Jennifer Mitchell recalled receiving a phone call almost two years ago informing her that her 69-year-old husband, Bill, had been involved in a car accident and was admitted to the Montana State Hospital. The state-run psychiatric facility for adults was located approximately 20 miles away from their residence in Butte.
According to medical records, physicians suspected that Bill Mitchell may have had dementia and posed a potential threat to himself or others. However, upon his admission, his wife’s concerns escalated. Due to COVID-19 restrictions, she was unable to visit him and obtain any information regarding his care or the medications he was being administered.
Jennifer expressed her frustration, stating, “I made attempts to understand what he was taking, or not taking, but unfortunately, I was unable to obtain any answers.”
After being discharged for 60 days, Bill’s medications for congestive heart failure were unexpectedly discontinued, a fact that Jennifer discovered. A month later, he suffered from cardiac arrest and had to be transferred to hospice care. Tragically, he passed away on July 30, 2021, just one day after celebrating his 70th birthday.
The psychiatric hospital in southwestern Montana has been under scrutiny since the federal Centers for Medicare & Medicaid Services decertified it in April 2022 following investigations into patient deaths and assaults. Federal officials found in the investigations that the hospital had failed to meet Medicare’s “basic health and safety requirements.”
Mitchell expressed her anger towards the absence of transparency regarding her husband’s treatment and expressed her desire for decertification to bring about positive change. However, the outcome has been the opposite. The removal of federal oversight and funding for the Montana State Hospital has also resulted in the public losing access to information about patient fatalities and injuries.
According to Jon Ebelt, spokesperson for the Montana Department of Public Health and Human Services, from April’s decertification until the end of December, five patients at Montana State Hospital have suffered severe injuries necessitating urgent medical attention or hospitalization. Additionally, there have been eight confirmed reports of abuse and neglect.
Although Ebelt declined to provide specific numbers or information on preventable deaths, it was revealed that six patients had died during that time.
The details surrounding those incidents remain undisclosed to the public. This is due to the fact that state-level investigations, unlike federal investigations, are not made available as public records.
The state health department denied a public records request for all investigations into Montana State Hospital patient deaths, injuries, and assaults since losing federal certification. Ebelt cited a Montana law that says any records about providing treatment to the seriously mentally ill are confidential and privileged.
David Hutt, the deputy executive director for legal services at the National Disability Rights Network, stated that the level of public disclosure regarding abuse and neglect at state-operated medical facilities varies significantly among different states.
Hutt pointed out the exceptional nature of the transparency issues at the Montana State Hospital, as it is an uncommon occurrence for a facility to lose both federal certification and oversight.
State-hired contractors have produced public reports highlighting improvements at the Montana State Hospital, such as a reduction in falls among geriatric patients. But those reports don’t disclose information related to patient deaths, severe injuries, or substantiated abuse and neglect cases, which had led to decertification in the first place.
Some lawmakers are becoming frustrated due to the insufficient information provided while assessing the request made by state health officials and Republican Gov. Greg Gianforte. The request includes a $300 million allocation to revamp the state’s mental health system, as well as a nearly $20 million request for capital improvements and CMS recertification efforts at the state hospital.
During his recent confirmation hearing, state health department Director Charlie Brereton informed state senators that following the decertification, we have achieved stabilization in MSH due to a change in leadership. Additionally, there has been no notable rise in fatalities, severe injuries, or substantiated allegations of abuse or neglect.
In this article, Brereton, who refused to be interviewed, did not address any potential occurrences of patient injuries and deaths, or confirmed cases of abuse and neglect during his hearing.
“We ought to have knowledge about the safety of individuals in the hospital.”
Ben Miller, a clinical psychologist and former president of Well Being Trust
State Rep. Mary Caferro, D-Helena, who serves on committees considering funding requests and other legislation to reform the state hospital, likened the current level of oversight at the state hospital to the fox watching the henhouse.
According to Caferro, “As legislators, we are able to create better policies that serve the best interests of the people we represent when we possess accurate and comprehensive information.”
Mental health experts agree with Caferro.
Ben Miller, a clinical psychologist and former president of Well Being Trust, a national foundation dedicated to mental health care, emphasized the importance of having knowledge about the safety of individuals in hospitals.
A bill that passed through the Montana Senate and is before the House would automatically send all abuse and neglect reports at the state hospital to Disability Rights Montana within five days of an incident. The nonprofit is the federally designated advocacy and watchdog organization for people with disabilities in the state. It recently released a report detailing how some patients were discharged to homeless shelters.
Bernie Franks-Ongoy, the executive director of Disability Rights Montana, expressed the organization’s desire to share pertinent information from the reports with legislators and the public. However, Franks-Ongoy acknowledged that state regulations impose significant restrictions on the release of such information. Caferro, on the other hand, intends to propose an amendment to the bill that would enable redacted versions of the reports to be accessible to lawmakers and the public.
The Montana Mental Disabilities Board of Visitors also has regular access to the facility and patient records, but its last inspection of the state hospital was in 2019 and the next inspection isn’t expected until next year.
Some lawmakers call the oversight adequate.
“I don’t worry so much about the administration at the hospital hiding anything because they really do have the light shown on them constantly with DRM and the Board of Visitors,” said Rep. Bob Keenan, R-Bigfork, who chairs the committee considering funding requests for the state hospital and the state’s mental health system.
Keenan and Gianforte blame the current conditions at the facility and loss of CMS certification at the state hospital on prior Democratic administrations. Federal officials noted serious deficiencies at the Montana State Hospital in 2017, but federal officials later deemed those issues resolved.
State health officials have stated that if the mental health funding requests are approved by lawmakers, the administration intends to establish two additional mental health facilities in the near future in order to alleviate the strain on the state hospital. Nevertheless, the hospital will continue to play a crucial role in Montana’s mental health system, as affirmed by mental health advocates and numerous lawmakers who believe it should be preserved.
Jennifer Mitchell, a grieving woman whose husband tragically passed away shortly after being discharged from the state hospital, holds the belief that the facility is irreparable and fears that more patients will meet the same fate. Jennifer reminisces about the numerous occasions when hospital authorities altered her husband’s medication due to his depression and refusal to eat. She firmly believes that her husband would be alive today had he not been admitted to that particular institution.
She remarked, “If only there hadn’t been so many small errors or minor details that could have been altered, the result would have been completely different.”
This story is part of a partnership that includes Montana Public Radio, NPR and KHN.
