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Home My WebLink AboutAttachment 7.g.vi. - Public Comments No 6PUBLIC COMMENTS NO 6 Caroline Young From: Ian Burger < Sent: Tuesday, September 7, 20214:36 PM To: Ian Burgar; Stan Donn Cc: Caroline Young; Tiffany Allen; John McCann; John Teevan; Luke.Bergmann@sdcounty.ca.gov; Jill Galver, mdiaz@chulavistaca.gov, Montano, Monica; Mary Sales; Patricia Salvacion; Steve C. Padilla; Bibi luko; Andrea Cardenas; j pencemoot@ icioud.com Subject: Scripps sued SD City attorney All, Hop you are well. I am sure you have heard but Scripps Is being sued by the SD City Attorney for Illegal patient dumping, specifically mentally ill patients. Those In favor of this project like to tell us "don't worry Scripps will provide overwatch on Acadia." The 5,000 residents who signed the petition and the 500 plus who commented In opposition on the EIR find this latest development extremely concerning and look forward to the findings from the Investigation. We are hopeful those in Chula Vista government will continue to take out concerns seriously. A civil complaint filed in San Diego Superior Court on Friday alleges that the hospital failed to have an effective process when discharging patients who are likely to suffer adverse consequences after leaving, and of failing to get the man to an appropriate facility for follow-up care. httos://enewspaper.sandleeouniontribune.c,om/infinity/article share.asox?guid=971baa23-53e2-4cOd-98ba- g7936a73000f Sent from my Phone 10119/21, 2'.31 PM htlps://enewspepersandlegounlontdbune.cam/lnfinity/article_share.aspx7guld=971baa23Z3a24oOd.98bo.o7936a7"T Scripps is accused of illegally discharging patient Health care system says city attorney's claims are `completely outrageous' By Teri Figueroa SAN DIEGO The San Diego City Attorney's Office has accused a Scripps Health hospital of illegally discharging a "gravely disabled" mentally ill man to a group home instead of finding him a bed in a locked skilled nursing facility. A civil complaint filed in San Diego Superior Court on Friday alleges that the hospital failed to have an effective process when discharging patients who are likely to suffer adverse consequences after leaving, and of failing to get the man to an appropriate facility for follow-up care, The civil action accuses Scripps Health of violating state codes prohibiting unfair competition. The City Attorney's Office is seeking civil penalties of $x million, "Our Office is putting San Diego hospitals on notice that `patient dumping' is inhumane, illegal, and will not be tolerated," City Attorney Mara Elliott said in a news release. "Scripps Health knew this vulnerable patient could not care for himself, and instead of putting his well-being first, left him to fend for himself. This conduct is inexcusable and horrific." In a statement, Scripps said it cannot comment on the specifics of any patient's case, but "we can say that we totally disagree" with the action filed by the City Attorney's Office. "We believe their claims have no merit, are completely outrageous and are unwarranted," Scripps' statement reads. The organization said it "would never engage in patient dumping," and noted that the California Department of Public Health found no deficiencies in actions taken by Scripps Mercy. "We find it unbelievable that the City Attorney's office would portray our role in this case the way they are and that they would use it to disparage the great work the staff at Mercy does day in and day out to help the most vulnerable among us," the statement reads. hthml/mews rsendleaounlontrlbune.00mAnMlty/eAcle share.asox7auWtl 071bas23- 2dcD699baa7936a730Mf 119 10/19/21,2:31 PM https://enewgpapersandiagounimtdbune,wnlinflniy/arUcla shaeAspx7guid=971baa23-53e2-4cod-98ba-e79W73000f According to the complaint, a 68 -year-old man who was diagnosed with schizophrenia was found naked and delusional — he thought the year was 1992 -- in the living room of the College Area group home where be resided in September 2019. He was placed on an involuntary psychiatric hold and taken to Scripps Mercy Hospital in Hillcrest, where he was found to be gravely disabled and unable to care for himself. The complaint asserts that the man was placed under a conservatorship, and in November 201g, a San Diego Superior Court judge ordered he be placed in a locked treatment facility. According to the complaint, his medical records indicate that skilled care facilities would not take him. In December 20ig, he was discharged to an independent living facility and left to take care of getting his own prescriptions and making his medical appointments, the complaint alleges. The City Attorney's Office contends that it that checked on the man and found him in a state that led the office to call a psychiatricemergency response team. The man was placed on an involuntary hold at a different hospital. Eventually, the man — who has no family, according to the complaint — was placed in a locked skilled nursing facility in Yucaipa, in San Bernardino County. teri.figueroa@sduniontribune.com httpad/enewspapersandlegonimtdb,m.wninfiniy/anicle,share.aapx79tdd=971baa23-53e24d)498b"793Ba73000( 22 Caroline Young From: Marylupe Flares - -1 _ o Sent: Thursday, September 2, 20219:24 AM To: Stan Donn Cc: Caroline Young; Todd Philips; Patricia Salvation Subject: Re: "I oppose the Eastlake hospital location due to safety concerns." Attachments: Eastlake EIR Comments Flyer June202l.pdf rr°^`7' Great, thank youl Errriil`' We've all added our comments opposing this project (we all support mental health) but Acadia has an atrocious track record and just recently Scripps was accused of illegally discharging thegravelly disabled and severally mentally ill patients form their care (all links below). This is exactly what we want to avoid near our homes. Thanks again, htt s: /www.change.org/p/chula-vista-plannin commission city council relocate proposed Inpatient psychiatric h ospita I -away -fro m -schools -parks -homes h tt ps: //www,cbs8.com/article/news/Iota I/a p pos itio n -growing -to -proposed -psychiatric -hos pita I -i n -ch u la-vista/509- 98fS4b72-7d7c-4366-a347-fa2fbac1482e https://Iaprensa-sandiego.org/cvmccanndebt/ https://enewspapersandiegouniontrlbune com/infinity/article share.asox?guid=971baa23-53e2-4cOd-98ba- e7936a73000f&fbclid=IwAR364I2BiBnLws5bW W sVww[HtmErAsNC170DRoB8 WVHsk6WVggmCQ8aAkzQ hms://californ iaglobe.com/section-2/politicians-prey-on-your-cam passion https://www,chulavistasafe.org/calls-for-service https://www.chufavistasafe.org/acadia-offenses Sent from my [Phone 6/)1/2021 NG_3020.FNG `- Eastlake Behavioral Hospital A 120 bed inpatient standalone psychiatric hospital COMMENT TO OPPOSE PROJECT LOCATION NOW! Open your phone camera and hold over this flyer to scan OR VISIT: tinyurl.com/OpposeAcadia 1A From: Marylupe Flores Sent: Tuesday, August 31, 20219:07 PM To; Stan Donn <Sdonn@chulavistaca,gov> Cc: Caroline Young <CYoun chulavistaca.eov_> Subject: Fwd: "I oppose the Eastlake hospital location due to safety concerns," Hello, I vehemently oppose this psych hospital being built near my home and children. I work in mental health and know both the need and benefits but everyone would be best served if it were built in the west side of Chula Vista. It would then be closer to Scripps medical hospital allowing for the full Integration of primary care and behavioral health. Also, I asked 2 yrs ago to be placed on the mailing list in the email below and never received anything. Please make sure I'm added to become aware of any updates. Thank you. Marylupe Flores 653 Prairie Drive Chula Vista, 91914 Sentfrom my Whone From: Miss M < .._-....,.,,__...