Montana State Hospital tallies high rates of falls, chemical restraints and staff vacancies

New reports from hospital staff and consultants show slow progress toward recertification.

The Montana State Hospital in Warm Springs, the state’s only public adult psychiatric facility, is continuing to see high staff vacancies, budget deficits, and shortfalls in health and safety standards more than a year after losing federal accreditation following investigations into patient deaths and injuries.

In a virtual public meeting Tuesday with the hospital’s governing board — composed of top administrators from the Department of Public Health and Human Services and the Warm Springs facility — staff and consultants delivered presentations about safety trends and plans for improvement while touting encouraging changes at the state-run facility. 

The state health department has said that the oversight from the recently created governing board and focus on improving conditions at the facility is part of the Gianforte administration’s commitment to regaining the hospital’s federal certification from the Centers for Medicare and Medicaid. One of the consultants hired by the state to help oversee hospital operations described that effort in a written report on Tuesday as a multi-year “rigorous journey,” an assessment echoed by members of the group during the hour-long meeting.

The hospital is currently operating at roughly 80% capacity, with about 216 patients residing there, including the geriatric-psychiatry Spratt unit and a forensic wing for evaluating and treating criminal defendants. The hospital’s forensic unit was the only part of the facility with a wait-list. It is licensed for 54 beds, but has operated at a consistently lower census since last year. As of June, it was occupied by 46 people with 70 people across the state waiting for admission that month.

There have been 159 patient falls — one of the key indicators of patient safety that federal investigators flagged in 2022 — recorded across all parts of the facility so far this year. The highest frequency of falls — an average monthly rate of 12.1 per 1,000 patient days — has occurred in the Spratt unit. Staff told the governing board on Tuesday that falls are being tracked and reported more accurately across the facility and are down on the geriatric unit by roughly 25% compared to last year. 

The hospital also reported failing to meet its goal of zero chemical restraints used on patients in the main hospital and geriatric wing. Chemical restraints — defined by the federal Centers for Medicaid and Medicare as “any drug used for discipline or convenience and not required to treat medical symptoms” — were most commonly employed in the main hospital, where the intervention was reported at an average rate of 8.85 instances per 1,000 patient days in 2023. The practice was less common in the Spratt unit, while the hospital’s forensic unit reported zero instances of chemical restraint this year.

A 2022 clinical resource document created by the American Psychiatric Association said that using medication to treat a patient’s agitation should be voluntary and that medication should “never [be] used as a ‘chemical restraint,’” but noted that the term is poorly defined and misunderstood. Involuntary medications, the publication says, “should be used as a last resort for situations that present as acutely dangerous.”

A spokesperson for the health department did not respond before deadline to questions about how the hospital defines “chemical restraints” and what counts as an “occurrence.” 

Bernie Franks-Ongoy, director of the federally designated oversight group Disability Rights Montana, said Thursday that while eliminating the use of chemical restraints entirely should be a priority, defining and documenting the misuse of medication is often complicated.

“It is difficult to know exactly what the numbers represent without knowing precisely how the term ‘chemical restraint’ is defined under current hospital policies and what the reporting requirements are,” Franks-Ongoy said. “It would be good to know, for example, how many occurrences of chemical restraint were the result of genuine patient safety concerns and how many were based on staff convenience.”

The rate of patient seclusion also exceeded goals in different parts of the facility, sometimes significantly. In the main hospital, hours spent in seclusion per 1,000 patient hours ranged from 16.68 in January to 1.81 in May, far exceeding the goal rate of less than .36 hours.

In the forensic unit, rates of seclusion also varied widely, recorded at .05 hours per 1,000 patient hours in March to 24.73 hours in May. In the Spratt unit, rates of recorded seclusion were much less common and consistently below the hospital’s goal.

The hospital’s quality improvement metrics did not include how many of its patients have died this year. A health department spokesperson did not respond to multiple questions from Montana Free Press about patient deaths before deadline. 

Safety issues resulting in serious injuries continue to occur, officials said Tuesday, with a total of 10 recorded between the main hospital and the Spratt unit so far this year, compared to 14 in the prior year. 

One patient recently ingested a “toxic cleaning agent” brought into the facility by a contractor, interim hospital administrator David Culberson said. The patient was transferred to another facility for a higher level of care and later returned to the psychiatric hospital. That patient has since been discharged, Culberson said, and the hospital has implemented five new safety protocols to more closely monitor contractors entering the facility in the future.

The hospital reported a 37% employee vacancy rate in June, down from 45% last summer. After a hiring surge in January, February and March of this year resulting in a net gain of 39 employees, the hospital reported losing nine staff members in May and June. 

The highest vacancy rates are among registered nurses, with an 82% vacancy rate, and clinical therapists, whose vacancy rate was 72%, according to the hospital’s latest finance and human resources report. 

With high rates of contract staff and traveling professionals continuing to work at the facility, the hospital’s director of nursing, Jocelyn Peterson, told the governing board that Warm Springs is working to extend the length of traveler contracts to 26 weeks instead of 13 weeks to increase training opportunities for short-term workers.

“This way we can give them a couple more weeks of actual training and speak to some of those areas of safety, and things to look for, and kind of give them a better idea of what the facility is like and how important it is to treat our patients and make sure that they’re safe,” Peterson said. 

Culberson also told the board that the hospital is working hard to respond to the passage of House Bill 29, which will restrict the admission of patients with a primary diagnosis of Alzheimer’s, dementia or traumatic brain injury to the Montana State Hospital beginning in 2025.

“That’s a good portion of the folks in [the] Spratt [unit] right now. And we will not only have to turn down admissions, but we will have to discharge everybody with those three diagnoses,” Culberson said. “So it’s a big project we’ve started here with the help of [contractor Alvarez & Marsal] and then the care team in Spratt.”

As of June, the hospital reported overspending its annual budget significantly, with about $93 million in expenses versus its stated budget of $48.9 million, a trend that has continued from 2022. Of the listed expenses, the finance report said roughly $3.9 million was spent on the cost of traveling staff in June, a figure that has fluctuated month-to-month.

The hospital was given nearly $16 million in additional funds by the 2023 Legislature to make facility repairs and upgrades to help regain federal certification. 

Out of that total budget for capital projects, the hospital’s Tuesday report outlined specific uses for $5.9 million, including repairing the HVAC system, replacing fire doors, and other safety and medical upgrades. The report said the remaining $10 million in legislative appropriations will be set aside as “contingency for unanticipated repair projects impacting recertification.”

The group did not receive any public testimony during the designated public comment period. It is slated to meet again in the fall.