Indian Health Service facilities sanctioned for dangerous, faulty care, leaving often-impoverished patients on remote reservations without services required by law

By Dan Frosch and Christopher Weaver

At the Indian Health Service hospital in Pine Ridge, S.D., a 57-year-old man was sent home with a bronchitis diagnosis—only to die five hours later of heart failure. When a patient at the federal agency’s Winnebago, Neb., facility stopped breathing, nurses responding to the “code blue” found the emergency supply cart was empty, and the man died. In Sisseton, S.D., a high school prom queen was coughing up blood. An IHS doctor gave her cough syrup and antianxiety medication; within days she died of a blood clot in her lung.

In some of the nation’s poorest places, the government health service charged with treating Native Americans failed to meet minimum U.S. standards for medical facilities, turned away gravely ill patients and caused unnecessary deaths, according to federal regulators, agency documents and interviews.

The IHS, a unit of the Department of Health and Human Services, operates a network of hospitals and clinics, much like the Veterans Health Administration. Under U.S. treaties that date back generations, the service is legally responsible for providing medical care to about 2.2 million tribal members.

But that system has collapsed in the often-remote corners of Indian Country, where patients live hours from other medical providers, often have no insurance and depend on the federal service.

“We’ve lost faith in the IHS, but we have no alternatives to go anywhere else,” said Lisa White Pipe, a tribal council member for the Rosebud Sioux, whose father died last year after a delay in cancer treatment that she blames on the agency. Read more about his and other cases, and see the regulator’s reports.

The problems have come to a head in recent months after IHS hospitals repeatedly failed inspections, shut down services or lost access to crucial federal funds. Such failures have prompted new calls for broader oversight of the IHS by Congress. The Rosebud tribe, whose reservation stretches across a rural swath of South Dakota, is also now suing the agency in federal court, alleging that the IHS has failed to fulfill its treaty responsibility to care for tribal members.

“People are dying here as a result of the care they are not receiving, or the care they are receiving,” said U.S. Sen. John Barrasso, (R., Wyo.), who until January chaired Congress’s Indian Affairs Committee, in an interview.

The latest crisis has arisen after the IHS and the Health Department failed to address a chorus of warnings over many years about neglect at the agency’s facilities. The warnings came from lawmakers in both parties, internal whistleblowers and the families of patients who died. Over and over, they reported that IHS hospitals were plagued by inadequate supplies, poor training, overwhelmed staff and critical positions left unfilled.

The agency has lacked a permanent director since 2015. People familiar with the matter said they expect a nominee for that post to be announced soon.

Chris Buchanan, the IHS’s deputy director and a rear admiral in the U.S. Public Health Service Commissioned Corps, which provides health workers to federal agencies, said in a written statement the issues facing the agency’s most troubled hospitals “go back more than a decade and did not occur overnight.” He said the new administration will evaluate the situation and figure out how the IHS can better serve Native Americans.

Back in 2010, a commission chaired by then-Sen. Byron Dorgan, (D., N.D.), found improperly credentialed medical staff were treating patients at some remote hospitals and employees accused of misconduct—even crimes, including stealing drugs from hospital pharmacies—weren’t disciplined.

The agency promised changes, but the situation has only disintegrated since, according to interviews with tribal officials, civil and criminal court records, and a raft of federal inspection reports.

Wilmer Spotted Wood hobbled into the IHS hospital in Winnebago but was sent home without treatment despite medical staff documenting his severe back pain—10 on a scale of 10—and ashen skin color, according to one of those reports.

Hours later, a nurse read a test result that showed his kidneys were shutting down. The finding would normally lead to hospitalization, doctors say. Instead, the nurse left a phone message telling Mr. Spotted Wood to avoid calcium products like the antacid Tums and come back in two days, a federal inspection report said.

One of his sisters, Betsy Spotted Wood, herself an IHS nurse who was at the hospital that day, said “his skin coloring was way off. You could tell something was seriously wrong.”

Mr. Spotted Wood didn’t make it to his follow-up appointment. He died in his bed of kidney failure on Jan. 1, 2015, the day he had planned to return to the hospital.

