The Rosebud Hospital is an Indian Health Service facility on the Rosebud Sioux Reservation in South Dakota. Photo: Office of Inspector General at the Department of Health and Human Services

Indian Health Service faulted for closure of Rosebud Sioux emergency room

When the Indian Health Service shut down an emergency room at a troubled hospital in South Dakota, the federal agency cited "staffing changes and limited resources" at the facility.

A case study made public on Monday uncovers another big reason for the seven-month closure at the Rosebud Hospital. Substandard care -- which placed patients in "immediate jeopardy" of serious injury, harm, impairment, or even death -- also was to blame for the last-minute closure of the emergency department (ED) in December 2015, the report stated.

Four patients in particular were found to have received substandard care during a review conducted by the Centers for Medicare and Medicaid Services prior to the shutdown:

• "A patient with chest pain who did not receive a timely medical screening exam, and had a delayed transfer to another facility better equipped to treat the condition;"

• "A pediatric patient with a possible head injury from a car accident who did not receive appropriate care or monitoring;"

• "A patient with chest pain who was not triaged appropriately and did not receive adequate monitoring or timely care; and"

• "A patient who delivered a pre-term baby unattended on the ED bathroom floor."

The closure itself also placed patients in grave danger, the case study found. By the time the ED reopened in July 2016, at least nine people died while being transported to hospitals farther away from the reservation, a situation that negatively impacted those facilities as well.

"Rosebud Hospital is a 35-bed medical facility located in the Great Plains Area and is the primary source of healthcare for the Rosebud Sioux Tribe in South Dakota," the Office of Inspector General at the Department of Health and Human Services wrote in the case study. "During the ED closure, patients had to travel farther for emergency services—the nearest emergency rooms were 45 and 55 miles away."

But staffing shortages, inadequate resources and substandard care weren't the only explanation for the poor state of emergency services on the reservation. Leadership issues and a lack of communication between the hospital, the Great Plains Area Office (AO) of the IHS and even agency headquarters right outside the nation's capital contributed to deficiencies that went uncorrected for years, the report stated.

Just like the Rosebud Sioux Tribe and the local community, the two non-Indian hospitals that received the bulk of the Rosebud patients weren't told in advance about the closure on the reservation. The facilities ill-equipped to handle the influx, which one administrator described as "an avalanche" of people needing care.

"IHS officials described the relationship between the AO and the Great Plains hospitals as lacking trust and clear roles and responsibilities," the OIG said. "Hospitals operated on their own, with little support or input from the AO, and there was a lot of 'finger pointing' and disagreement about who was responsible for addressing issues that arose at the hospital level."

"IHS officials also reported that the AO provided little information to IHS headquarters about the problems in the Great Plains, including Rosebud Hospital," the case study added. "Although IHS headquarters leadership were aware of problems and asked questions, they did not know the extent or severity of the problems."

"Shortly after the ED closed and patient diversion began, the Great Plains Area Director and the Area CMO left their positions at IHS," the reported noted, referring in the first instance to Ron Cornelius, a member of the Oneida Nation was serving as Area Director for the region at the time.

Leaders from tribes in the Great Plains pose together before a hearing of the Senate Committee on Indian Affairs in Washington, D.C, on February 3, 2016. The hearing, and a follow-up listening session, focused on the "substandard quality" of care provided by the Indian Health Serivce. Photo by Indianz.Com (CC BY-NC-SA 4.0)

Cornelius was removed from that post on the eve of a big Capitol Hill hearing that focused on the "substandard quality" of care in the Great Plains. No reason was given publicly for the reassignment and he eventually left the IHS altogether after more than 30 years at the agency.

"Was it because this hearing was going to happen and IHS didn't want him to testify?" Chairman Harold Frazier of the Cheyenne River Sioux Tribe wondered at a listening session following the hearing, which drew leaders from all over the Great Plains, a region that includes South Dakota, Nebraska, North Dakota and Iowa.

As for the Chief Medical Officer, or CMO, the Great Plains had four between July 2011 and July 2016, according to a different report from the Government Accountability Office, a sign of the high rates of turnover. A permanent person finally came on board in September of that year.

But not before tribal leaders and patients from the Great Plains complained about the way they were being perceived at IHS headquarters, thousands of miles away in Rockville, Maryland. Susan Karol, a citizen of the Tuscarora Nation who was serving as Chief Medical Office for the entire agency, apologized at that big hearing before the Senate Committee on Indian Affairs for making comments that appeared to downplay the birth of the baby on the floor of the Rosebud hospital.