> Sent: Sunday, August 29, 202111:09 PM To: Caroline Young <CYounaCdchulavistaca,eov> Subject: Re: Eastlake Psychiatric Hospital Email~ Good evening Caroline, I was referred to you in order to obtain the following information: A list of all the projects from 1/1/2016 through present that have received an approved CUP from the city of Chula Vista, Also, I want it on record that in regards to the EIR that was submitted for public comments, I would also like to add that numerous times within the EIR the last sentence in many paragraphs was "impacts would be less than significant." This is an arbitrary statement meant to sway the reader while having little to no factual basis. What is significant to one person may not be significant to another. The purpose of the EIR was to show facts and data NOT to give an opinion over and over to persuade the reader. Furthermore, many of the individuals that commented in support of the facility are not true community supporters of the project. Here is a breakdown of some of the individuals that showed support for this project: ** Michael Vogt - owner of the property to be sold. A vested interest in the project being approved and therefore not a reliable source. Also does not live in Eastlake. ** Arabella Adolfsson - relative to the Vogt family and does not live in Chula Vista. Biased and not a true community supporter for this project. `* Robert Scott - Volunteers for Scripps and only supports if impacts to the neighborhood are properly mitigated. ** Jim Lowther - insurance broker with a vested interest in the project being approved also not a resident of Chula Vista. Not a true community supporter of this project. ** Greg Abell - Owns an electric company in Lakeside and does not live in Chula Vista. Not a true community supporter of this project. ** Omar Michel - Does not live in Chula Vista. Not a true community supporter of this project. ** Jim Mulvihill - Does not live in Chula Vista. ** Michael Real - Does not live In Chula Vista. Not a true community supporter of this project. ** John Sheridan - Does not live in Chula Vista and refers to the company as Arcadia multiple times. Not a true community supporter of this project. ** Howard Greenberg - Does not live in Eastlake and refers to the company as Arcadia. Not a true community supporter of this project. ** Catherine Nicholas - Does not live in Eastlake. Not a true community supporter of this project ** approximately 4-5 supporting comments from the Chula Vista Chamber of Commerce. The main function of a chamber of commerce is to promote interest in local business possibilities, They assist businesses with the latest marketing and promotional techniques. Their job is to promote business and not to objectively analyze and determine whether a business is a good fit for the community. Thank you Sent from Outlook Caroline Youn From: an Burgar Sent: Tuesday, March 23, 2021 BAS AM To: Caroline Young; Tiffany Allen Cc: John McCann; John Moot; John Taevan; Luke.Bergmann@sdcounty.cagov; gammiere,tom@scrlppshealth.org; lilt Galvez; Mike Diaz; Montano, Monica; Mary Salas; Patricia Salvation; Steve C, Padilla; tallen@chulavista.gov; Bibi luko; Andrea Cardenas Subject: New Acadia Lawsuit ki¢Yhal ' All, I hope this note finds you well. The complaint In the lawsuit aligns with CVSAFE's position that Acadia rlt8il is not the for profit corporation to care for our residents and be a good corporate actor and neighbor. Here Is the complainant and site. CVSAFE is looking forward to participating in the EIR process. Kaskela Law LLC announces that it is investigating Acadia Healthcare Company, Inc According to the amended complaint, during that time period the "defendants engaged in a scheme to defraud and made numerous materially false and misleading statements and omissions to investors regarding Acadia's business and operations," including by falsely stating that: (i) offering quality care was of fundamental importance to Acadia's business model, and that its facilities provided high-quality care that would drive Acadia's success; (ii) Acadia adequately staffed its facilities to ensure its ability to provide appropriate care to patients; (iii) Acadia's facilities were in compliance with relevant regulatory requirements https://kaskelalaw.com/case/acadia-healthcare-comi)any-inc Sent from my Whone Caroline Youn From: Ian Burgar Sent: Friday, October 2, 2020 7047 AM To: Caroline Young Cc: John McCann; Jahn Moot; John Teevan; Luke.Bergmann@sdcounty.ca.gov; gammiere.tom@scrippshealth.org; Jill Galvez; Mike Diaz; Montana, Monica; Mary Sales; Patricia Salvation; Steve C. Padilla; tallen@chulavista.gov; In luko Subject: Acadia - Real Escapes and calls for Service [Email'.._ All, If you read only one of my updates on this topic this is the one. The residents of Eastlake have shared that escapes (elopements) do happen and are a major concern along with calls for service. Please read the actual police lois from September of this year for an Acadia facility. The link to the source article is included as well. These issues are real and the risks to residents are real. Acadia at the open house said this does not happen. If what happened at this facility happened here you would have CVPD units and K9's chasing patients through our neighborhoods and child focused businesses. Here are the police logs: FAYETTEVILLE POLICE INCIDENT REPORTS September 18 and 19 PRTC had at least five visits by law enforcement. Concerns included missing persons, a found person, and disturbance. The reports were obtained through a Freedom of Information Act request. 9/18/20 6:59p. Assist Agency, Fayetteville. Request police assistance with compliant subjects. Asking for an emergency response. The original call is for a fire alarm. Subjects possibly attempted to burn something causing the alarm to go off. Fire Marshal has been advised, 19:05p. Subjects in question are detained. 19:06p, juveniles running everywhere and having Issues containing them. Sixteen staff to deal with approximately 100 subjects at the facility. 19:08p, Breach of the facility and subjects have fled on foot.19r09p. Piney Ridge now stating juvenile fled. 19:10p. Left on foot northbound toward Zion. W/M approx. 15-16 years old, sandy brown hair. T-shirt and jeans. 19:12p. Have several subjects causing riots, attempting to break down doors. Officer safety. 19:17p. Open line with male cursing, upset about a K9, screaming, plotting, 19:18p, Can hear police sirens, cursing about the police, 19:19p. Close to 2800 block of Zion. 19:20p. Staff member reporting a juvenile who eloped (female). [Officer] Have stepped back off the premises at this time, 19:21p, Have staff members questioning why units are on the scene. A 10-19 [officer en route] to location. 1912p. Waiting for the CEO to arrive. Made contact with the original staff member who called on both incidents. Two juveniles ran off. 19:25p, They do not want units inside with weapons. They will attempt to solve everything inside, without assistance. We will hold a perimeter and attempt to locate the missing subjects. 20:00p. The juvenile has been located at the Kum & Go on Thompson in Springdale. 20:26p. WM,15 years old. Report 20-71442, BOLD (be on the lookout) issued. 20:56p. The juvenile is entered as missing. Records notified. 9/18/20.9:54p. Recovery Report. 22:06p. Juvenile recovered, will include in original report 20-71442. 9/19/20.9.22p. Disturbance. 21:22p. Advised that four to five inmates have escaped and are assaulting staff members. 21:23p. Physical. Denying medical. One subject left on foot toward Zion. 21:24. W/M, brown hair, 6 feet, 180, wearing a T- shirt, jeans, no shoes. Four subjects still on the scene fighting with the staff, verbal only at this time. 21:25 Main aggressor, unknown what caused them to start fighting with staff. No illness concerns. 21:40p. One juvenile running in the woods calling for help. All other juveniles have been recovered. 21:42p. Last juvenile recovered. 21:45. Two more juveniles missing. 21.56p.Two confirmed missing, 23:04p. Missing W/M. Blue eyes, dirty blond hair. Left on foot, only family is in Wyoming. 23:12p. Entered subject as missing. 23:1 7p. Subject is approx. 5-8,143. 9/19/2020. 1 Op, Missing Person. 22:01p. Incident for missing person. 22:27. W/M, age 17, 6 feet, 192 pounds, blue eyes, brown hair. Cast seen wearing a black hat and jacket, jeans, and white shoes. Between June to September, law enforcement dispatch logs show eight missing person calls from PRTC. Below are portions of two reports. 8/20/2011:45a. Missing Person. A juvenile, 13 -year-old male, climbed over the fence. Two staff are possibly chasing after him. Unknown what he was wearing. He has not escaped before. No other juveniles left with him. 11;51a. Last seen southbound on Crossover. His group usually talks about eloping. 