Tag: CMHIP

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.

Shocking Video Released Of Man Suffocating in Prone Restraint

Man Struggles In Vain To Breathe While Strapped Down at Pueblo Psych Hospital.

RestraintsCall7 Investigators in Denver obtained the surveillance video of a man, strapped face down in restraints and left alone in an isolation room, struggling for air and slowly suffocating at the Colorado Mental Health Institute at Pueblo.

CMHIP staff are seen forcibly putting the man in prone restraint, then leaving the room.  They fail to monitor him adequately during his fatal asphyxiation.

Troy Geske, 41, was obese and suffering from a respiratory infection when he was forced face down on a table, then held down by four CMHIP staff while being strapped so tightly that he is unable to move, his own weight pressing down on his lungs.  During the take-down, one employee is seen pressing Geske’s face onto the table, and another has his elbow in Geske’s back, further impairing the man’s attempts to breathe at a time he was clearly panicked and in need of oxygen.

The reason for the restraint that ultimately led to this cruel and inhumane death?  Geske was refusing to take the psychiatric drug(s) staff were trying to administer to him.

The state had gone to court to try to block release of this shocking video.

Just as shocking is the fact that a Pueblo grand jury failed to return any criminal indictments against any of the staff involved.  (See our article, “You Be The Judge: Pueblo Grand Jury Returns Findings In Death of State Hospital Patient.”)

The Call7 Investigators report and video can be seen by clicking here.  WARNING:  This an extremely disturbing video.

If you or someone you know has been put in restraints at a psychiatric facility or has any experience with CMHIP, we want to talk to you. You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Pueblo DA Skeptical of Changes At Colorado Mental Health Institute at Pueblo

Says Whole Scrapping Of The Culture Is Needed.

Pueblo County District Attorney Bill Thiebaut publicly expressed his skepticism of claims by the Colorado Department of Human Services that improvements have occurred at the Colorado Mental Health Institute at Pueblo (CMHIP) in the wake of a patient death there last August.

According to the Pueblo Chieftain, Thiebaut said “I don’t have a lot of confidence that there’s been a change out there.”  He went on to say that change would require a whole scrapping of the culture at CMHIP.

“We have a culture that has permeated the institution for years,” Thiebaut said.

That culture was the focus of a report issued by a Pueblo County grand jury that investigated the August 2010 death of patient Troy Geske.  The 41-year-old, who was obese and suffering from a respiratory infection, suffocated while being restrained face down and left unattended in a seclusion room at the facility for refusing to take psychiatric drug(s) prescribed to him.  See a summary of that report in our article “You Be The Judge: Pueblo Grand Jury Returns Findings In Death of State Hospital Patient.”

“The grand jury said things need to change from the top down,” Thiebaut continued.

Geske had been readmitted to CMHIP in July 2010 because he was experiencing mental symptoms that included auditory hallucination, depression, worsening confusion and aggressive behavior.

All of these behaviors are side effects of psychiatric drugs.  Geske’s ultimate death while under the control of CMHIP staff may well have been the direct result of the psychiatric drugs he was prescribed by psychiatrists at CMHIP – drugs that he was struggling to refuse at the time of his death, drugs he may well have known were destroying him.

Adverse reactions to psychiatric drugs, as detailed in research studies, warnings from international regulatory authorities and reports to the FDA, can be accessed through CCHR International’s psychiatric drug side effect search engine.

   If you have experience with “the culture” at CMHIP, we want to talk to you.  You can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Pueblo Grand Jury Returns Findings In Death of State Hospital Patient

Part of the ongoing series:
You Be The Judge

A Pueblo grand jury has found official wrongdoing, but no criminal conduct in the death of a patient at the Colorado Institute of Mental Health at Pueblo (CMHIP) last August. Troy Geske, who was obese and suffering from a respiratory infection, suffocated while being restrained face down and left unattended in a seclusion room at the facility after refusing to take psychiatric drug(s) prescribed to him.

According to the grand jury report, staff at the institution committed “misfeasance and malfeasance with regard to a governmental function, and abused their authority resulting in the death of Mr. Geske.” Malfeasance includes the failure to perform a legal duty or the violation of state laws or rules. But the grand jury declined to hand down any indictment, which could have included a charge of criminal negligence.

Geske reportedly was taken to a seclusion room after he resisted taking prescribed psychiatric drug(s). There he was put facedown in prone restraint, with leather straps binding his arms and legs to a  gurney, and an additional leather strap across his torso to hold him down. He was then left alone in the room and was improperly monitored by staff outside the room. He slowly suffocated during nearly 10 minutes of struggling to breathe while in restraint.

