The Lander hospital where a patient in 2020 gouged out the eye of another patient failed a safety inspection about two weeks after the incident, according to documents filed in federal court.
A Centers for Medicaid and Medicare Services “unannounced” inspection of the Lander SageWest Hospital conducted in December 2020 concluded that mental health patients were inadequately supervised, recommended drugs were not given, and a psychiatric patient later charged for murder had been able to wander the facility.
The inspection report was filed Thursday in federal court as part of a wrongful death lawsuit filed against Riverton Memorial Hospital, SageWest’s parent company, by the family of Elaine Tillman, whose eye was gouged out on Thanksgiving 2020 by fellow patient Patrick Rose.
‘What Do You Really Do To People Here?’
Tillman died nearly two weeks after her eye was gouged out while she lay in emergency care at Lander SageWest Health Care on Thanksgiving of 2020.
Tillman had been taken into custody involuntarily for mental health issues and medical documents said her repeated attempts to disrobe and run away from home “like a stray dog” showed a potential for self-harm.
According to the documents filed as part of the lawsuit in U.S. District Court, Tillman was reportedly suspicious of hospital personnel and afraid that someone was trying to hurt her.
“Why are you guys doing this to me?” Tillman had asked a nurse who was trying to take her for a walk.
The conversation occurred on Tillman’s sixth day in the hospital, one day before the eye-gouging incident.
“What do you really do to people here?” she continued.
Later, after some calming efforts by the nurse, Tillman thanked the nurse and others “for all you do.”
The Fremont County Attorney had been trying, medical documents said, to get the Wyoming State Hospital to accept Tillman.
Wrong Drugs
Dubois resident Patrick Rose, then 53, was a fellow psychiatric patient admitted to the hospital on Nov. 25, 2020, one day before the gouging incident.
Rose was awaiting transfer to Casper Wyoming Behavioral Institute for a higher degree of mental care and oversight. But, medical documents state, WBI would not take him until his COVID-19 test returned negative.
Documents said Rose was taken into involuntary mental health custody after he “suddenly” quit taking his valium and hydrocodone, burned his clothing, ran naked from his Dubois home in freezing November temperatures, put a sheet over his wife’s head and held her in a brief chokehold until she asked him to stop.
When examined, he reported hallucinations.
“I saw myself swimming in a pool of Pepsi and even tasted it,” he told an evaluator, also stating “I am in extreme dangerous situations,” and reporting imagery such as cars and rocket ships flashing in his consciousness when he tried to sleep.
Though he’d reportedly quit taking the drugs prescribed for his acquired brain injury of 18 years, Rose tested positive for THC (an intoxicant found in marijuana) and benzodiazepines, which can be used to treat anxiety or alcohol withdrawal.
Medical personnel recommended antipsychotic and anti-anxiety drugs for Rose during his brief hospital stay, but “the (CMS) review showed neither medication was administered,” an inspector concluded.
Rose left his room multiple times during his stay, his care ledger said, wandering outdoors or to other rooms or the hallway.
Half Supervised
Hospital personnel insisted that one staff member watch Rose at all times, for a 1:1 supervision ratio.
Instead, according to a nurse interview taken after the gouging, one person was assigned to watch both Rose and Tillman – a 1:2 supervision ratio.
“(The) 1:1 sitter ratio had not been maintained,” reads the CMS report. “Shift to shift and sitter to nurse communication and physician to physicians communication lacked continuity, documentation was incomplete.”
Homicide, Release
While still awaiting his transfer to WBI, Rose reportedly fled his own room, rushed into Tillman’s, leapt onto her and gouged both her eyes with his thumbs.
One eye was dislodged completely and dangled on Tillman’s cheek, held by an optic nerve. The other eye remained in its socket but was blinded and badly damaged.
Nurses restrained Rose until police arrived.
Tillman died 13 days after the gouging, at the University of Utah Hospital, where she’d been flown for treatment. A Utah death examiner deemed the fatality a homicide.
Rose was charged with second-degree murder but was released from state custody to live with his wife in Dubois in June of 2021, due to a limitation in Wyoming’s mental health and court proceeding laws.
‘For-Profit Business’
In a motion filed with the lawsuit asking the court to force the hospital to provide more information, Bob Schuster, attorney for the Tillman family, noted the hospital is owned by companies with headquarters far outside Wyoming.
The hospital’s interests “are not aligned with the safety of patients who live in Fremont County, Wyoming,” Schuster wrote. “Rather, they are aligned with the corporate profit interest of the conglomerates” who own the hospital.
SageWest was owned by LifePoint Health Inc. during the attack; LifePoint in turn was owned by Apollo Global Management, Inc. The hospital then was shifted to another Apollo chain, ScionHealth, which was owned by LifePoint and Kindred Healthcare, Schuster noted in the motion.
“(It) may be thought of as a hospital,” Schuster continued. “In reality, it is simply a business asset – treated like an unwitting cash cow passed from one business conglomerate to another and happily milked by each of them.”
Under its various owners, the Riverton and Lander SageWest Health Care facilities have cut services: the obstetrics ward was removed from Riverton; both buildings were sold to a trust, causing the hospitals to pay rent on buildings they once owned, and – notably in the case of Rose and Tillman – the hospital’s psychiatric ward, PineRidge, was closed down in 2019.
Schuster is requesting evidence from the hospital that has not yet been granted, including internal emails discussing the incident, phone numbers and call histories for “specific individuals who were involved” in the hours surrounding the attack and key documents surrounding “the decision to dismantle PineRidge.”
The hospital, claimed Schuster, “has attempted… to shield information and documents from discovery in unwarranted fashion.”