"Those comments are totally unacceptable [and] were really made after a long day," Karol said after being called out by the leader of the committee.

According to Sen. John Barrasso (R-Wyoming), who was serving as chairman of the panel at the time, Karol told Congressional staff during a conference call: "If you’ve only had two babies hit the floor in eight years that's pretty good."

"I really am sorry that I made any reference to any negativity to patient care. My 100 percent priority is improving patient care, providing quality is my highest priority," Karol added. By the following year, she had been reassigned to a position at the Centers for Medicare and Medicaid Services, the very agency that uncovered the quality of care issues at Rosebud and other hospitals in the Great Plains.

Despite the challenges, the case study confirmed that the IHS took the situation at Rosebud very seriously. By early January 2016, a month after the shutdown, the U.S. Public Health Service began sending teams of Commissioned Corps officers to the hospital and to other facilities in the Great Plains.

Although the team members were rotated on a seemingly short basis, they were instrumental in helping the emergency room get back on track. Altogether, 52 officers worked at Rosebud -- out of 193 total sent to the Great Plains -- and they stayed through December 2016, well after the department reopened.

"As described by an IHS official, Rosebud was able to 'stop the bleeding' with the help of the Commissioned Corps officers," the report stated.

The IHS also took additional measures at Rosebud to improve the quality of care, according to the case study. But difficulties remain -- staffing is still a major problem, with both hospital leadership and rank-and-file affected.

"In September 2018, Rosebud Hospital had 69 vacancies (7 were in the ED) that were mostly filled by contracted providers, and between July 2016 (the ED reopening) and September 2018, Rosebud had 6 CEOs, 3 Clinical Directors, and 9 [nursing directors]," the report said.

As a result, the hospital has continued to suffer from deficiencies. As recently as last July, CMS surveyors found significant problems at the emergency department:

• "A pediatric patient with alcohol intoxication who was left unattended in a separate room during which the patient attempted suicide; and"

• "An adult patient suffering from paranoia and with methamphetamine in the system who died after being chemically and physically restrained."

While these "immediate jeopardy" issues were addressed a month later, additional deficiencies were found during another CMS visit last August, the report said.

"Given that these were condition‐level deficiencies, Rosebud Hospital was again placed by CMS on a track toward termination from the Medicare program," it stated.

Termination from Medicare program, or loss of certification from the CMS, represents a significant blow. Due to chronic underfunding within the IHS, hospitals, clinics and other health facilities rely on revenues from Medicare to stretch inadequate budgets and keep services going. Losing these funds almost always requires cutbacks, according to tribal officials and hospital administrators who have dealt with the situation elsewhere in the Great Plains.

The IHS avoided loss of CMS certification at Rosebud last November "two weeks before the expected termination date," the report stated. Despite the near-miss, the case study warns of continued deficiencies unless major changes are made.

"The factors that contributed to the noncompliance, including staffing inadequacies and changing leadership, were longstanding and occurred before, during, and after the closure," the report reads. "These issues will require IHS’s continued focus. Innovative solutions are needed to avoid cyclical noncompliance by Rosebud and prevent residual impact of that instability on the hospital and the overall agency."

According to the case study, a draft version was presented to IHS on April 26. In a response, Principal Deputy Director Michael Weahkee, a citizen of the Pueblo of Zuni who serves as the de-facto leader of the agency because President Donald Trump has failed to name a permanent one, agreed with four recommendations to improve staffing, enhance training, adopt "early intervention" for problems at hospitals and do a better job with emergency department closures.

But in almost all of the cases, the IHS response is still very much a work in progress. A "comprehensive workforce plan" to address recruiting, retaining and other employee issues isn't due for completion until May 2020, for example.

Similarly, a "best practices" document won't be ready until October 31, with additional policies completed by March 31, 2020. And a "ED Closure Procedure" document to help address problems like those that arose at Rosebud won't be ready until December 31, some four years after the shutdown at the hospital.

As for the Great Plains, the Area Office finally got a permanent director in April. James Driving Hawk, a citizen of the Rosebud Sioux Tribe, had served as "acting" director for the last two years.

“I’m proud to lead the IHS Great Plains Area and I’m excited to continue the incredible progress staff across the region has made in improving and sustaining access and quality of care for the patients we serve," Driving Hawk said at the time. "I look forward to continuing to build and maintain relationships with tribal leaders and members across the IHS Great Plains Area.”

Office of Inspector General Report
Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening (July 17, 2019)

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