11:54a. This Is not unusual. They try to pian an escape all the time.T 11:57a. [PRTC employee] has him in her vehicle now. 11:58a. Walling in the building now with him. 8/22/20.20:59p. Missing Person. Unknown date of birth of 15-16 year old. Hopped the fence. Last seen westbound toward the apartment complexes. W/M, approx. 5'8", 140, sandy blond short hair. Shirt, shorts, tennis shoes. 21:02p. Concerned about the wooded area southwest of the location. 21:05p. Unknown where he may be going. There were others trying to leave with him. 21.26p. BOLO issued. Last seen running west from PRTC 25 minutes ago. 21:52p. Searched the area did not locate the juvenile. 8/25/20.14.53p. Required to remove juvenile as missing _ notified. Fayetteville Fire and Dispatch logs indicate, on average, calls were made every other day for four months from June 1, 2020, to September 22, 2020. Many calls were to the fire department for an alarm going off, or a sprinkler, Other calls involved missing children, assault/battery, disturbance, mental person, https://www.nwahomeoage-com/news/a-closer .1oo Va-dose r-look-p in ey-ridge-treatm ent-cente r - u nderstaffed-sou rces-say/ Caroline Young From: Justin Layman - > Sent: Saturday, September 5, 2020 3:07 PM To: Caroline Young; Kelly Broughton; jmccann@chulavista.gov Subject: Opposing the construction of the Acadia facility $mail'. I have been a resident of CV since 88 and I oppose this facility being built in the proposed area. The closest hospital Is 5+ miles away. Such facilities are traditionally located on or near an established med campus for the safety of patients. Stats show similar facilities generate numerous calls for service for missing persons (elopements) as well as violence -related offenses. Due to budget constraints, there is no organic police presence In eastern CV, as a result response times are less than desirable. Patients admitted Involuntarily have the ability to refuse further treatment, and leave on their own ..without atreatment planinplace, or they may demand a premature discharge. Profit driven operators (Acadia) release patients when their Insurance runs out. Given the proposed location, In a suburban neighborhood, where will the patients go and what environmental or similar damage will be caused to the area as a result during that time? Elopements (escapes) and other disruptions may trigger lockdowns at schools/businesses within a t mile radius. Acadia will be 80% majority owner. In 2019 Acadia, 11 days b4 they filed an app with the City to build the proposed facility, agreed to a $17M h -care fraud settlement resulting from a scheme to defraud Medicaid, They have been named in lawsuits claiming sexual abuse of its patients,. failure to adhere to professional standards of care, and terminating employees for reporting criminal/illegal or otherwise unsafe operation s/activities, Justin Layman Caroline Young From: Ian Burgar Sent: Thursday, September 3, 2020 4:19 PM To: Caroline Young Cc: John McCann; Kelly Broughton; All Galvez; Mike Diaz; Mary Salas; Patricia Salvacion; Steve C. Padilla; montano.monica@scrippshealth.org; gammiere.tom@scrippshealth.org; Luke.Bergmann@sdcounty.ca.gov; John Teevam; John Moot Subject: How Acadia Treats Employees - COVID Chula Vista deserves better: At a Santa Fe rehab, masks were optional — but showing up at work with COVID-19 symptoms was mandatory Everhart, a mental health therapist, had good reason to fear she'd been exposed: There recently had been an outbreak of 10 cases at the rehab center where she worked. Everhart called her supervisor at Life Healing Center in Santa Fe and described her symptoms. She thought she should stay home in quarantine. Instead, her supervisor told her that if her temperature cooled down by morning — which it did — she should show up at work. A few days later, she tested positive for COVID-19. "It was egregious," Everhart said. Not only did she have symptoms, but her supervisor knew she'd been in direct contact with clients who'd tested positive for the virus. "For them to be asking me to come in anyway just seemed really ridiculous." She resigned over the incident. Acadia Healthcare, the multinational behavioral health behemoth that owns Life Healing Center. Life Healing Center's CEO, David Hans, declined a request for an interview. An Acadia spokesperson did not respond to multiple interview requests. httos;//searchlighmm.org/the-working-sick/ Sent from my Whone Caroline Young From: Ian Burgar < Sent: Thursday, July 23, 2020 3:41 PM To: Caroline Young Cc: John McCann; Kelly Broughton; Jill Galvez; Mike Diaz; Mary Salas; Patricia Salvacion; Steve C. Padilla; montano.monica@scrippshealth.org; gammiere.tom@scrippshealth.org; Luke,Bergmann@sdcounty.ca.gov; John Teovan; Johnm@jmootlaw.com Subject: Acadia kids & COVID All, Sharing a new example of Acadia and those in their care—doesn't Chula Vista deserve better? According to former staff we are in touch with this is almost half the children in their care: The Piney Ridge Center is a treatment center for minors and adolescents who are struggling with problematic sexual behaviors alongside mental illness. There have been 40 reported coronavirus (COVID-19) cases at the Piney Ridge Center in Fayetteville, with 38 of the cases still active, according to the Arkansas Department of Health (ADH), The 38 active cases include 29 residents at the center and nine staff members htC s: wygw Bnewsonline com/mobllelartide/news/local/ninev-rldee,£entor-fayetteville-coronavirus-cases/527- 3b326302-7c74-4e9a-80ce-919a7f8ccb52 Sent from my !Phone 38 active coronavirus cases repor(ed at Piney Ridge Center in Fayetteville ( 5newsontine.c... Page I of 3 Your browser is not fully supported. L"thIIfast" aauppert,Ana."'grade 10" h"dere hewon, s' a, as �Mreal U, 10Cn1. NEws 38 active coronavirus cases reported at Piney Ridge Center in Fayetteville There have been 40 reported coronavirus cases at the Piney Ridge Center In Fayetteville, with 38 of the cases still active. t.-., <. ,lar Anrom 5NEWS Web Starr nmmcnaa_Safe PM CDT An, 7,102a ......... leas PM GOT lel, 7, iota FAYETTEVILLE. Ark. — There have been 40 reported coronavirus (COVID-19) cases at the Piney Rltlge Center In Fayetteville, with 88 of the cases still active, according to the Arkansas Department of Health (ADH(. The Piney Ridge Center is a treatment center for ntino*s and adolescents who are struggling with problematic sexual behaviors alongside mental Illness. 38 active coronavirus Cases reported at Piney Ridge Center in Fayetteville I 5newstarthi .c... Page 2 0l'3 The 38 acilve cases Occlude 29 resldents at the center and nine staff members. Two staff members have recovered from the vlrus, according to the ADPL As of Tuesday. July 7, there have been 4,137 COVID-09 cases repeated In Washington County, with 1,106 of the cases still solve. RELATED: Coronavirus kt Arkansas: Tracking COVIO.19 Where You Live RELATED: Records: Fayetteville Youth Treatment Center Broke Federal Rules T.dey's Refl/nence lint, 9,Iwt Lau.Aasont 2.41x/ma% Cakulnto Panto( ALL 15 vena Fla,a I'ftnm//twnuw Snr,...omu li nc ram/set;" N/news/I nrn I W...V_.;1I n.1--"v,,-f —ft—; lln_nnnn ,v..1. 9/1 QMAOA Caroline Young From: Andrea Landis _ Sent: Friday, July 17, 2020 10:57 AM To: Patricia Salvacion; Mary Sales; Jill Galvez; Mike Diaz; jccann®chulavistaca.gov'; Steve C. Padilla;'kbrouhton@chulavistaca.gov'; Caroline Young Subject: Support for Eastlake Behavioral Health Hospital Attachments: SBCS Support Letter- Eastlake Behavioral Healthpdf am- Enternal Good morning, Emait On behalf of Kathie Lembo, President and CEO of South Bay Community Services, I am submitting the attached letter of support for Eastlake Behavioral Health Hospital. Thank you, Andrea Landis ANDREA LANDIS Director of Communications South Bay Community Services 019.420-8020 x2190 SouthSayCommunity8ervices.org l CVPromise.org IMPORTANT NOTICE: This e-mail message is intended to be received only by persons entitled to receive the confidential Information it may contain. E-mail messages may contain Information that Is confidential and legally privileged. Please do not read, copy, forward, orstore this message unless you are an intended recipient of it. If you have received this message in error, please forward itto the sender and delete it completely from your computersystem. isbcsD 4: 'was &%N' F:wr:alul,il., July 7, 2020 Mr. Gabriel Gutierrez, Chair City of Chula Vista