As western Colorado\u2019s largest hospital and only level-two trauma center, Intermountain Health St. Mary\u2019s Regional Hospital serves droves of people each day.<\/p>\n
But according to records from the Colorado Department of Public Health and Environment, more than 70 patients were reported \u2018missing\u2019 across 2025.<\/p>\n
Most of those reports are benign, concerning pre-admitted patients who left the hospital without completing treatment or telling anyone, likely because of the wait. Still, roughly one-in-five missing persons across 2024 and 2025 required a call to local law enforcement.<\/p>\n
Separate from the hospital\u2019s self-reported occurrences, a CDPHE inspection in late March found that the facility \u201cfailed to ensure a suicidal patient was monitored in accordance with facility policy and providers\u2019 orders in two of three records for a patient who was suicidal.\u201d<\/p>\n
<\/p>\n
Larry Robinson\/The Daily Sentinel<\/p>\n
A Grand Junction Police Department cruiser sits outside of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital on April 1. According to records from the Colorado Department of Public Health and Environment, more than 70 patients were reported \u2018missing\u2019 across 2025 at St. Mary\u2019s.<\/p>\n
Larry Robinson\/The Daily Sentinel<\/p>\n
Bryan Johnson, president of Intermountain\u2019s Western Colorado Market and St. Mary\u2019s Regional Hospital, said the hospital strives to provide the safest, highest-quality care, and a CDPHE spokesperson affirmed the hospital is apt to continue operations safely.<\/p>\n
Still, the recent inspection and occurrences signal a strain on the emergency department, especially from individuals in a mental health crisis.<\/p>\n
\u201cSt. Mary\u2019s Regional Hospital strives to provide the safest, highest quality care to all our patients.<\/p>\n
\u201cRecent closures of multiple inpatient behavioral health resources in the Western Colorado region have created significant challenges, including an increase in patients presenting to the emergency department for treatment,\u201d Johnson said. \u201cDespite these challenges, we remain committed to quality patient care and will continue to work closely with state agencies.\u201d<\/p>\n
<\/p>\n
Larry Robinson\/The Daily Sentinel<\/p>\n
The front entrance of Intermountain Health St. Mary\u2019s Regional Hospital is seen on April 1. Occurrences, or in-hospital events, vary drastically in severity and topics, including the misappropriation of a patient\u2019s property, equipment malfunction, sexual abuse, neglect and brain damage. In 2024 and 2025, St. Mary\u2019s had 114 occurrences and 98 of those concerned a \u201cMissing Person.\u201d Looking closer at St. Mary\u2019s occurrence reports, the majority concerned a patient who received an initial assessment but became impatient or ran out of time and left without seeing a doctor or notifying hospital staff.<\/p>\n
Larry Robinson\/The Daily Sentinel<\/p>\n
MISSING SOMETHING?<\/p>\n
As the agency tasked with the regulation and oversight of health care facilities statewide, CDPHE maintains a public database of all its hospital inspections. In addition to inspections and any documented violations, the database tracks \u2018occurrences\u2019 that hospitals are legally required to report.<\/p>\n
Occurrences, or in-hospital events, vary drastically in severity and topics, including the misappropriation of a patient\u2019s property, equipment malfunction, sexual abuse, neglect and brain damage.<\/p>\n
Between March 2023 and 2026, a CDPHE spokesperson said that, statewide, hospitals reported an average of roughly 12 occurrences per year.<\/p>\n
Hospitals with a bed count between 200 and 499 averaged 9.75 annual occurrences. St. Mary\u2019s falls in that range with nearly 350 beds, yet the hospital reported an average of nearly 50 annual occurrences over the past three years.<\/p>\n
<\/p>\n
A look at the outside of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
But the hospital\u2019s high number of occurrences is a somewhat recent development, as St. Mary\u2019s reported 12 in 2023. Occurrences jumped to 35 in the following year, and grew yet again in 2025, with 79 reported.<\/p>\n
Despite the many types of occurrences, 98 of the hospital\u2019s 114 reports (86%) across 2024 and 2025 concerned a \u201cMissing Person.\u201d<\/p>\n
For comparison, the Sentinel identified the frequency of missing person reports and overall occurrences (in 2024 and 2025) at other Colorado hospitals with a similar size and scope of care:<\/p>\n
UCHealth Medical Center of the Rockies (242-bed, level 1 trauma center and regional hospital): 15 of 29, or 51%.<\/p>\n
Intermountain Saint Joseph Hospital (400-bed acute care facility): 50 of 78, or 64%.<\/p>\n
HCA HealthONE Swedish Hospital (408-bed, level 1 trauma center and acute care facility: 61 of 77, or 79%.<\/p>\n
Denver Health Medical Center (555-bed level 1 trauma center): 28 of 65, or 43%.<\/p>\n
It\u2019s worth noting that occurrences are self-reported, so the willingness to report can vary by hospital.<\/p>\n
Looking closer at St. Mary\u2019s occurrence reports, the majority concerned a patient who received an initial assessment but became impatient or ran out of time and left without seeing a doctor or notifying hospital staff. Since they were admitted into the hospital\u2019s system but not discharged, they meet the reporting requirement for a missing person.<\/p>\n