While it is not known what psychiatric drug(s) Geske had refused, he reportedly had been re-admitted to CMHIP from a community placement in July for hallucinations, confusion, passive-combative behavior and depression. All of these conditions are common and well-known side effects of drugs routinely prescribed to psychiatric patients. (For more information on the dangerous side effects of psychiatric drugs, click here.) It is unknown what psychiatric drugs he was taking when he was readmitted, what increased dosages or additional drugs he may have been prescribed after being readmitted, or what side effects may have led him to refuse to take the drug(s).

The incompetence and extreme indifference of CMHIP staff towards Geske in the final minutes of his life were cited in the grand jury report, according to Denver’s 7News and the Pueblo Chieftain:

• “The staff member controlling the patient’s torso was using a disapproved control technique by using his forearm to apply pressure to the patient’s back during the entire restraint process,” while at the same time “Mr. Geske appeared to be struggling by trying to lift his head and torso off the bed” to breathe.

• “During the process of applying the restraints, a staff member used inappropriate pressure to the back of the patient’s head, holding his face at or near the surface of the mattress” on the gurney.

• Once restrained and unable to move or breathe sufficiently, Geske was left alone in the room, with staff failing to monitor him carefully: “It is apparent that Mr. Geske was not under direct observation at all times.”

• When staff finally realized Geske had stopped breathing, they rushed into the room but had difficulty undoing the restraints, losing precious time before CPR was started and a defibrillator used, both ultimately unsuccessful.

• Metal shears that were supposed to be available in the room to cut the leather restraints were not used “because staff either were unaware of their location or believed the shears were locked at the nursing station.”

• When staff tried giving Geske oxygen, the oxygen tank was empty. The report said, “CMHIP policy mandated oxygen tanks be tested every shift and documentation showed the tank in use had been checked off as full during the previous shift.”

• The report stated that “it appeared that no one had authority to assume – or did not assume – control of the efforts to revive Mr. Geske.”

The grand jury report concludes that “there was a systematic failure to adequately train staff, to insure staff followed policies for seclusion and restraint and patient safety related thereto, and to disseminate safety information concerning restraint procedures that was readily available, and if put into practice would have prevented the death of Mr. Geske.”

While insufficient funding or staffing continue to be blamed for ongoing problems at CMHIP, the grand jury report “finds the problems leading to Mr. Geske’s death could have been corrected with little or no impact” to CMHIP’s budget.

The grand jury also found overarching failures at CMHIP: “Public servants of the CMHIP breached their duty of care to adequately train its employees,” to “effectively communicate,” “effectively document evidence for patient care,” and “effectively investigate the death of Mr. Geske.”

CMHIP’s own investigation of the incident was reportedly carried out by a member of the facility’s public safety department, who himself had taken part in the restraint of Geske. While two top officials of the public safety department testified they didn’t believe the investigator had a conflict of interest, the grand jury disagreed. It found that the investigator never interviewed all the staff involved in the incident and did not even review the video surveillance of the incident before completing the investigation report.

Prone restraint had been banned by the Colorado Department of Human Services in its Division of Developmental Disabilities, but the rest of the divisions within the department were not notified that the procedure was banned until after Geske’s death. Other state departments, including the Department of Corrections and the Department of Education, have not banned prone restraints.

The grand jury found no criminal wrongdoing, so no one involved in the incident has been criminally charged.

Linda Stephens, mother of Troy Geske, made it clear that no one person could be blamed for her son’s death because they were all responsible. “It was the system [at CMHIP] that killed my son.”

What do you think? Did the Pueblo grand jury come to the right conclusion?

Restraint “procedures” are the most visible evidence of the barbaric practices that psychiatrists choose to call therapy or treatment. For more information on restraints, click here.

If you or someone you know was put in restraints in a psychiatric facility or has been harmed by psychiatric drugs, you can contact us privately by clicking here or by calling 303-789-5225. All information will be kept in the strictest confidence. We welcome your comments on this article below.

Man Died in Restraints at Colorado State Psychiatric Hospital

CMHIP withholds data requested by the district attorney and county coroner

An obese man who died in the custody of the Colorado Mental Health Institute at Pueblo (CMHIP) suffocated while being restrained face down on a table. He may have been hog-tied.

Troy Allen Geske, 41, died August 10 at the psychiatric institution. An affidavit for a search warrant says that Geske died after he was put in four-point restraint, in which the feet are attached to the hands behind the back.

