Editor’s note: This article contains references to sexual assault and harassment.  In the spring of 2024, a cancer patient at St. Peter’s Health in Helena, the longtime local hospital, made a disturbing report to one of the staffers in the oncology unit. The patient, a 51-year-old woman, said that a male nurse had “touched and fondled her breasts,” according to the recollection of the staffer whom she told. The patient also insisted that she did not want that male nurse to care for her anymore. In a publicly available report detailing the incident, federal hospital inspectors said the employee then shared the patient’s allegation with an on-duty supervising nurse. Two other staff members later told inspectors that they were also informed about the patient’s claim the day after it was made.  But according to the 2025 investigation by the Centers for Medicaid and Medicare Services, the federal agency that serves as a watchdog for patient abuse and neglect, none of the four staff members who learned of the patient’s grievance documented the complaint in the hospital’s official system for such allegations. That inaction allowed the report to go uninvestigated for several months, and for the staff member accused of assault to remain employed until much later that year.  READ THE REPORTDownload In October of 2024, another patient came forward to accuse that same staff member of assaulting her a year earlier, when she was hospitalized in the intensive care unit. That allegation, reiterated in the federal inspection, matches the felony charge and licensing investigation against former St. Peter’s nurse Aaron Gams. Gams has pleaded not guilty to the charge, although a recent court filing shows he is scheduled to change his plea later this month.   According to the federal inspection, investigators said the lack of official documentation of the complaints against the male nurse was part of a “systemic” failure in how St. Peter’s handled multiple reports of sexual abuse by two staff members in 2023 and 2024. The report indicates that, during its unannounced inspection prompted by an anonymous complaint, the federal agency identified a dozen staffers at St. Peter’s who had failed, on more than a dozen occasions, to file required reports about hospital employees allegedly sexually harassing and abusing patients. “These failures created an unsafe environment and had the potential to place all hospital patients at risk for sexual abuse,” the inspection stated. Investigators concluded that the ”severity and cumulative effect” of the hospital’s reporting failures and other violations in patient safety protocol justified putting St. Peter’s in “immediate jeopardy” status — a designation that could have resulted in the hospital losing its ability to bill the public health insurance programs Medicaid and Medicare. Within a week of that finding, inspectors said, St. Peter’s submitted a plan for correcting how it tracks and investigates reports of sexual abuse. Once that plan was accepted by investigators on Jan. 28, 2025, the hospital’s immediate jeopardy status was lifted. Excerpts of a 2025 inspection into St. Peter’s Health in Helena by federal investigators with the Centers for Medicare and Medicaid Services, a watchdog agency that reviews patient abuse and neglect reports. Credit: Lauren Miller / Montana Free Press, CatchLight Local/Report for America A nonprofit hospital, St. Peter’s is one of the largest employers in Helena, with roughly 1,800 employees. It serves around 100,000 residents from Lewis and Clark and surrounding counties, according to the hospital’s website.  A spokesperson for the hospital declined to answer specific questions from Montana Free Press about the findings of the federal investigation and the hospital’s response. The hospital also declined several requests from MTFP to interview hospital CEO Wade Johnson or other administration officials about the report.  In a series of statements, St. Peter’s spokesperson Jacquelyn Tescher said the hospital has changed its protocols in light of the federal investigation’s findings. “All of us at St. Peter’s Health are deeply troubled and saddened by what happened. The actions of these individuals do not reflect the care and commitment we have for our patients, families, and this community,” Tescher wrote in an email to MTFP.  The hospital did not provide specific dates or details about its internal actions, but Tescher said that the repeated lack of documentation flagged by federal investigators didn’t necessarily mean that hospital staff had been unresponsive to patient complaints.  “While our staff took immediate action and began an internal review on each concern, the initial concern and actions taken were not always immediately documented. In some instances, documentation occurred after a concern was founded and corrective actions had been implemented,” Tescher said. “… We have learned through this process that [the Centers for Medicare and Medicaid Services] requires more timely reporting and specific documentation mechanisms be used in addition to the protocols we have in place. We have adopted those updated protocols, and our entire team has been trained to use them.” Although the Helena hospital appeared to avoid long-term repercussions from federal officials for its mishandling of sexual abuse complaints, the findings of the investigation raise new questions about the internal safety protocols at St. Peter’s after officials there said publicly that one of its longtime cancer physicians, Dr. Thomas Weiner, had harmed patients. St. Peter’s has faced several lawsuits over alleged negligence and malpractice related to Weiner’s care since it fired him in 2020. Tescher did not directly answer a question about how the hospital intends to rebuild the community’s trust in the wake of the federal investigation. As part of the hospital’s statement, she said St. Peter’s takes “very seriously” the privilege and responsibility of caring for patients’ health and well-being.  “St. Peter’s is committed to acting with integrity as we continue to rebuild trust and provide the great care and experience our community deserves,” Tescher wrote. ‘STAFF MEMBER A’ The accused male staff member, along with all other employees, is anonymous in the federal investigation and only referred to by a letter of the alphabet. Inspectors labeled the male nurse as “staff member A.” But the details of that employee’s actions and the timeline of his related disciplinary proceedings, as laid out by federal health inspectors, match those included in a felony criminal complaint and a state licensing investigation against Gams, the former St. Peter’s nurse the hospital fired in October 2024. Federal investigators recounted that, roughly six months after the oncology patient complained about staff member A, another patient contacted a different hospital employee to report that staff member A had abused her when she was incapacitated in the intensive care unit in 2023.  The patient had, for nearly a year, believed her recollections were a figment of her imagination, according to the report she later filed with local law enforcement. That perception changed when the nurse texted her in late September 2024, introduced himself as Gams and asked to talk about what had happened, according to charging documents. The patient concluded that Gams had obtained her personal cellphone number from her medical records, a breach of patient privacy laws.  On Oct. 8, 2024, less than two weeks after she first heard from Gams, federal investigators said the patient reported the text messages and her recollections from the ICU to a hospital employee. But health inspectors found that multiple staff members who learned of the incident — either directly from the patient or from colleagues — did not immediately complete an official report about the woman’s account.  Inspectors noted that another higher-up staff member was informed about the second patient’s accusation the following day, a Wednesday, but that staff member A was not placed on administrative leave until Friday, two days later. At that time, inspectors noted that “no incident report was created,” an omission that they found violated the hospital’s own internal protocols. Investigators said that someone in the facility eventually entered the incident into the hospital’s official reporting system in mid-November, more than a month after the former ICU patient first reached out. Asked by MTFP to respond to the federal findings about documentation failures related to staff member A, Tescher pushed back, describing the hospital as having taken assertive action in the case that was also reported to local law enforcement.  “Upon receiving the report of this nurse’s behavior towards a patient, they never worked another shift, and they never cared for another patient. St. Peter’s Health followed its reporting procedures and fully cooperated with law enforcement in its investigation,” she said in an emailed statement. “To be clear, when an allegation is reported, we take immediate action to protect patients and work with appropriate authorities on next steps.” But the federal inspection indicates that the first known complaint against staff member A, originating from the since-deceased oncology patient, did not reach the upper levels of the hospital’s administration until January 2025, roughly nine months after it was originally made.  Two days after MTFP reported on Gams’ arrest on Dec. 31, 2025, one of the staff members who had been told about the oncology patient’s sexual abuse complaint shared the account with a higher-level hospital employee, according to internal emails reviewed by federal investigators and their interviews with staff.  “Review of a facility email from staff member C to staff member W, dated 1/2/25 at 4:15 p.m., confirmed that allegations of sexual abuse made by patient #2 against staff member A around April 2024, were not communicated to staff member W until approximately nine months after the allegations were made,” the inspection said. Excerpts of a 2025 inspection into St. Peter’s Health in Helena by federal investigators with the Centers for Medicare and Medicaid Services, a watchdog agency that reviews patient abuse and neglect reports. Credit: Lauren Miller / Montana Free Press, CatchLight Local/Report for America Tescher did not respond to specific questions about the multi-month delay in the report about the oncology patient’s complaint. Hospital officials did take action after Gams was placed on administrative leave in October 2024 to determine whether he had improperly accessed other patients’ medical records.  The hospital’s internal audit confirmed that he had. In total, the federal inspection said, St. Peter’s staff found that staff member A had inappropriately accessed “around a dozen” patient records. In an interview with investigators, one upper administration official said there appeared to be “a pattern of staff member A accessing former ICU patients’ charts after they discharged from the facility.” The federal report did not say whether Gams used those records to contact other patients, but it noted that the administrator said that the hospital had not reached out to the affected patients “to inquire with the patients or their representative if they had concerns regarding their care.” Tescher did not respond to MTFP’s questions about whether the hospital had notified those patients about its findings since the federal inspection ended.  