An IHS spokeswoman, Jennifer Buschick, provided a statement saying the agency wouldn’t comment on specific medical cases, lawsuits or regulatory findings. Officials at the IHS’s Maryland headquarters fielded queries from The Wall Street Journal related to the agency’s individual hospitals and clinics.

Following Mr. Spotted Wood’s death, U.S. hospital regulators found the Winnebago facility failed to meet basic standards in 11 of 30 random cases they reviewed, including his case, during a routine inspection.

Winnebago is one of seven IHS hospitals that the regulator, the Centers for Medicare and Medicaid Services, said had put patients in danger since 2010—more than a quarter of the 26 hospitals the IHS manages around the country.

The IHS and tribal health advocates say Congress underfunds the agency, and the Trump administration’s 2018 budget proposes cutting about $300 million, a roughly 6% decrease from its 2017 level.

The IHS spent $3,688 on care for the average patient in 2015, according to an agency document. The Veterans Health Administration, for comparison, spent an average of $11,056 on medical services for each veteran receiving VA health care in 2015, that agency’s records show. The two agencies count the users of their services differently, and their populations vary.

Obesity and diabetes on the Rosebud and Pine Ridge reservations are more than 40% higher than nationwide, according to a Journal analysis of data from the University of Wisconsin.

At least 50% of residents of those two reservations, as well as a third of those served by the Winnebago hospital, earned less than the federal poverty line, 2015 data show.

Such factors, coupled with remoteness—Rosebud is more than 100 miles from the nearest Wal-Mart —make recruitment difficult. The IHS said vacancy rates for medical staff at its Great Plains facilities run as high as 37%. By contrast, the Massachusetts Health and Hospital Association reported only about 6% of nursing jobs vacant in 2015.

Earlier this year, a longtime Pine Ridge pediatrician was indicted for allegedly sexually assaulting his patients. The doctor, Stanley Patrick Weber, who resigned last spring from the agency, pleaded not guilty. His lawyers didn’t respond to a request for comment.

The top medical officer at Winnebago was indicted late last year on allegations he defrauded Tennessee’s Medicaid program before joining the IHS, court records show. The doctor, Scott McLain, had been brought on in a shake-up the IHS said showed commitment to high-quality care.

Dr. McLain entered a plea of not guilty and has asked a judge to dismiss the case, his lawyer said. He said Dr. McLain had resigned from the IHS.

In its written statement, the IHS declined to comment on the indictments. It said the agency has revamped staff credentialing procedures, overhauled management of many hospitals and brought in outside contractors to fill vacancies.

The agency’s seven sanctioned hospitals—in Pine Ridge, Rosebud and Rapid City, S.D.; Cass Lake, Minn.; Crow Agency, Mont.; Acoma, N.M.; and the Winnebago facility that treated Mr. Spotted Wood—all put patients in “immediate jeopardy” of harm and failed to meet hospital requirements, according to federal regulators.

The South Dakota and Nebraska facilities have each been cited for putting patients in danger multiple times. Since 2011, regulators reviewing cases at those four IHS hospitals said inadequate care contributed to at least 11 deaths, documents show.

In many cases, the hospitals haven’t fixed their problems, according to regulatory documents. In April, inspectors cited ongoing failures at the Rosebud hospital for at least the third time in a row; in 2015 and 2016, its emergency room was closed for seven months. In May, inspectors found the Pine Ridge facility had failed U.S. hospital requirements for the second time in five months. The Winnebago hospital has been barred since 2015 from billing Medicare because it failed to meet requirements for hospitals participating in federal programs, a punishment given to just five general hospitals in the U.S. that year, federal data show.

In its written statement, the agency cited data showing many non-IHS hospitals in North and South Dakota and Nebraska also failed to meet requirements. It is less common though for regulators to cite hospitals for putting patients in danger in connection with such failures. Regulatory data show half of the eight facilities run by the IHS in the three states were found to have put patients in danger from 2011 to 2015. The data show the proportion for all non-IHS general hospitals with a patient-harm finding in those states was 7%.

Some of the families of patients who died unexpectedly under the IHS’s care said the toll extends beyond the hospitals that have been sanctioned. Among them, is Wakanda Gonsalves, a high school senior and prom queen, who went to an IHS clinic in Sisseton, S.D., on May 4, 2012, because she was coughing up blood. She was sent home that same day, with cough syrup, an inhaler and antianxiety medication. Two nights later, her parents woke to Ms. Gonsalves’s screams, her mother, Lisa, recalled. They found her convulsing in bed before she went limp.

