Behind The Walls Of State Mental Hospital

CALL7 Investigators Obtain Exclusive Access To Hospital After Reporting On Preventable Deaths

CALL7 Investigator John Ferrugia has uncovered four preventable deaths at Colorado Mental Health Institute at Pueblo, and Ferrugia is the first reporter allowed to bring cameras behind the walls of the secure facility to see the changes brought by his reports.

“It certainly through your reporting as well as independent consultants who came into the hospital … it was very clear that the hospital had some changes that had to be implemented from a policy stand point and infrastructure standpoint, a staffing standpoint as well as training,” said Reggie Bicha, the executive director of the Colorado Department of Human Services that runs CMHIP.

The high-security facility that houses the criminally insane has undergone a series of changes since CALL7 reports that question policies and procedures at the CMHIP that led to patient deaths.

Ferrugia saw a room similar to the one where Troy Geske was held in a prone restraint position until he died. Prone restraint has now been banned in CDHS facilities.

“In some of those cases some of those policies were in place, and they weren’t being done,” Bicha said. “In other cases, they weren’t in place.

“We have also trained folks on how to avoid seclusion and restraint in the first place,” he said.

Another change is that doors that can no longer be secured by inmates. That is a result of our investigation of the suicide of Edward Benge who hung himself after jamming the door in his room.

It took staff more than 10 minutes to get to him because they did not know how to use a simple tool to dislodge the door. They finally beat the lock off the door with an oxygen canister.

“So you can open the door this way or this way?” Ferrugia asked.

“Yes, it can swing either direction,” said acting CMHIP Superintendent Theresa Bernal, explaining that the doors can be removed in less than 30 seconds.

A new policy is also in place to make sure plastic bags are accounted for. Our investigation found that Sergio Taylor suffocated himself using a plastic bag that was forbidden on the unit. Now, bags are inventoried often to make sure they are not available to patients.

If one were found on any unit, there is an immediate “search of the entire area and do an actual count,” said Bernal.

There have also been significant changes in the way patients are monitored every 15 minutes to insure their safety. Our investigation found that nursing staff did not check on Sergio Taylor as was required on the unit. Proper monitoring may have saved his life.

But observers and staff are waiting to see if the changes will make a long term difference. Many inside and outside the hospital say it may depend on who Bicha hires to permanently oversee the facility. The previous superintendent resigned in the midst of CALL7 Investigation.

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