Rosebud's ER improved after forced 2015 closure. It didn't last, report shows.

Improvements made in the wake of the Rosebud Hospital emergency room's 2015 closure have tapered off now that the pressure to resolve the problems has lifted, a federal watchdog agency found.

Resolving Indian Health Service's staff and leadership retention problems at the facility are among the corrective actions recommended in a new report by the Office of Inspector General for the U.S. Health and Human Services Department. 

More:Violated: How the Indian Health Service betrays patient trust and treaties in the Great Plains

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

Rear Admiral Michael Weahkee, the deputy director of IHS, agreed with the four recommendations in a letter to the Office of the Inspector General and outlined the work that's underway to implement them:

• IHS plans to have a comprehensive workforce plan completed by May 2020 to address recruiting and training staff for leadership positions, especially at remote facilities.
• IHS has also begun an agency-wide leadership training program and is convening a work group to create a new best practices policy for leadership by March 2020.
• IHS created an Office of Quality in December 2018 and has taken several steps to improve accountability at its facilities. 
• A work group is forming to develop procedures for closing an emergency room, to be completed by December.

More:Violated: Negligent care costs patients time, money and limbs at Indian Health Service hospitals

A history of problems 

The Rosebud emergency room closed for seven months after an inspection in 2015 found both quality-of-care and operational problems, and the hospital was cited for noncompliance with nearly a third of federal requirements, according to the report. The influx of patients at other hospitals caused by the closure was taxing for those facilities and the understaffed tribal EMS staff. Patients had to be transported to nursing homes 45 to 55 miles away during the emergency room's closure.

To reopen the Rosebud emergency room to patients again, IHS entered into an agreement with the Centers for Medicare and Medicaid Services outlining specific tasks that needed to be completed. The improvements were completed to the federal agency's satisfaction in September 2017.

However, the Rosebud Hospital was found to have deficiencies again last year, according to the inspector general's report. The compliance issues included failing to provide emergency care to two patients who arrived with behavioral health needs: an adult with paranoia and methamphetamine in the system who died after being chemically and physically restrained, and an intoxicated child who attempted suicide after being left unattended.

Additionally, the hospital had 69 vacancies, seven of which were in the emergency room, in September 2018.

The corrective actions completed by the hospital after the 2015 closure weren't ingrained in the hospital procedures due to the hospital staff and leadership turnover, and that partly caused the lapse in compliance last year, according to the report. The hospital was found to be in compliance a few weeks before its November 2018 deadline to complete a corrective action plan, according to the report. 

More:Seven months later, Rosebud ER set to re-open

Changes a 'necessary' step to fix problems

The Office of Inspector General is recommending four changes to resolve the underlying issues that are causing the continuous problems at the Rosebud emergency room.

The "necessary first step" to address the problems long-term is to implement a program to retain and train staff and leadership to work in remote hospitals, according to the report. 

According to the report, IHS also needs to: 

• enhance its training of new leaders to ensure they follow IHS directives and continue the improvements 
• take steps to ensure that it has early and effective intervention when problems are identified
• and develop procedures for temporary emergency room closures to ensure other hospitals are adequately prepared to handle the influx of diverted patients it would cause.