“My husband kept doing CPR and chest compressions. Over and over,” Lisa Gonsalves said. “But she had no pulse.”

An autopsy showed Ms. Gonsalves suffered a blood clot in her lung. The IHS-contracted doctor who treated her said in a court deposition he didn’t review an X-ray showing a lung abnormality, or follow up after an irregular blood test. The staffing agency that employed the doctor settled a lawsuit with Ms. Gonsalves’s family for an undisclosed sum in 2015.

In court filings, both the doctor and the contractor denied any wrongdoing. Lawyers for both didn’t respond to requests for comment.

When confronted with regulatory failures, top IHS officials prioritized other matters, and Health Department leadership brushed aside warnings, records and interviews show.

After a 2010 Senate hearing on Sen. Dorgan’s probe outlining serious deficiencies in care and training, then-IHS director Yvette Roubideaux emailed agency employees, acknowledging problems and saying fixes “cannot happen overnight.” She asked staff to, among other things, “put a story in the local newspaper about all the good things you are doing,” according to a 2010 email reviewed by the Journal.

In 2014, despite complaints of understaffing, Ms. Roubideaux dispatched 21 IHS medical staffers to West Africa to aid the U.S. response to the Ebola outbreak, over protests of tribal health officials.

“If the federal government is going to send public health officials anywhere it should be sending them to Indian Country,” a tribal health committee wrote to Dr. Roubideaux.

Dr. Roubideaux argued the outbreak was an unprecedented epidemic. The agency statement to the Journal said the staff was needed to help prevent a potential U.S. outbreak.

Dr. Roubideaux, a Rosebud tribal member and Harvard-trained doctor who left the agency in 2015, referred inquiries from the Journal to the IHS about what she called “longstanding” problems.

At a meeting of regional IHS heads in 2013 called by agency leadership, “we were basically told, ‘these are your problems, you deal with it,’” said Anna Whiting Sorrell, who formerly ran the IHS’s Billings, Mont.,-based region, where a hospital was sanctioned for dangerous care in 2014.

The agency told the Journal that the IHS’s regional chief medical officers have “primary responsibility for clinical issues.”

One doctor, Alida Asencio, said she was ridiculed at staff meetings after telling the Winnebago medical director about problems in 2014. Dr. Asencio later raised a concern about a death at the hospital with regulators, who, documents show, concluded it was avoidable. She later complained to top agency officials that her supervisor pressured her to take paid leave ahead of an inspection to keep her from raising further concerns, an email viewed by the Journal shows.

U.S. Sen. Mark Begich, an Alaska Democrat, said he met with former Health and Human Services Secretary Kathleen Sebelius in 2012 to discuss IHS concerns. He said it was clear from the conversation that implementing the Affordable Care Act “eclipsed things.”

Ms. Sebelius said in an interview “it’s totally appropriate for him to say, ‘they just didn’t do enough,’ ” referring to her own department. She said she took the IHS’s failures seriously and tried to address them by seeking more funds and improving communication with tribes.

The current Health Department secretary, Tom Price, said during his confirmation hearing in January he was committed to turning the IHS around.

Some people who rely on the troubled hospitals said they are afraid to seek treatment there.

Among them is the family of Tonya Drapeau, a 39-year-old mother of five from the Omaha reservation, who died suddenly in March 2016 after a visit to the Winnebago hospital. Days later, a government doctor wrote in a letter to an IHS official that Ms. Drapeau’s treatment “was below the standard of care.”

Her family filed a legal claim alleging negligence in February with the Health Department, their lawyer said, the first step in filing a lawsuit against the U.S. government.

Medical records show Ms. Drapeau went to Winnebago because she was having trouble breathing.

The agency’s records of her past care, which medical staff reviewed that morning, showed she had diabetes and a history of respiratory complications. A doctor didn’t check her blood sugar and sent her home later that day with antianxiety pills.

Hours later, Ms. Drapeau’s teenage son found her unconscious. The records show she died, after being airlifted to a private hospital, of diabetic shock.

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