Planning Commission 276 Fourth Avenue Chula Vista, CA 91910 RE: Support for Eastlake Behavioral Health Hospital Dear Chairman Gutierrez: On behalf of South Bay Community Services, I am writing to share our support for the Eastlake Behavioral Health Hospital, proposed as a joint venture between Scripps Health and Acadia Healthcare. This project will significantly expand critically needed behavioral health treatment capacity in the South County region. For nearly 50 years, South Bay Community Services has been dedicated to supporting the well-being and prosperity of San Diego children, youth and families. Through comprehensive and coordinated services and supports focused in the areas of child wellbeing; youth development and education; family wellness and community engagement, we assist all individuals and communities to reach their fullest potential, touching the lives of more than 50,000 each year. SBCS' services include: • Housing assistance • Academic support • Independent living skills • Employment readiness • Financial literacy services • Mental health counseling • Domestic violence Et child abuse intervention • Juvenile crimes prevention • Therapeutic educational programming • Meals and nutritional support As a provider of mental health counseling ourselves, we are acutely aware of the shortage of inpatient beds in our community and region. Based on recommendations from the California Hospital Association about the number of beds needed, South County currently has less than half of the beds we need to serve our community. At the same time, the demand for mental health care continues to grow. This is a public health issue that urgently needs to be addressed. South Bay Community Services 430 F Street • Chula Vista, California 91910 SouthBayCornrinunfityServices.org 0: 619.420.3620 • F: 619.420.8722 4tiy:t lays„ isbcsl F .i��.u.lIPp16 lII tl9� . vP,,I .m. el . Y ... Approving the Eastlake Behavioral Health Hospital will add 120 beds, which will bring the number of beds in South County to about 90% of what we currently need. Scripps Health has a strong track record and history in our region of providing high quality and accessible health care to the community. Their partner, Acadia Healthcare, has the demonstrated behavioral health expertise to provide individualized and quality care to patients in need and has agreed to abide by Scripps' charity care policy, ensuring that these services are available to all. This partnership will bring a much-needed public health resource to our community. I hope you will join us in supporting this important project. Thank you for your consideration. Sincerely, Kathryn Lembo President & CEO South Bay Community Services cc: Mayor Mary Salas Councilmember John McCann Councilmember Mike Diaz Councilmember Jill Galvaz Councilmember Steve Padilla Planning Commissioner Max Zaker Planning Commissioner Michael De La Rosa Planning Commissioner Jerome Torres Planning Commissioner Krista Burroughs Planning Commissioner Javier Nava Planning Commissioner Jon Milburn Kelly Broughton, Director., Development Services Department Stan Donn, Senior Planner, Development Services Department Caroline Young, Associate Planner/Project Mgr, Development Services Dept, Patricia Salvation, Planning Commission Secretary South Bay Comrnunity Services 430 F Street • Chula Vista, California 91910 Sou thBayCoirimunityServices. org 0: 619.420.3620 • F: 619.420,8722 IIITWW =0WRIZZ,Mh v"ArrM � 1 ,.:,fir .u. , WWZ Caroline Young From: Patricia Salvacion on behalf of Department Administration Sent: Wednesday, July 1, 2020 10:19 AM To: Caroline Young Subject: FW: City of Chula Vista: Web Contact Us - General Inquiry From: Communications <communications@chulavistaca.gov> Sent Tuesday, June 30, 202010:23 AM To: Department Administration <dsd@chulavistaca.gov> Subject FW: City of Chula Vista: Web Contact Us - General Inquiry From: w 1bMN e,J,@chulavistacg,ggy [webmaster@chulavistaca.gov] Sent: Monday, June 29, 2020 9:11 AM To: Communications Subject: City of Chula Vista: Web Contact Us - General Inquiry A new entry to a form/survey has been submitted. Form Name: General inquiry Date & Time: 06/29/2020 9:11 AM Response p: 5145 Submitter ID: 78881 IF address: 12.247.158.78 Time to complete: 8 min. , 45 sec. Survey Details Page 1 General Inquiries First Name Diana Last Name Gonzalez Email Address Comments Good morning - I am emailing you today to see If there Is any update on the Eastlake Behavioral Health Hospital, I am In full support of this project but I want to see If It was still happening and If there is anyway I could look at the submitted application/design, Thank you Thank you, City of Chula Vista This Is an automated message generated by the Vision Content Management Systema. Please do not reply directly to this emall. 2 Caroline Youn From: Ian Burgar _.___..—.-..- Sent: Wednesday, June 10, 2020 6:21 AM To: Caroline Young Cc: John McCann; Kelly Broughton; Al Galvez; Mike Diaz; Mary Salas; Patricia Salvaclon; Steve C, Padilla; montano.monlea@scrippshealth.org; gammiere.tom@scrippshealth.org; Luke.Bergmann@sdcounty,ca.gov; John Teevan; Johnm@jmootlaw.com Subject: Acadia and the "misery mill" All I hope you are well. We appreciate everything you are doing during this difficult period. I wanted to resume our updates: This from the Chicago Tribune: httos://www.chicagotribu ne.com/investigations/ct-millcreek-arkansas-foster-child ren-sidebar-20200311- pbpgk5fzrrbm bm7n2771bu5avu-htmistorv:html Police logs, children, families paint troubled portrait of Millcreek 'misery mill' "Out of the various placements I was in, Millcreek was by far the worst, and to this day I would say Millcreek has been my worst life experience. That place beat out losing my family," said Specht, now an Academic All-Star at the University of Arkansas Pulaski Technical College. Said Specht: "We called it the misery mill." ...Millcreek and its parent company, the for-profit Acadia Healthcare, declined to comment. Sent from my !Phone Polio; logs, children, families painttroubled portrait of Millcreek'misery mill' - Chicago ... Page 1 of 9 LOG IN CORONAVIRUS IN ILLINOIS UPDATES INVESTIGATIONS Police logs, children, families paint troubled portrait of Millcreek'misery mill' By DAVID JACKSON CHICAGO TRIBUNE I MAR 12, 2020 v in & Stefan Specht, 24, shown last fall at home In North Little Rock, Arkansas, spent eight months at Millcreek in 2012 and 2013. He said residents called the facility "the misery mlli." (Stacey Wescott/Chicago Tribune) httnJhxn.nv nh{nnnntriknnn rnm/invn�rinntinnc/rr_...ilin.�.n4_�.L�,,..o�_fn�m._nhild..,n_o7A,..ho,7/9IOMn Police logs, chitdrea, families paint trooblcd portrait or Mi Ile tOck 'raiscry mill' - Chicago ... Page 3 or This story is being co -published with ProPublica Illinois. Leh IN CORONAVIRUS IN ILLINOIS UPDATES Millcreek Behavioral Health in Fordyce, Arkansas, has become a common destination for foster children from other states who are sent away for mental health treatment. But dozens of children from Arkansas also have cycled through Millcreek, and they, too, reported mistreatment and violence. Millcreek and its parent company, the for-profit Acadia Healthcare, declined to comment on specific facilities or individuals but said the company delivers superior outcomes for troubled children. The company said its facilities had never been decertified by any government health program or lost a license. In a statement provided to reporters, Acadia cautioned against drawing conclusions from "anecdotal, non -representative incidents." `A horrific time' The girl described her nine months at Millcreek as "horrific." She was 11 during her stay there. [Most read] Coronavirus in Illinois updates: 869 new known COVID- In cases reported as Lightfoot and Chicago officials threaten to shut down bars with violations over holiday weekend Now 16, she said she suffered a broken finger when a girl kicked her and that an employee punched her in the head while attempting a restraint, leaving her with a bruise on her forehead as well as sore ribs. Police logs, children, families paint troubled portrait of Millcreek 'misery mill' - Chicago ... Page 4 of 9 A 16 -year-old girl, far right, walks outside her home in Royal, Arkansas, with her 6 -year-old brother and her father last fall. The girl was 11 when she was treated at Mlllcreek aehavioraI Health, (Stacey Wescott/Chicago Tribune) Fordyce police logs from 2015 contain a one -sentence report based on a call the girl's mother, Susan Hunter, made about her daughter. "She has reported abuse from an adult at Millcreek and nothing has been done," said the police summary. It's unclear if the report relates to the girl's complaint about being restrained or another incident. Police declined to comment on whether they investigated. 