A spokeswoman for the Colorado Department of Human Services, which oversees the psychiatric facility, denied Geske was in four-point restraint. But Pueblo County District Attorney Bill Thiebaut said the information in the affidavit is corroborated by evidence that has been collected, including video of Geske in restraints, according to the Pueblo Chieftain:
http://chieftain.com/news/local/article_f75a23c2-b72f-11df-9494-001cc4c002e0.html
http://chieftain.com/news/local/article_59e5ca9c-b653-11df-8d64-001cc4c002e0.html

At 5-feet-8 and 265 pounds, Geske was at greater risk of “positional asphyxiation” when he was restrained on his stomach with his own weight pressing down on his lungs and diaphragm. Federal law requires constant, close monitoring of anyone face down in restraints to prevent suffocation.

The results of an autopsy and toxicology tests have not yet been released.

After Geske’s death, hospital police could have called in the 10th Judicial District’s critical incident team (CIT) for an independent investigation of the incident by a team of investigators from outside law enforcement agencies, but did not do so, according to the Pueblo Chieftain: http://chieftain.com/news/local/article_b4e5d92e-b7f1-11df-abf2-001cc4c002e0.html

The CIT investigates serious incidents involving police officers under an agreement to which CMHIP is a party. Hospital police were reportedly present when staff attempted to revive Geske.

CMHIP has also refused to turn over certain information requested by investigators. District Attorney Thiebaut says he will go to court if necessary to get information he believes his office is entitled to, according to the Chieftain.

For more than 40 years, the Citizens Commission on Human Rights has advocated against any form of psychiatric treatment that is torturous, cruel, inhuman or degrading, as laid out in its Mental Health Declaration of Human Rights.

Another Death at Troubled State Psychiatric Institution in Pueblo

Facility received 1,100 patient complaints in 2008-09, reported 11 patient deaths in 2009

Another person has died while in the custody of the Colorado Mental Health Institute at Pueblo (CMHIP), according to the Denver Post: http://www.denverpost.com/news/ci_15822489. The cause of death of 41-year-old Troy Allen Geske, who died several days ago, will not be known until an autopsy is complete.

His death is being closely followed because of recent revelations of other deaths at the psychiatric facility, including the suicide of Sergio Taylor.  An autopsy report indicated 23-year-old Taylor died of asphyxiation in September 2009 after complaining about conditions at the CMHIP.  He was found by law enforcement officers under blankets with a plastic bag over his head in a supposedly high-security area of the psychiatric facility.  About a month earlier, Taylor and 19 other patients had signed a petition that said, “The sense of hopelessness has set in….  History has shown here…that when patients are feeling bored, hopeless and warehoused, …assault and suicide attempts transpire.”

As a direct result of Taylor’s death and citing concerns that other patients could die, the Colorado Department of Health conducted an immediate investigation of CMHIP in October 2009, according to The Denver Channel (KMGH): http://www.thedenverchannel.com/print/24085289/detail.html. In its report, the health department found patients at the state hospital in Pueblo to be in “immediate jeopardy” and detailed serious errors by the institution’s staff.  The department conducted an unannounced inspection of the facility again this past May.

CALL7 investigators from The Denver Channel, who have been reporting on deaths at the state hospital for months, also uncovered the death of another patient of the CMHIP, whose death was never reported to the state health department by CMHIP.  Josh Garcia died after being overdrugged and neglected by staff at the psychiatric institution.  According to his family, Garcia was given a number of powerful psychiatric drugs and suffered serious adverse effects, including severe abdominal pain.  He complained to the staff but was ignored, according to his family.  By the time Garcia was taken to a hospital, it was too late.  His bowels burst, severe infection set in, and he was brain dead within hours.  His family sued and recently received a settlement from the state over his death.

The Colorado Legislative Audit Committee has also called for repeated investigations of the CMHIP in recent years, due to complaints it receives.  In a report released in December 2009, the Office of the State Auditor found numerous deficiencies in the operations of the CMHIP that compromised safety and proved costly to the state.  Among these deficiencies, the institution did not adequately record, investigate or resolve patient complaints.  For 25 percent of the 1,100 patient complaints relating to staff behavior and quality of treatment issues the facility recorded in fiscal years 2008 and 2009, the database did not even contain the names of the 270 staff members who were the subject of the complaints.  The report also revealed that there were 11 patient deaths at the facility last year, the highest number in the three years covered in the report.  How many of those were suicides, besides the suicide of Sergio Taylor, is unknown.  Another audit is underway currently, again at the request of state legislators, to determine if there are other patients who have died of neglect at the state psychiatric hospital.

The CMHIP also has a history of failing to keep the public safe from the mentally ill housed there who have been found not guilty by reason of insanity in connection with serious crimes.  Nine such patients escaped in 2009, with patient escapes at a three-year high.