\u201cAll attempts to locate the client were unsuccessful,\u201d a September 2025 CDPHE report stated. \u201cThe record review showed the client received an assessment but eloped prior to completing their treatment or being formally discharged.\u201d<\/p>\n
When that happens, hospital staff are supposed to inform security, conduct a ground search of the facility and contact the patient\u2019s phone number on file.<\/p>\n
In the case of \u201cat-risk\u201d patients, whether they are a physical or mental threat to themselves or others, staff are supposed to request a welfare check from law enforcement. In select instances, St. Mary\u2019s requested a welfare check for patients who aren\u2019t at risk, but beyond physical concerns like an IV catheter that hasn\u2019t been removed, the reasons aren\u2019t specified.<\/p>\n
Between 2024 and 2025, roughly one-in-five missing persons reports (20 of 98) involved law enforcement, including: six patients under a mental health hold or suicide watch; two patients who were too intoxicated to drive; six patients who left with an IV catheter still inserted; and a police detainee.<\/p>\n
\u201cThe client escalated after receiving visitors, tore out their IV and ran out of the building,\u201d a December 2025 CDPHE report stated. \u201cThe client was considered at risk to themselves related to suicidal ideation and was under a mental health hold with a sitter at the time. The client was missing for more than 8 hours and could not be located.\u201d<\/p>\n
<\/p>\n
A look at the outside of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
When asked about certain occurrences and whether any reports were duplicative, a spokesperson for Intermountain said they are unable to address specific patient encounters out of respect for patient privacy and federal privacy laws.<\/p>\n
\u201cAs the Western Slope\u2019s only Level 2 trauma center, St. Mary\u2019s cares for some of the most severe medical conditions as well as those patients who are not critically ill but still require emergency medical attention,\u201d the spokesperson added. \u201cThe volume of patients seeking care at St. Mary\u2019s emergency department continues to be very strong.\u201d<\/p>\n
The spokesperson was unable to address additional questions regarding the scope of patient ground searches and whether security staff had increased in response.<\/p>\n
<\/p>\n
The front entrance of Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
SUPERVISION SLIP-UPS<\/p>\n
When asked whether any action had been taken regarding the occurrences, a CDPHE spokesperson said that the department only identifies non-compliance and requires action through routine and complaint-based inspections.<\/p>\n
They added that, at the time of commenting in mid-March, the hospital\u2019s last violation was in November 2024 and was corrected soon after.<\/p>\n
But that has since changed, according to a March 23 inspection report obtained by the Sentinel.<\/p>\n
The report, which CDPHE said was motivated by a complaint and unrelated to last year\u2019s occurrences, determined that St. Mary\u2019s failed to ensure a safe care setting for a patient presenting with suicidal ideation.<\/p>\n
\u201c\u2026 Patient #16 was (assessed to be) at imminent risk for suicide, (and) the provider ordered suicide precautions and safety checks every 15 minutes starting at 4:07 a.m.,\u201d the inspection report stated. \u201cThe ED Care Timeline revealed a 15-minute safety check was not completed until 7 a.m., two hours and 53 minutes later.\u201d<\/p>\n
<\/p>\n
An ambulance pulls out of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital after dropping a patient off on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
Beyond not following the provider\u2019s instructions of 15-minute safety checks, the report added that the nearly three-hour gap went against St. Mary\u2019s suicide risk procedure policy, which mandates \u201ccontinuous monitoring at all times, until the patient (is) assessed and the order (is) discontinued.\u201d<\/p>\n
The inspection report didn\u2019t specify whether proper 15-minute checks were conducted after the 7 a.m. visit, but the patient was medically cleared and discharged from the emergency department at 2:18 p.m.<\/p>\n
Yet only two hours and 18 minutes later, just after 4:30 p.m., the same patient returned. It\u2019s unclear whether the patient \u201cpresented\u201d voluntarily or was brought into care by law enforcement or someone they know.<\/p>\n
Their chief complaint was no longer suicidal ideation. It was a suicide attempt.<\/p>\n
By 5:06 p.m., a provider had again determined the patient was at an imminent risk of self-harm and ordered \u201csuicide precautions,\u201d which the report did not define but said did not include safety checks.<\/p>\n
<\/p>\n
A Grand Junction Police Department cruiser seen outside of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
\u201c(The omission of safety checks) was in contrast with the Suicide Risk Procedure policy, which read, suicide precautions for patients at imminent risk should have included continuous monitoring at all times until the patient was assessed and the order was discontinued,\u201d the report stated.<\/p>\n