61h..•//.. . .. �6:,. ..ro..:1....,0 ....... 1:..oe,.H..,,F:..«,. /,.F _M1 --d. ....L-«....,. A..w... _U!I.1.--. :b.,__ n11/norm Police logs, children, families paint troubled polaraitof Millereek'uuseq mill' - Chicago ... Page 5 of 9 When the 74A came home for an aunt's funeral, Hunter said, she spotted a bruise on her abdomen and her daughter told het• about how she was OG IN being treated at MillcfffiP. MAW AMM RiMMe facility. What disturbed the girl most about Millcreek, she said in an interview, was watching other girls suffer beatings. One incident started when volunteers brought blouses and two girls started to fight over them. One girl was beaten by the other while workers stood by, Hunter's daughter said. [Most read] Column: A chance encounter at a South Bend park leads to an honest dialogue on race » Afterward, a Millcreek worker urged the girl and her roommate to deny they'd seen anything, the girl said, adding: "She bribed me with McDonald's and a pink hair wig." `He got worse' In May 2018, Sara Pruitt recalled, Millcreek notified her that the facility was investigating an allegation that a worker had assaulted her 11 -year-old sen. But according to Pruitt, Millcreek would not provide details or put the boy on the phone. So Pruitt called Fordyce police. "Ail accusation of abuse by a staff member has been filed but no one will let her know what is going on / She wants a welfare check to be performed on her son," said the one -sentence police report. Police declined to comment on whether there was any follow -tip. Polios logs, children, families paint troubled portrait of Millereek'misery mill' - Chicago ... Page 6 of 9 A 12 -year-old boy climbs In the trees outside his home in Rogers, Arkansas, last fall. HIS mother, Sara Pruitt, alleges that an employee of MIIIcreek assaulted him when he was 11.(Stacey Wescott/Chicago Tribune) After Pruitt made that call, she said, her son was allowed to talk to her. He said a female worker had pushed him down, grabbed him by his hair and put her foot in his back. [Most read] New face masks made to battle the summer `sweat factor' but do they work? Here's what you need to know. Police logs, children, families paint h'ollbled portrait of Mil [crock 'misery inilP -Chi cago ... Page 7 of 9 Pruitt said `'er son's six months at Millcreek were a setback. "He got worse," she said.. LOG IN CORONAVIRUS IN ILLINOIS UPDATES `The misery mill' Stefan Specht, now 24, was shuttled through various foster homes and institutions after both of his parents died when he was a child. He spent eight months at Millcreek in 2012 and 2013. "Out of the various placements I was in, Millcreek was by far the worst, and to this day I would say Millcreek has been my worst life experience. That place beat out losing my family," said Specht, now an Academic All- Star at the University of Arkansas Pulaski Technical College. "The `cottages' were a cozy name for a not -cozy setup. You were around constant chaos," Specht said. "It was basically impossible to escape guys who would do anything to start a fight. Constant psychological warfare and assault." Said Specht: "We called it the misery mill." dyjackson @chicagotribune.corn ■ David Jackson David Jackson has been a Chicago Tribune investigative reporter since i991, ex opt for a yearat The Washington Post, whore 11e shared the 1999 Pulitzer Prize For public service for articles on citizens shot by police. At the Tribune he is a 4 -time Pulitzer finalist, httn://www.chicauotribune,contlinvestiL,ation.a/ct-millcreek-,irknnsas-fo,gte,r-children-gide.hnr_ 7/200M c*AITPf Wfq¢ QKRMIC 916YMCTgTKC 90a &11YE 2tl0 TE CAPIT04. ROOM4095 y1ryryjya`�ryry 6gWlXf fpWrtffR SACRAM6HTO. CA 9SS14 �QqR Yq��y�.yyy�y ��.yy((.�YY yy��yv Qy �4hM1 1A4ah h4 yY,y �HAL.y{`fiy#Rf MFix V(Mx9G4y1WJM:ggy [919161fiRh4pG0 (/' VV� ♦L bw FX %181e1 @SM149g0 SENATOR ' nnunuuo-uQcxQ4{greQ a C4o.S"lTG.Ck4OY wVcauegw.aQµwrgrma ' MEN NUESO wlxvlotrtwGva Qafm,tgyX FORTIETH SENATE 015TRICT'. ff,fa.mwRnrsn ' wvmrxwagac9KgRma MOR' a'f AMMW.MYTN 1TnrlRlrtea?gW"MQ 4Q Irs CRrf[Hx "Mm1SWG f\�'f kM4o 1. JUNTIWiIAllirpWf q4 ' - 641A1ArNM5gMLI[IEs- February27,2020 - - Dr. Sonia Angell, Director California Departmem of Public Health 1615 Capitol Ave. Sacramento, CA 95814 Dear Director Angell;' A request for the licensing of a 120 -bed acute psychiatric hospital proposed to be located In Chula Vista, apart of the 40"1 Senate District, will be submitted to this department. only 6 the site is approved by the Chula Vista Crty Council fora Conditional use permit. The primary Is Acadia Healthcare, which Is estimated to own between 80-9090 of Eastlake Behavioral Health, LtC, which is the entity requesting the conditional use permit, it Is the primary partner of this LLC that Is the subject of this letter. Should the Chula Vista City Council grant a condhlonal use permit and this LLC seeks licensing then 1 with to note several concerns that are not about mental health hospitals which I support, but are concerns very specific to how the majority partner in this LLC, Acadla Healthcare, conducts itself with their other acute psychiatric facilities here, across the United States and abroad. If even some of the multitude of reports are to be believed, understaffing seems to be the thread of - concern. The major Incidents noted in their other facilities here, across the United States, and abroad point to a chronic lack of a full staff. Some have alleged,albeit somewhatunrellaply, that understafli gis actually their business model, What is truly concerning Is this company has:a nationwide history of .misconduct and escapes from their other acute psychiatric hospitals, including a report of 160 escapes from one facility alone.. A few short months ago in December of 2019, a Georgia facility was raided after reports of unexplained patient Injuries and It Is being Investigated for patient abuser neglect and fraud. In 2019, It was reported that Acadia Healthcare's two Californla acute psychiatric hospitals, where this company is the major partner and/or administrator, had 43 complaints/incidents in one facility versus a statewide average of 6, which Is 72% off average. In that same facility, them were 16 surveydeficlencies versus a statewide average of 2, or 80% off the statewide average. In AcadWs other California facility, there were 24 complaler s/Incidents versus a statewide average of 6,. 40% off average, and 13 survey deficiencies versus a statewide average of 2, or 65% off average. In one year, for both facilities in complaints and Incidents, Acadia Healthcare Is 76% off the statewide average. It 1152% off the statewide cNOW VK+n INNTPYT tMCIL`F QKRMIC 916YMCTgTKC 90a &11YE 2tl0 IQ3i6rLTa {TPLR�6UnEb tHULAVI9TA,VWTT, LA 91910 CL C¢IYTNfi CA WY 49 TQutl1914P}i59a fLL'Wkhl $4e2 fY 1619141»�:LM 9a(gity�. r4%RWf]06 Lj4 average In survey deficits.. These do"not seem to be encouraging statistics for responsible business practices. The fiscal health of a company Is also Important, In West Virginia last year, theirfacillty had to repay $17 million dollars fora billing scheme that defrauded Medicaid, This company's debt fn the United Kingdom appears to be substantial, potentially In the billions. A superficial look at their accounting istroubling, especially since the type of accountingutilized does not include many of their largest financial obligations. There is a class action lawsuit, which is In part, focused on their accounting practkes. Under Health and Safety Code Section 126$.3, If the Department of Public Heahh looks to licensing this facility, respectfully, I request the department pay special attention to whether Ow appltrant is responsible in Its business practices and whether or not It has demonstrated any particular pattern of violations of state "federal laws, here and nationwide, - What is important to me is the