggered by a complaint filed by the Citizens Commission on Human Rights of Colorado.

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 know what happened.  You can contact us by clicking here or by calling 303-789-5225.  All information will be kept strictly confidential.