BILLINGS - Nina DiMauro holds a tiny rock in her hands with the words “love you” written on it. It’s a gift from her brother, Lucio.
“He had a good sense of humor,” she said.
At the age of 67, her brother, known as Lu, died in August of 2021 while under care at the Montana State Hospital in Warm Springs.
This is where Nina’s fight to get justice for her brother’s death begins.
Nina called her brother “Lu” for short. She remembers his outgoing personality and how he was a free spirit — and Lu was always looking out for her.
“Even though he was younger, he was like the big brother, you know,” she said during a recent interview at her Bozeman home.
Scattered on a table are countless photos of Lu.
One of her favorites is from a warm Montana day with green grass in the backyard and Lu holding onto her dog. That one is framed and sitting on a shelf in Nina’s Bozeman home.
Lu was one of five patients who died in a single month at the hospital, which led to stiff federal fines.
The Montana State Hospital lost $7 million in federal funding in 2022 after it failed to meet basic health and safety standards, even after multiple warnings.
The Centers for Medicare and Medicaid Services issued a letter terminating its provider agreement with the hospital in April of last year.
The federal agency says the involuntary termination of the agreement was a last resort.
In February of that year, investigators found deficiencies at the state hospital that led to patient deaths, and when the agency gave the state until March to improve, it eventually failed to come into compliance.
Nina says she’s preparing to bring a class action lawsuit against the state of Montana and the State Hospital for malpractice and is hoping others will join.
“I can’t help but think he is up there looking down, going, 'you go girl'," Nina said.
Nina kept a journal of more than 80 pages detailing the grueling days Lu stayed at the State Hospital.
It turns out her journal would come in handy.
At first, she started taking down notes because, she said, there were often so many different people she was corresponding with about her brother’s case that it got confusing.
“I kept a journal from September of 2020 all the way until he died,” she said.
The journal evolved into a playbook of misconduct and documented proof of inconsistencies of care.
“We weren’t really happy. The entire time that he was there we were trying to get him into a group home,” said Nina.
Nina says Lu’s health struggles stemmed from a traumatic brain injury he sustained while living in Bozeman.
In 2012, he fell down a staircase leading to his basement apartment.
“It just changed his personality and the way he perceived himself,” she said.
After a stay in Lewistown and a Billings group home, Lu arrived at Warm Springs, able to walk with his walker, talk clearly and eat.
“It was from that point on that things started to deteriorate,” she said.
Nina says her brother was heavily medicated, and calls to him were rarely connected.
“He couldn’t hold his head up, he couldn’t move his arms, he couldn’t hold a cup of water. They let him have water. It was terribly, terribly upsetting,” she said.
Nina was able to visit her brother and sometimes would observe him in an overly medicated state, with drool coming from his mouth.
The investigation into the Spratt Unit — which houses patients with Alzheimer's — other forms of dementia and traumatic brain injury, revealed Lu fell 15 times, something Nina never even knew until after he died.
“It’s something straight out of a movie,” said former state Rep. Danny Tenenbaum, a Missoula Democrat, who helped sponsor legislation to address the conditions at the State Hospital and especially the Spratt Unit where Lu was staying.
Tenenbaum visited the unit intending to see firsthand the conditions and look for ways to improve patient care after the report surfaced.
He was faced with abysmal conditions where rooms were overcrowded (four patients in one room), electronic records were not found and staff was too small and lacked training.
“We’ve heard at this point, an unending stream of complaints about abuse and neglect avoidable falls," said Tenenbaum.
The bipartisan legislation drafted by Tenenbaum and other lawmakers is currently sitting on Republican Gov. Greg Gianforte’s desk.
Tenenbaum says it would take the amount of money allocated to the Spratt Unit per patient per day and instead fund a community placement for the individual to provide appropriate care.
Tenenbaum says those community placements would ideally be closer to the patient’s home or closer to family to improve quality of life.
“The residents of Spratt didn’t commit any crimes. These are just people living with dementia that couldn’t get into proper memory care,” he said.
Those with the governor’s office say Gianforte is encouraged by the work of the state health department to resolve longstanding issues with the Montana State Hospital.
“Governor Gianforte believes conditions at the Montana State Hospital are unacceptable after years of neglect from past administrations, which is why he proposed a $300 million, generational commitment to our state's behavioral health system and the state hospital in his Budget for Montana Families,” a Gianforte spokesperson said in a statement.
His office also says the governor received Tenenbaum’s bill last Thursday and will carefully consider it.
The Montana Department of Public Health and Human Services (DPHHS) would not comment directly on Lu's case.
"Information regarding any Montana State Hospital patient is not releasable under 53-21-166, MCA, concerning 'treatment of the seriously mentally ill': All information obtained, and records prepared in the course of providing any services under this part to individuals under any provision of this part are confidential and privileged matter and must remain confidential and privileged," an agency spokesperson said in a statement to MTN News.
“I want people to know that my brother was a really good person who was going through a hard time,” said Nina.
Nina’s legal case alleges the State Hospital had a duty to provide Lu with reasonable services, supervision and care and that the Montana State Hospital breached its duties, causing Lu to suffer serious and painful physical and emotional injuries, eventually leading to his death.
“I just couldn’t accept it,” said Nina. “I was doing it for him.”
In her fight for justice for Lu, Nina is hoping that others will also come forward, who had loved ones lost under the care of the Montana State Hospital because she knows there have to be others.
“And if there are other people like that and I think there are, that he’s not the only one that they shouldn’t go through that,” she said.
For more information on the class action suit, families can call Heenan & Cook Trial Lawyers at 406-839-9091.