The state mental health hospital failed to adequately monitor medications for at least one convicted killer who then escaped, while two other patients were able to simply walk away after their medications were not regularly checked, according to a state audit.
The Office of the State Auditor also found numerous other deficiencies in the operations of the Colorado Mental Health Institute at Pueblo that compromised safety and proved costly to the state.
The state hospital, which houses all of the state’s criminally insane patients, did not adequately document patient complaints on a database that tracks trends and failed to investigate workers’ compensation claims that cost $9 million in four years.
Ken Cole, Mental Health Institute Division director, who supervises the Pueblo hospital, said he agrees with most of the recommendations in the audit report in November and hospital supervisors have made changes or are fixing the problems.
“These were valid recommendations to improve an already well-run facility,” Cole said.
The report says nine forensic and 14 civilly committed patients fled the hospital in fiscal year 2009, including patients who might not have been taking their medications when they escaped. When they fled, as many as 22 hours passed before they were declared escapees. The hospital notified only one nearby school and delayed notifying the media.
A month before state hospital patient Mark Hartman escaped from an unlocked outpatient home on Feb. 17, 2009, his doctor said his treatment plan for medications was incomplete, according to the audit.
Hartman had been convicted of second-degree murder in 1983 and was later committed to the Pueblo hospital. He was arrested in Concord, N.C., a month after the escape.
When he escaped, The Denver Post reported that the hospital notified the public only about Hartman’s most recent offenses of escape and contraband possession.
The hospital did not mention that during a cross-country crime spree in 1983, Hartman stole a car, burglarized a Golden church, fatally shot security guard Lawrence Gale and torched his body in Douglas County, and was in the process of kidnapping an Arvada woman when he was arrested.
Cole said hospital staff are now doing criminal background checks on escapees and releasing that information to the public, notifying several schools when patients escape and initiating protocols to more aggressively search for escapees.
The hospital is also improving communications with mental- health centers across the state to ensure patients have current medication plans and are taking their medications.
The audit also said the hospital failed to keep sufficient records on its patient-complaint database. The database did not include the names of 270 staff members who were the subject of the complaints and in many cases didn’t state what the complaint was.
Cole said the hospital has made changes to its computer database so that names of accused staff members will be included.
State auditors found the hospital paid workers’ compensation claims in 2009 totaling $525,000 to 206 hospital employees, or one-fifth of the hospital’s total workforce, for injuries ranging from lifting or restraining patients to patient assaults.
The state found that in nine of 26 claims submitted by hospital employees, the hospital did not confirm they were justified as state law requires.
In the past four years, the most frequent injury was classified as “strain,” accounting for 170 claims totaling $4 million in compensation payments. Pinnacol Assurance denied only about 5 percent of claims.
The hospital is now training supervisors in how to perform initial reviews of the complaints to determine whether the staff member qualifies, Cole said.
Kirk Mitchell: 303-954-1206 or kmitchell@denverpost.com
