After a decade without a reported suicide, the hospital has come under fire in recent months for a series of fatal events that are now the subject of a grand jury investigation. Troy Geske died in August from asphyxiation while in restraints; officials say the particular "prone restraint" procedure he endured is no longer used at the hospital.
Last year, another patient, Sergio Taylor, hanged himself . The family of a third fatality, Joshua Garcia, reached a $223,000 settlement with the Colorado Department of Human Services after alleging that he was over-medicated in the state hospital, leading to a burst colon in 2007.
The new report states that CMHIP may be understaffed by as much as twenty percent; that patient-to-psychiatrist ratios are too high and staff morale is low; and that the "organizational structure at CMHIP is in disarray."
"Several staff members reported punitive consequences for expressing disagreement with policies, procedures and clinical care," the investigators found. "There appeared to be a significant disconnection between administrative decisions and clinical care."
The report also takes issue with the hospital's mirrors, which are made of metal for security purposes but present a distorted, "funhouse" image -- not so fun, the report suggests, for mental patients already struggling to keep a grip on reality.
Hospital officials say they're reviewing the recommendations of the report, implementing new suicide prevention procedures and working on training issues -- but maintain that the facility continues to be severely underfunded.
For more on the insanity defense in Colorado and the state hospital's role, see our 2008 feature "The Good, The Bad & The Mad." Click here to read the complete "Colorado Mental Health Institute at Pueblo Behavioral Health Consultant Report."