After a string of deaths at the state mental hospital, inspectors said infrequent programming, unmanageable staffing levels and out-of-touch decision makers led to patient despair.

A report issued last week recommended the hospital reduce physical restraints and seclusions by half, empower hands-on staff to make more clinical decisions and restore programming.

Three independent evaluators — Dr. Joel Dvoskin, Dr. Susan Stone and social worker James Smith — issued the report after interviewing staff and reviewing hospital records following the patient deaths.

Troy Allen Geske, 41, died Aug. 10 while in restraint; Sergio Taylor, 23, killed himself Sept. 10, 2009, shortly after signing a petition asking that programming be restored; and Joshua Garcia, 21, died Oct. 8, 2007, after being overmedicated. The hospital settled a lawsuit by Garcia’s family for $223,202.

Denver’s 7News also reported last week that Pueblo District Attorney Bill Thiebaut had initiated a grand-jury investigation of recent deaths at the hospital. Thiebaut did not return messages Tuesday.

The report by the hospital inspectors said staff morale was low in a hospital culture focused on security rather than clinical care.

“The entire hospital is on suicide watch,” one of the inspectors said. “Staff members appear anxious, significantly heightening patient stress levels.”

“Based on this report and other internal reviews the department has conducted in recent months, we will develop a comprehensive plan going forward to improve the care and treatment we provide to patients,” Colorado Department of Human Services executive director Karen Beye said in a statement.

The new forensic hospital was designed for all-day programming, but programming facilities are rarely used because of staff shortages, the report says. Patients stay in their residential pods most of the time.

The atmosphere is “stark.” Patient rooms didn’t have personal photos on walls, and “fun-house” mirrors give distorted reflections of patients and should be replaced with safety mirrors.

“Hope is also difficult to maintain when patients feel that their progress and privileges are being arbitrarily denied, ” the report says.

The hospital — which averages 700 restraints and seclusions a year — relies far too often on these tough measures. Patients could be sent to “comfort rooms.”

The hospital is understaffed by 20 percent, leaving psychiatrists frustrated and “angry.”

The report recommended revamping the hospital’s leadership structure, in which administrative policy decisions were “knee-jerk” and not driven by front-line workers who best understood issues.

The inspectors recommended that the hospital create a suicide-prevention committee.