health, safety and well-being of the residents In my district, all at the residents in m"istrict, including the mostvulnerable, and it would be derelict of myoffhe toignorethe historyofthis company. - Thank you for your time and attention to this matter, dyou have any questions, pleasefeelfreeto contact me at (619) 4097690. sinctre, 6FN HU ESO na Setor, 40- District - cc: John McCann, Chula Vista Councilmember, District) BHAh Caroline Young From: Ian Burgar Sent: Saturday, February 29, 2020 6:55 PM To: Caroline Young Cc: John McCann; Kelly Broughton; Jill Galvez; Mike Diaz; Mary Salas; Patricia Salvation; Steve C. Padilla; montano.monica@scrippshealth.org; John S. Moot; gammiere,tom@scrippshealth.org; Luke, Bergmann@sdmunty.ca.gov; John Teevan Subject: Acadia returns to the news—not good. https•//www news -press com/story/news/local/2020/02/28/park-royal-hospital-patient-accuses staffer sex-assa u lt/4870513002/ Park Royal Hospital, Lee County's only inpatient psychiatric hospital, has faced a number oflawsuiks in recent years involving farmer patients who claimed they were sexually assaulted. In one of the mo`e Inirmuus canes, seven former petle:ris reached undisclosed settleirrcvnes wi[Pt the hospital in 2016 over alleged sex assaults thaf took place in 2013. Those cases involved an employee named Benjamin 0[anti, who served 31/2 years In prison after pleading guilty to two counts of sexual abuse of a disabled adult. The privately operated, 1.14 -bed Park Rayal is rivaled by the Franklin, Tounes8ec-based company, Acadia Healthcare, Sent from my !Phone On Jan 24, 2020, at 2:11 PM, an Burgar clan.burgar@gmail.com> wrote: Happy 2020 all, Here is the first of what will likely be many stories,.. The Lawn Institute, a healthcare think tank, has released its third annual Shkreli Awards, a list of the top 10 worst actors In healthcare from the last year. The institute awards people and businesses that exemplify "profiteering and dysfunction in healthcare." Acadia #7! 7. Franklin, Tenn. -based Acadia Healthcare. The psychiatric hospital chain is facing claims that personnel at their hospitals neglected patients, stole from them and abused them. hitt s://www.beckersliosDitilrevlew.cornZrankings-anci,-ratlnes,/the,_ C -shkrel!-award-rednients-thaC- exemplified-profiteer) na-and-dysfunction-in-healthcare. htmlat Sent from my (Phone On Dec 9, 2019, at 10:11L AM, Ian 6urgar <ianburgarftria il.conv wrote; In this weeks Installment of Acadia in the news: Pollee spent hrsurs searching and seizing patient records and computers, as well as interviewing workers at the administrative office. Detectives said they believe they will find evidence of dozens of crimes. "This is a very large-scale investigation," said Gwinnotl County Police Spokesperson Michele Phone. Officials brought their own trunk and van for all the evidence they expected to find. Authorities said they are looking into complaints of abuse, over -drugging and fraud at the facility owned by Acadia Healthcare. "It appears all the employees are cooperative, they all understand why we are here," Plhera said, https://www.wsbtv.com/news/local/gwinnett.county/50-oflicers-raid-locoI-mental- health-faCllltiesdn-la ig scale -investigation -/1016165355 Sent from my phone On Dec 3, 2019, at 2:05 PM, Ian flurgar <ian.burgar@gmalt.coin> wrote Why does the Scripps team continue to consider this company a partner? It's getting slily at this point... https://www.tampabay coin/iiivestlutionsZ2019/"`12/"03/foriiier-nfl- p I aver-not-actu a I V-qu a I if led- to -r un -hospital -feels -fes Hie inspection, however, said there was "no evidence" that the CEO "fnet the education or experience requirements defined in the position description." He diff not have an appropriate bachelor's degree for the job or three to five years of experience in senior hcalthcareleadership. When inspectors asked for his application for the position, an executive assistant said she couldn't provide one because the application was "electronic, not paper." Coleman continued to regulators that he was appointed as CEO even though he did not meet the minimtmi requirements Sent from no, iPhone On Nov 19, 2019,.at 5:11 PM, an Rurgar <!anburgarOgre a! xom> wrote: They are in the news constantly: ht5p-: www nwahomej)Mq,g2 newsji nwa land - n u I I e d -f o r -v o u t h -t rea t m e n t-ce n t e r-21 Planning and Community of Development Director Patsy Christie says in 2o16, the planning commission gave the green light for construction on the center to start. "If they have not started construction within a year, the plan would be null and void," Christie said. Fast forward three years and other that) a little bit of work on stormwater mitigation — no major construction has been done, halting the development. Christie says she hasn't beard from anyone with the healthcare provider in over a year but if they were still interested in building on the lot -- they'd have to go through the process all over again The facility would be like the one in Fayetteville — which is being investigated by the Department of HUMERI Services for allegations of neglect, abuse and sexual misconduct among residents. Park Royal Hospital patient accuses a staffer of sex assault HARRY'S SHOULD AN B•PACK OF BLADES REALLY COST $32? WE DON'T THINK SO. Page I of 4 r x Park Royal Hospital patient claims staffer groped her, tried to pay her for sex er.n_MkGIII, The Nu Prtss I'ublhhN T.00 wn 6 r Yah 28, 2020 Awoman who received emergency mental health treatment at Park Royal Hospital (had. h vww parkroyalhosoital com0 in 2018 claims In a lawsuit that an employee of the psychiatric health center groped herand offered to pay her forsex. Park Royal's CEO Coleby Wright said he can't specifically respond to the allegations but said the south Fort Myers health center plans to "vigorously" defend Itself in mud He added, In a written statement: "Every employee at the hospital undergoes a comprehensive preemployment screening and background check, In addition, the hospital maintains a zero -tolerance policy for any action that could endanger the physical or emotional well-being of a patient." The woman, named In the lawsuit as "Samantha Doe" to protect her Identity, said an unidentified male employee touched her breasts over and under her clothes during her stay In June 2018 and "further sexually assaulted and battered" her, awarding to the lawsuit hied this month In Lee Circuit Court, 6 free articles left, n Only 994 per month for 3 months. Save 90%. I ...... v ."v—,—v n..... ....,r....moo., I11MAIn Palk Royal Hospital patient accuses It staffer ol'sex assault WHAT'S TRENDING You may be Interested In iZ(ipY}gitpoi§trgrih9llSU]d@:1Ygy„y{4t[@.6YIgp.IftglySAgVaV�g plf0,g, F u Myers (lel '// 11= RLgSs„e¢m[5jpyyLppyy,5(J(}r„pt[�p,20/02/28/fort-rovers-toonolf-expected-make.debr t-text-sgtpn/48964P0002/P Ulm d8UtW medllte&ut=jQrylj,oE&uGnten t=ng_wi@utm tern=t5tz§B50oij 42924electiosTheeyotEl1.SL. ou on Vfhtts (fjyyy-lxylpyyE;,R pg�gp;[P: tlepth /no.s/2020/02/2 5 2020 eecti s'n e v [er-I' t-jda/450331800217 um source=.embed&utm medic m=onsite&u[a tamoalg9--q; I' & t on n =nevrs utm term=151$ Ot i Law aty> kers propose suffer ours u t still seek more leeway for (Wos://www.naolosnews.con/etptylnews/Iocel[jLaflda/2020/02/27/floc"da-nursln.-home-inspection - libumlamwLQSd9hen- o - 1 - er-cl ec ------ utrin source=oembedgutmd' - It & t cam Palo I - o,vliaas&LIl contelit- & [ t -15128850011 4 Police and uicide. Retired officer Puts mental health �Ijes in the open (httosr//wwwna.1esm,wstom/story/news/local/242 1 a is men Issues-ooen/4737729002/] Ulm rOLscc=ocmbed&mGr med1um=gmijtg&ujm campamn=stgryjjnesAutm content=news&mm to =15128850011 FL11r�F�-d1IIS7[3.]{IFI4:7'•Si147t3F.R: . . .r: . : .. Page 2 of 4 She was admitted to Park Royal under the state's Baker Act, which allows for Involuntary mental health evaluations for people considered a threat to themselves or others. The woman, 33, also claims that the employee gave her a razor blade and tweezers and watched her shave her genital area. And, she said, he asked her how much he could pay her for sex and what kinds of drugs she wanted. APVERTIefiMErll Furthermore, the lawsuit alleges that patients and staff members warned the hospital about the employee's other "Oiltatious and Inappropriate sexual commentsl' And, It claims, the employee 'provided an Employment application and resume that was false and misleading, and that said falsities ... were easily detectable," More: Our investigation Into doctors h don'( carry malpractice-nsurance in Lotitbt FI 'd (I 1 / wall A92019/12/13/going b 1' t' n Into o e lice Ins r nce/4 470021 6 has articles left t ^ The wmo%Ynt <lo�s n s°gedN°w3halil°n%ramai5io wa0s allegedly false or easily contradicted by an adequate background check. 