State's report says staffing shortage, burnout and training issues played role in Shodair patient death

Shodair Children's Hospital
Posted at 4:43 PM, Sep 06, 2021
and last updated 2021-09-06 20:31:33-04

HELENA — MTN has obtained a Montana Department of Public Health and Human Services (DPHHS) report detailing a Shodiar Children’s Hospital patient’s death by suicide earlier this year, which pointed to staffing issues as a contributing factor.

First reported by the Montana Free Press, the DPHHS investigation said: “The facility has failed to ensure patient safety as evidenced by repeat occurrences of inadequate supervision…” for the May death.

Shodair told MTN in a statement: “We are deeply saddened by this loss. It is our top priority as a children’s hospital that specializes in providing comprehensive psychiatric care, that we do everything in our power to care, heal, and inspire hope for our patients.”

Shodair, which began 123 years ago as an orphanage and home for abandoned children, is now one of only two residential treatment facilities in Montana for children with mental illness or other psychiatric problems.

Investigators interviewed 25 Shodair staff members and said staff expressed “extreme concern” for both patient and staff safety, including inconsistent orientations for new employees who have direct contact with patients.

Staff also felt a 1 to 8 patient-to-staff ratio created dangerous conditions, with the ratio sometimes being 1 to 12 during night shifts.

The night of the May death by suicide, a mental health technician called off their shift and was not replaced. The report also states the patient that died was left alone for more than a half-hour without a verbal check and more than 45 minutes without a visual check.

The Root Cause Analysis report provided to DPHHS cited human factors contributing to the patient's death by suicide, including the facility's staffing shortages for over one month and therapist burnout.

Addressing staffing issues, Shodair said: “We do not take the loss of a patient lightly and can ensure that our team had sufficient staffing for patient needs and followed safety protocols. Following the incident, we took immediate action to put additional precautions in place including updating our policies, increasing patient-to-staff ratios, reducing our census, enhancing training, and implementing strategic practices to heighten safety measures within our hospital.”

In addition to the root cause analysis, Shodair also submitted a plan of correction to the state.

All units have changed work assignments to have one mental health technician who is assigned to complete checks on all patients on their assigned units as their sole responsibility. Staff are also now required to complete a competency assessment to ensure their Patient Monitoring policy is being strictly followed.

Shodair has also updated its facility procedures to prevent any similar situations from happening that led to the patient’s death.

“We are committed to providing the highest quality of care to our patients and providing treatment for Montana’s most vulnerable residents. The health of the children in our community is our highest priority and we will continue to care for patients with the greatest diligence,” said Shodair in a statement to MTN.

The DPHHS report also said Shodair did not follow proper procedure for reporting the death to the state and destroyed documentation related to the incident.

The children’s hospital has updated its reporting procedures to ensure compliance and document retention. Shodair noted that the documents destroyed were “assignment sheets” outlining breaks and other common check-ins that were regularly shredded every couple of weeks, and had no correlation to patient records.

If you or a loved one are having thoughts of suicide, please reach out.

The Montana Suicide Lifeline is 1-800-273-8255 or you can text “MT” to 741 741. The service is available 24 hours a day, seven days a week.

More information about resources available for suicide prevention and survivor of suicide loss can be found here.