Recurring safety checks were eventually ordered at 10:18 p.m., just over five hours after the provider assessed the patient as an imminent risk to themself.<\/p>\n
But CDPHE\u2019s report added that there was no record of a single safety check in the following seven-and-a-half hours, until the provider\u2019s orders were discontinued.<\/p>\n
The report didn\u2019t specify when the patient was officially discharged, but it likely followed their medical clearance. CDPHE also states in its reports whether a patient was harmed or died, and no such reference was found in the Sentinel\u2019s review of records through 2025.<\/p>\n
<\/p>\n
An ambulance seen at the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital after dropping a patient off on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
CDPHE & ST. MARY\u2019S SHARE NEXT STEPS<\/p>\n
According to the state health department, inspection violations may result in a license suspension, but enforcement action is rare.<\/p>\n
\u201cWe focus on supporting health facilities in correcting issues of non-compliance by requiring them to develop an acceptable plan of correction rather than routinely relying on the implementation of enforcement action,\u201d a spokesperson said.<\/p>\n
In St. Mary\u2019s case, the hospital was given a corrective plan. The plan mandates updated education for patient safety attendants, including expectations, documentation requirements and room safety checklists.<\/p>\n
According to CDPHE, the education was assigned to all inpatient caregivers and security staff by April 17, and must be completed by the end of June. New caregivers will receive the training upon hire.<\/p>\n
<\/p>\n
A photo of the exterior of Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
The plan of correction also requires St. Mary\u2019s emergency department director and assistant nurse manager to audit at least 20 records of patient mental health holds per month.<\/p>\n
The audits will verify whether a one-on-one sitter was in place and whether safety checks were documented every 15 minutes as required. CDPHE said the audit will span April 15 to June 15, at which point the results will be shared with the \u201cPerformance Excellence Committee.\u201d<\/p>\n
When asked about the inspection, Johnson reiterated that the recent reductions to inpatient behavioral health care across the region have required St. Mary\u2019s to step in \u2014 despite lacking the infrastructure required for crisis care.<\/p>\n
\u201cSt. Mary\u2019s is not a licensed inpatient behavioral health facility,\u201d Johnson said. \u201cIn alignment with our mission, we continue to support and stabilize behavioral health patients who come to our emergency department in crisis.\u201d<\/p>\n
<\/p>\n
A look at the outside of the emergency department entrance at Intermountain Health St. Mary\u2019s Regional Hospital on April 1, 2026.<\/p>\n
Larry Robinson \/ The Daily Sentinel<\/p>\n
With that said, it\u2019s worth noting that St. Mary\u2019s passed all three of its 2025 inspections without a citation.<\/p>\n
One of those investigations was to ensure compliance with the Emergency Medical Treatment and Labor Act, a federal law that requires Medicare hospitals to care for anyone with a medical emergency, including mental health crises, regardless of ability to pay.<\/p>\n
\u201cWe are deeply committed to providing the best care possible for patients when they come to us in crisis and need to be stabilized,\u201d Johnson added. \u201cWe also want to extend our sincere appreciation to our emergency department caregivers, who continue to support complex patient care situations and provide the highest level of care to our patients.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"As western Colorado\u2019s largest hospital and only level-two trauma center, Intermountain Health St. Mary\u2019s Regional Hospital serves droves…\n","protected":false},"author":3,"featured_media":833474,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_share_on_mastodon":"0"},"categories":[35],"tags":[68284,96359,341785,210,1141,1142,6478,93546,517,13987,8152,9159,1738,1197,67,132,68],"class_list":["post-833473","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-audit","tag-emergency-department","tag-emergency-medical-treatment-and-active-labor-act","tag-health","tag-health-care","tag-healthcare","tag-hospital","tag-inspection","tag-mental-health","tag-patient","tag-safety","tag-social-issues","tag-suicidal-ideation","tag-suicide","tag-united-states","tag-unitedstates","tag-us"],"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@us\/116666475817161850","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/833473","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/comments?post=833473"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/833473\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media\/833474"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media?parent=833473"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/categories?post=833473"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/tags?post=833473"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}