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Investigation confirms problems at Indian Health Service facilities

Friday, October 7, 2016

Indian Health Service staff take part in a round dance at the Rosebud Powwow, held on the Rosebud Sioux Reservation in South Dakota in August 2016. Photo from Facebook

Lack of staffing, improper training, vacancies in leadership and outdated facilities are causing harm to patients at the Indian Health Service, according to a pair of reports released on Friday.

Employees told investigators from the Department of Health and Human Services that they are "struggling to meet patients’ basic care needs" at hospitals across Indian Country, one report stated. The facilities are required to maintain minimum quality and safety standards but there's limited oversight of their operations, the Office of Inspector General said.

As a result, patients are suffering and some are even dying, according to the reports. Emergency rooms at some hospitals lack adequate staff and some aren't even properly trained, investigators wrote, an issue that has affected at least three facilities in the past two years alone.

"Administrators from one hospital reported that staffing shortages sometimes force the hospital to turn patients away. In another hospital, administrators said that insufficient staffing was the cause of its recent 'immediate jeopardy' citation," one report stated.

"Not only did the hospital fail to properly staff the emergency room, it also failed to provide patients with adequate waiting areas and proper medical transfers," it continued.

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Although investigators interviewed staff and key officials at all 28 hospitals run directly by the IHS, none of the facilities were called out by name. But the problems outlined in the report will not come as a surprise to tribes in the Great Plains Area, a region that includes Nebraska and South Dakota.

"Since at least 2007, the Winnebago Hospital has been operating with demonstrated deficiencies that have been so numerous and so disturbing that in 2015 we actually became the first federally-operated facility -- and, to our knowledge, the only one -- to lose our Medicaid and Medicare reimbursement certification," Victoria Kitcheyan, the treasurer for the Winnebago Tribe of Nebraska, told lawmakers at a hearing on Capitol Hill in July.

"And to this day, we are still without that certification," Kitcheyan added. The Omaha Winnebago Hospital, which also serves the neighboring Omaha Tribe and other tribes in the region, remains without a key source of funding for more than two years now.

The second report in fact tracks nearly word-for-word several of the concerns that Kitcheyan has raised about the hospital. In 2014 alone, the Centers for Medicaid and Medicare Service, the federal agency that withdrew certification for the facility, attributed at least three patient deaths to inadequate care at Winnebago.

"CMS surveyors found that hospital staff lacked training and knowledge on how to conduct emergency resuscitations and that the 'crash cart' (a wheeled container carrying medicine and equipment that physicians and nurses use in emergency resuscitations) lacked essential medications and equipment," the report stated. Although the hospital wasn't mentioned by name, that description is virtually identical to the known deficiencies at Winnebago.

"Surveyors also found that staff lacked knowledge on how to call emergency codes across the intercom system to summon assistance, were not adequately trained to recognize symptoms of a life-threatening condition, and failed to provide necessary stabilizing treatment," the report continued.

The Fort Yuma Service Unit in Yuma, Arizona, is the oldest Indian Health Service facility in the nation, with buildings that date to 1852 and 1963. Groundbreaking on a replacement facility took place in February 2016. Photo by Quechan Tribe

Despite the work done by CMS, which Kitcheyan has praised as the only independent and verifiable review of the problems at Winnebago, investigators noted that the agency does not inspect IHS facilities on a "routine" basis. But neither does the IHS -- half of the area offices do not perform surveys that could help them improve quality of care, the first report stated.

Beyond oversight issues, investigators called out the seemingly large number of vacancies in hospital leadership, another issue seen with frequency in the Great Plains. Of the 28 hospitals run by IHS, administrators at 24 said top positions are being held by people in an "acting" -- or temporary -- capacity, according to the second report.

"The most common acting position was that of the CEO (11 hospitals), followed by the clinical director (10 hospitals) and the director of nursing (9 hospitals)," the report stated.

"One administrator reported struggling with the constant change in leadership after having multiple acting CEOs; another administrator described that scenario as a 'historical dilemma for IHS,'" it continued. "In one case, described in a report by an IHS-contracted consultant, a hospital had three different acting CEOs within a 6-week span."

Again, no facilities were identified by name but the Rosebud Sioux Tribe in South Dakota has complained about the revolving door at the hospital on its reservation. The last CEO -- who lacked direct experience in health care before being hired by the IHS -- was only on the job for four months in 2015 before he "just up and left, and left us high and dry," council member William Bear Shield told The Washington Post in March.

A month after the CEO left, the IHS shut down the emergency room at the Rosebud Hospital. Before it reopened in July, nine tribal members died while being transported to facilities further from the reservation

And just last month, the emergency room at a different Great Plains hospital was shuttered by the IHS. The Sioux San Hospital in Rapid City, South Dakota, is now telling patients seek urgent care elsewhere.

"This is another example of poor consultation with tribes that have members immediately affected by the federal government’s failure to abide by the trust responsibilities provided by treaty," Chairman Harold Frazier of the Cheyenne River Sioux Tribe said last month.

The Indian Health Service hosted a Medicaid/Medicare enrollment event on the Rosebud Sioux Reservation in South Dakota on August 25, 2016. Photo from Facebook

Aging facilities were cited as yet another longstanding concern. According to the second report, the average age, or length of time since a major renovation, of IHS hospitals is 37 years -- nearly four times the national average.

Administrators at 15 of the 28 hospitals cited problems that hindered their ability to provide adequate care, according to the report. The backlog in maintenance in fiscal year 2013 was $166 million, with one area in particular accounting for nearly a third, or $47 million, of that amount, investigators wrote.

"Staff from this area office reported that hospitals sometimes have to divert patients because of facility issues," the report stated, without naming the area in question. "For example, one hospital has had to occasionally shut down its operating room because of mechanical problems."

Since the start of the year, the IHS has outlined numerous steps it is taking to improve quality of care in the Great Plains Area. Consultations are ongoing with tribes to determine what changes are needed at the office in Aberdeen, South Dakota, which is located far from most of the reservations in the region.

"HHS, IHS, and CMS’s recent efforts provide a strong foundational response to the issues identified in this report. Many of these activities, however, are currently localized to the Great Plains Area and it is unclear the extent to which these efforts will be applied to other areas," investigators wrote. "We encourage IHS to ensure that the lessons learned in the Great Plains Area will also be used to benefit the whole of IHS."

Inspector General Reports:
Indian Health Service Hospitals: More Monitoring Needed to Ensure Quality Care (October 7, 2016)
Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention to Support Quality Care (October 7, 2016)