1...,.,,. oaten .............. ....n, li.o aTgn...de.eye9l......l nlYlnllYl r°RL...JI. ........r t....,...:...1 _...:,. _. _...„.....,. .,.sv,,.. ...... �nnnv. Park Royal Hos gital patient accuses a Staffer of sex a6SdUIt The woman's attorney, Terry Cramer, declined to comment at length about the case, saying the lawsuit "pretty much speaks for Itself." Page 3 of 4 The woman reported the incident to other hospital staff, which prompted a slate Department of Children and Families Investigation. State hlbil (http//www.leg 1 l fl unstidueelindex fm?8pp onme=DloplayStabh&Sei SI' -&URL-04000499/041515 li s/0415107 hl it the release of their report to the public because It involves a "vulnerable ai She did not file a police repel and is unlikely to do so In what now is a "he -said -she. said' Noe of case. Cramer said. Subscribers get exclusive news about local Investigations and politics. Only 99t per month for 3 months. Save 90%. Subscribethttps://subscribe.news- Now press.com) Park Royal Hospital, Lee County's only inpatient psychiatric hospital, has faced a number of lawsuits In recent years involving former patients who claimed they were sexually assaulted. More: Victims of alleged Caoe Coral Hosoltal sexual assaults case deliver tearful testimonies fl t I sr - /2020/01/08/) - ems k d book coup h4courts-attention-stale-aHornev@839276001D In one of the more Infamous cases, seven former patients reached undisclosed settlements with the hostile I In 2016 over alleged sex assaults that took place In 2013. Those mass Involved an employee named Benjamin Bland, who served 3 1/2 Years In Prison .hit/Ayex,dcstate.fl.us/offenderSearch/tl tall as x? a e-Detail&DCNumberY54 75 T after pleading guilty to two counts of sexual abuse of a disabled adult. Another lawsuit filed against the hospital around the same time claimed employee Anthony Guarino had fondled a patient. Guarino was fired, though he was never criminally charged. The parties later settled the case out of court. In 2017, a patient reported that another patient had sexually assaulted her. She sued, though that case was later dismissed. Wright, who became CEO in May of last year—the hospital's third In two years —said employees suspected of abuse are immediately suspended, pending an investigation. Those determined to be guilty are subject to disciplinary action, including terminatlon. The privately operated, 114 -bed Park Royal Is owned by the Fronklln. Tennessee -based company, Acadia Healthcare !fides'//waw acadIaheallhcare com/1. Follow this reporferon Twitter, D.FraninGl rck lhfrnsyflwlrfer com/FrenkGl rckl Read or Share this story: https://www.news-press,com/story/news/local/2020/0212Wpark-royal-hospital-patient-accuses-staffer-sex- assauIV48705130021 6 free articles left. n Only 990 per month for 3 months Save 90%, litti)s://www. news -press, com/story/news/local/2020/02/28/park-rova I-liosr)ital-patient-accuses-staffer-sex... 3/2/2020 The 10 Shkrcli Award recipients that exemplificd'pro £uouring and dysfunction' in Irealthe... Page 3 of R The Lown Institute, a healthcare think tank, has released its third annual Shkreli Awards, a list of the top 10 worst actors in healthcare from the last year. The institute awards people and businesses that exemplify "profiteering and dysfunction in healthcare." The award is named after Martin Shkreli, the disgraced pharmaceutical exec who gained notoriety for inflating the price of a lifesaving anti -infection drug. Nominees for the list are determined by the Lown Institute staff with input from readers of its blog. A panel of 18 patient activists, clinicians, health policy experts and journalists determine who receives the awards from that list. Here are the 10 recipients 10. Jose Baselga, MD, PhD, the former CMO of New York City -based Memorial Sloan Kettering Cancer Center. Dr. Baselga resigned from the medical center after falling to disclose millions of dollars in payments from drug companies. After his resignation, he was tapped to lead AstraZeneca's new oncology research unit. 9. Newark (N.J.) Beth Israel Medical Center and Mark Zucker, MD, the hospital's heart and lung transplant program director. The hospital is accused of keeping a vegetative patient alive for a year to boost its heart transplant program's survival rate, at the direction of Or, Zucker, 8. The 35 people, Including nine physicians, who were charged In 2019 with billing Medicare $2.1 billion for unnecessary and expensive genetic cancer tests. The physicians were allegedly paid to prescribe the testing without any patient interaction or with only a brief telephone call with patients they never met. The Lown Institute didn't provide the names of the 35 people. 7. Franklin, Term. -based Acadia Healthcare. The psychiatric hospital chain is facing claims that personnel at their hospitals neglected patients, stole from them and abused them. t..__. I......... .._r,.. _.. _....:._i_... e,.... .._.__r___,.:__., _,a .....:_,..✓.�-,, rn ..u._..r �nnn�n I lie 10 ShkreIi Award recipients that exempIifted'protiteeruig and dysfunction' in heaIthe... Page 4 of 8 6. UNC Children's Hospital In Chapel Hill, N.C. The university medical center made the list because It reportedly pressured its cardiologists to keep referring pediatric patients for heart surgery despite noticing an uptick in surgical complications and deaths. 5. Richard Sackler, MD, owner and former president of Purdue Pharma, In court filings unveiled last year, Dr. Sackler attempted to cast opioid users as "reckless criminals" to divert blame of the opioid crisis away from the company. 4. Carlyle Group, a private equity firm that is taking over nursing homes. The Carlyle Group earned a Shkreli Award because of the surge in neglected and abused nursing home residents since it took over the ManorCare nursing home chain, 3, San Francisco, Calif. -based Dignity Health. The health system reportedly used a technicality to force a $898,984 medical bill on a new mother, who was also a hospital employee. Lauren Bard gave birth to her premature daughter and said she called her health plan administrator who assured the child would be covered under the employer health plan. But Dignity Health later said the medical care wouldn't be covered because she didn't use the company website to enroll, according to the award site. 2. TeamHealth and Envision, physician staffing companies backed by private equity firms. The two organizations spent more than $28 million on advertisements to defeat surprise -billing legislation through an organization they created called Doctor Patient Unity. Surprise bills are unanticipated out -of -network medical bilis that often stick patients with large sums to pay off. 1. Nonprofit hospitals that sue patients for unpaid bills. Topping this year's list are the nonprofit hospitals that have sued thousands of patients for unpaid medical bills, garnished wages and seized houses. The list names several hospitals: Charlottesville, Va.-based UVA Medical Center; Fredericksburg, Va.-based Mary Washington Hospital;. Carlsbad (N.M.) Medical Center; Memphis, Tenn: based Methodist Le Bonheur Healthcare; Poplar Bluff (Mo.) Regional Medical Center, and Johnson City, Tenn. -based Ballad Health. Access the full list, methodology and panelist accreditations here. More articles on rankings and ratings; Leapfrog names 2019 Top Hospitals America's Health Rankings: How all 50 states fared US states ranked by suicide rate V Copyright ASC COMMUNICATIONS 2020. Interested in LINKING to orREPRINTINO this content? View our policies by clicking here. To receive the latest hospital and health system business and legal news and analysis from Becker's Hospital Review, sign-up for the free Becker's Hospital Review E -weekly by clicking here. Subscribe to the Becker's Hospital Review newsletter for the latest in healthcare newsl Email* First name Last name https://www.beckersliospitaireview.coni/raukings-and-ratings/the- I0-shkreli-award-recipien... 