Gams’ attorney did not respond to a list of questions from MTFP about the findings of the federal investigators, including the account about another patient who apparently accused Gams of sexual assault in 2024.  “Because this is an ongoing case, I am unable to comment on your questions,” Gams’ Helena attorney, Misty Gaubatz, wrote in an email, noting that her client had pleaded not guilty to a single pending charge, which prosecutors brought based on the account of the former ICU patient. ACCUSATIONS AGAINST A SECOND NURSE  Federal investigators detailed allegations against another staff member accused of harassing and inappropriately touching patients. The report identified her only as “staff member AAA,” describing her as a female nurse who worked on the Behavioral Health Unit.  According to the inspection, the nurse was accused of sexually harassing and abusing a male patient who had been hospitalized in the psychiatric unit in June 2024. The patient informed other staff members in writing that he had “experienced sexual harassment/abuse” from the nurse during his hospitalization, including, in the patient’s words, “inappropriate touching in private areas kissing hugging trying to have a relationship.” As part of that complaint, the patient described his confusion about the woman’s treatment of him, adding that he wasn’t “in the right frame of mind” and that it took him “a few days to realize that this behavior is very inappropriate and extremely unprofessional.” Excerpts of a 2025 inspection into St. Peter’s Health in Helena by federal investigators with the Centers for Medicare and Medicaid Services, a watchdog agency that reviews patient abuse and neglect reports. Credit: Lauren Miller / Montana Free Press, CatchLight Local/Report for America Within days of the patient delivering his written grievance, at least five staff members read or learned about his allegations against staff member AAA, federal investigators found. None of them documented the patient’s complaint in an official incident report, the inspection said.  One of the employees, when passing the patient’s allegation onto her supervising director, shared other misgivings about the female nurse’s behavior. Among those concerns, that colleague recounted hearing staff member AAA describe another patient as “cute” and that she had given that patient “a backrub.” Federal inspectors spoke to the male patient who originally reported staff member AAA. In that conversation, the former patient “stated he had been struggling every day since the sexual abuse.” He also told investigators that he was “concerned that staff member AAA had sexually assaulted other patients on the unit.” In response to questions about the nurse’s current employment status with St. Peter’s, Tescher said that staff member AAA had been a contracted nurse who was “immediately” removed from patient care after the hospital administration learned of the allegations. “Upon receiving a report of this safety concern, the contracted nurse was immediately removed from patient care. Their employer was contacted and we sent a report to the nurse licensing board. They never worked at St. Peter’s Health again,” Tescher wrote. Tescher said that the abuse allegations against the female nurse came only from one patient, despite the federal inspection report referencing another staff member’s observations about her conduct toward another patient.  Tescher did not respond to an additional question from MTFP regarding when the hospital became aware of the report against the contracted nurse and when she was removed from caring for patients. REBUILDING TRUST Throughout the report, federal inspectors reiterated the systemic shortfalls in the hospital’s process for documenting and investigating sexual assault complaints. Those failures, investigators said, had put all patients at risk of inappropriate treatment. In June of last year, hospital officials updated the federal agency on its progress in a report on St. Peter’s letterhead. The hospital said it had increased training about how to handle reports of sexual abuse, including featuring “educational content” in its internal newsroom about the importance of “responding to, reporting, and investigating abuse and neglect.” The hospital also said it had launched in-person training for its employees about “patient safety culture,” facilitated by CEO Johnson.  That same month, federal officials completed a follow-up inspection about the hospital’s compliance with requirements about documenting abuse reports. Investigators found that St. Peter’s “had corrected the areas of deficient practice.” In an email earlier this month, a spokesperson for the federal agency confirmed to MTFP that St. Peter’s is in compliance with its policies and regulations.  “[T]here have been no additional surveys at the facility since,” the spokesperson said.  Tescher, the hospital spokesperson, said the hospital’s disciplinary status had been removed because of the significant improvement in its protocols. “The immediate jeopardy classification was lifted because St. Peter’s implemented a robust reporting/documentation training program for all 1,800 caregivers. This focus on reporting/documentation training continues for all employees annually and new employees during their onboarding process,” Tescher wrote.  “Patients and families trust us to provide quality, safe and compassionate care each time they come to St. Peter’s,” she continued. “We are committed to earning our community’s trust each day by learning and continually improving in everything we do.” In-depth, independent reporting on the stories impacting your community from reporters who know your town. The post Inside the ‘systemic’ sexual abuse reporting failure at a Helena hospital appeared first on Montana Free Press. ...read more read less