The Colorado News Collaborative is a coalition of more than 160 news outlets across the state. One March 21, 2022, they ran a piece titled Investigation finds patterns of ‘life-threatening’ prescription errors at Colorado mental health center. The sub-title is: State agencies sought to keep report secret despite ongoing concerns about Mind Springs.
Authors of the article are Christopher Osher of the Colorado Springs Gazette and Susan Greene, Colorado New Collaborative.
The introductory paragraph reads:
“Mind Springs, one of 17 regional community health centers in Colorado, drastically cut outpatient services after it opened a new $34 million psychiatric hospital in Grand Junction in 2018. It now spends nearly three times more on hospitalizations than other centers and its patients are readmitted at four times the rate.”
The full article can be found here.
DETAILS OF THE ERRORS
Rocky Mountain Health Plans is a private company that contracts with the State of Colorado to manage Medicaid payments in Western Colorado and to investigate complaints. RMHP reportedly opened an investigation into Mind Springs’ practices after a whistle-blower at the Mental Health Center contacted them about problems that were harming patients at the facility.
RMPH conducted their investigation last spring and submitted a report to the Colorado Department of Health Care Policy and Financing in June 2021.
According to the article in hand, the Department of Health Care Policy and Financing released the RMHP report “only after its executive director Kim Bimestefer learned that news reporters from the Colorado News Collaborative and the Colorado Springs Gazette were obtaining it another way.”
Here are some quotes from the Osher-Greene article:
“Records show that a psychiatrist, Dr. Thomas Newton, resigned from Mind Springs in May after he was placed on administrative leave due to ‘aberrant prescribing’ practices revealed during the investigation. Newton remains licensed to practice medicine in Colorado, and regulators in charge of physician licensing at the Colorado Department of Regulatory Agencies have posted no details about the controversy over his care at Mind Springs on its online license lookup tool.”
“An elderly Mind Springs patient who later died was discharged from West Springs hospital with prescriptions for high doses of benzodiazepine and other medications that, when used together, can cause problems with breathing, the investigation found. The man’s death was due to respiratory failure, though the investigation could not definitively link it to improper care.”
“In December, Rocky Mountain Health Plans notified state health officials that from July 1, 2018, through Dec. 15, 2021, it had reviewed 472 quality of care concerns involving Mind Springs and West Springs. Of those, 251 — nearly 60% — had some validity, with 68 of those — or 16% — found to have posed severe, life-threatening risks to patients. Some of those cases occurred after Mind Springs agreed to corrective actions last spring.”
“In the sampling of 58 outpatient clients prescribed high doses of the tranquilizer benzodiazepine between February 2020 and February 2021, there were concerns about the quality of care given to 52. Twenty-eight patients received care so poor they faced ‘severe, life-threatening impact.’ Mind Springs’ medical staff had prescribed many of those patients high doses of stimulants in addition to their benzodiazepine, which places a patient at risk of overdosing. Benzodiazepine use also is particularly risky for people with substance use disorders.”
“Nearly half of a sampling of 54 people receiving in-patient care at West Springs had received deficient care. Those patients were readmitted to the psychiatric hospital from February 2020 through February 2021 within 30 to 60 days of having been released.”
Clearly things were not going well at Mind Springs Health and at the West Springs Hospital. Whether the “aberrant prescribing practices” were due to carelessness or reckless disregard for safety, we don’t know.
According to Doximity, Thomas Newton, MD, obtained a license to practice medicine in the State of Missouri in 2021.
Perhaps the most serious issue is the allegation that state officials withheld the results of the investigation from the public for more than nine months.
“‘If there are things being investigated there and problems being found, the public has a right to know,’ says Wendy Wolfe, a Summit County resident whose son has been treated by Mind Springs for more than seven years. ‘Without public disclosure, how else do we know it’s safe to send our families, our community there?'”
“State regulatory agencies declined to say why they didn’t alert the public to the prescribing errors.”
So, on the basis of the Osher-Greene piece, we have a fairly good idea of what happened, but we don’t know why the state officials tried to keep the matter under wraps, though I imagine that most of us could make some educated guesses.
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Please read the original Osher-Greene article, and pass it along.