3/2/2020 501- officers raid meulal health hospital after patient found in freezer, other disturbing clai... Page I of 3 Watch Llve Weather News Video Traffic Q Lag In/ Register 50+ officers raid mental health hospital after patient found in freezer, other disturbing claims More than 50 local ponce officers raided a local mental health hospital. 0 shase, --] By: They Thomas Updated: December 6, 2014- 6:14 PM GWINNETT COUNTY, Ga. — More than 50 local police officers raided a local mental health hospital. Only Channel 2 Action News was there when detectives pulled evidence and questioned employees, littos://www. rvsbtv.coin/news/l ocal/L,witinett-cou n tv/50-offkers-rai d-1 ocal-men tal-heal th-P,v.. 1/2/2.070 50+ officers raid mental health hospital after patient found in t}eezer, other disturbing ehti... Paye 2 of 3 Investigators spent hours going through evidence today at two Lakeview Behavioral Health buildings in Gwinnett County. Content Continues Below One is located on Medlock Bridge Road and the other is on One Technology Parkway. For months, former patients and their families have complained of unexplained injuries after leaving Lakeview. Police spent hours searching and seizing patient records and computers, as well as Interviewing workers at the administrative office. Detectives said they believe they will find evidence of dozens of crimes. "This is a very large-scale investigation," said Gwinnett County Police Spokesperson Michele Pihera. Officials brought their own truck and van for all the evidence they expected to find. Authorities said they are looking Into complaints of abuse, over -drugging and fraud at the facility owned by Acadia Healthcare. "It appears all the employees are cooperative, they all understand why we are here," Pihera said. Channel 2's Tony Thomas has been investigating Lakeview for months. RELATED STORIES: Patient found in freezer, child loses toe: 46 claims of abuse Investigated at mental health facility Police confirm death at behavioral health facility already under Investigation Behavioral health facility under Investigation after accusations of theft, sexual abuse Beth Tipton said her mother Is a former patient and victim. httr)s://www.wsbtv.com/news/local/vwinnett-county/50-o icers-raid-lueal-inentaI-health-fa... 3/2/2020 50+ officers raid mental health hospital after patient found in Creezer, other disturbing clai... Page 3 of 3 "She had bruising all oval," Tipton told Thomas. "It angers me." Thomas flew to Arkansas and New Mexico this fall, listening to whistleblowers at other company sites. In Gwinnett County, police confirm they're focusing on 51 former patients. "They could eliminate some of those cases, but they could also find evidence of more criminal activity,' Pihera said. At Lakeview, no one would talk to Channel 2, but group CEO Jim Spruyt emailed saying: "We continue to work collaboratively and transparently with law enforcement as they follow up their Investigation of uncorroborated complaints" "It's just a matter of going through a lot of paperwork," Pihera said. No charges have been filed. Both facilities are still open. Here is the full statement from Lakeview Behavioral and Acadia Healthcare on today's search warrant by @GwinnettPd @wsbty iatwitter,corn/0QdIzDYH6i — Tony Thomas (@TonyThomasWSB) December 6, 2019 * 2029 Cox Media croup News Weather Contact Us Local Weather About WSBTV Watch Live Stormtracker 2HD What's On WSBTV Nation/World EEO Statement Video WSBTV Public File Traffic O 2020 Cox Media Group. By using this website, you accept the terms of our Vlsltor,A {r reermmat and Privacy Policy, and understand your options regarding Ad choices. This station is part of Cox Media Group Television. Learn about careers at Cox Media Group. m�..1Ln.,%:.,...... ..,:d 1—..1 ... ...,a..11,.,.,W, V- 1hhn�n Former NFL player hot actually qualified to run hospital, fells find Page I of6 Tanya ?lag Thncs 0 ,III P l I r: I., II LONG READS / INVESTIBATIONS Former NFL player not actually qualified to run hospital, feds find Regulators also found widespread problems with patient care ager a Tampa Y3ay Times invesligatlon into the facility © 0 O < NHIII Tama, eeaav oral Heolm in WeNey Lhapel JOIN 'END YG RA, I I uinszl By Nell sd! auauunod aec 1 M I epdaeadell 1 1111 North9'ampa Rehm iorol Wealth's Na.nedDN k -hinted -C EO Jus Tett the hospital aft,,a a smtthing inspection (bund he d(d not meet the Tec tniements DD nnming the facility. hi[nsJ/www.dnnnahnv.corn/invastipatinns/9.1)19/19./(1'i/Ynrmer-nFl-nlNvar-ant nomnliv-Wool ifl 7/7/9f190 Former NFL player not actually qualified to run hospital, feds find Pago 2 of 6 Qa111'PA Dag MuttC., hospital's Parent eompany, Tennessee-baaodAcadia Healthcare, said 4 ryon Coleman Jr, had accepted another poaltionwithin the orgari,.tioa. A spokeswoman said the move "had nothing to do with any regulatory findings," A 8epternher investigation by flu: Tampa Buy Time, found that Wleman, 31, had no experience in healthcare when he accepted the hospital's top Job In 2018. His resume included qu iderback[ng the Green Bay Packers practice squad, overseeing sales for a trucking company and managing employee benofils for an Insurance company. Coleman could not be reached for comment The Yams investigation detailed broader problems at North Tampa Behavioral, including that the hospital exploited patients held under the state's menta] health law, known as the Baker Act, Tho hospital used loopholes in the law to keep patients longer, than allowed — u tactic that Ixxxsted its bottom line, the not es found. It also illegally cut patients off from their families. af/ATRa: Readlhe lnveetl qqn: How one Flwka psychiatdc hospital makes mllllonself tents she have no choice After the report, lawmakers calledFnr reviewg,yf N9Ah Tgmya Reluvioral. Inspectors showed up in November and documented serious problems, including that the hospital had not held its medical staff accountable for poor can and patient complaints. They found that declare had restrioud one patient's telephone use because she was rolling her husband and familyto complain about the hospital, After her phone privileges were suspended, she had another patient not her husband to get word to that. A psychiatrist confirmed to inspectors that there was an aetualJostifiration for restricting the patient's rights, The federal Centers for Medicare add Medicaid Novices threatened to withhold public funding if the most severe issues weren't immediately fixed, according to a letter it sent the hospital Meet ofthe hospitals revenue comes from the taxpayar-futaled insurance programs the agency ovorsees. Acadia spokeswoman Gretchen Hommrkh denied the hospital was at risk of losing public funding and said regulators did not emintr dethat Coleman lacked gaalificatlovs. The inspection, however, said there was 'no .vide.[? thatthe CEO "cod the education or experlencerequirements defined in the position httt)s://www.tamt)abay.coemvestigationsl2Ol9/12/03/former-nfl-plaver-not-actually-oualifi._ 3/2/2020 Former NFL player 1101. actually qualified to run hospital, Us find page 3 of 6 Tampa ,cicrlpnmr' He did net have an approprime u u cern p d� Millet -le, nehcloi a degree for tbo.inbur three. to Ike )"a' i'v' :m_a ithL=1 orispe, Ot..e n tenlnr heo]thcarc leadcrshlp. When InspeWors asked frit,- Ws application do the position, ml exuudve nssMort said she could,, t prohddc one be,tame the applinrtnn hvas "elaetroeic, not paper.' Coleman courunicd to regulators that he was appointed as CLO men though he did not meet the minimum roqulremo-nls. It, that role, icgulattns said, he ]lot] "failed to establish elsur lines of responelbl0ty and aceauntahllily, dr,vlop effective comnwn]esml over hanianrs among daphrtments, anpletnchIan m'@etiva ourchsIlam far responding to eomplaluts concurnbtg patient cure and enc ore appropriate training rt tali'." Earlier this yeru', Coleman told the Tines thin hospital CGOs m'e sometams real anted from other industries, He sold ha had experience In logistics, financial fiacravunal and customer service, us well us'\aluable, transf ttabla skills and ant theirs including toren leaderohlp,'it uatonul unuly la and sound dccisian-makinb" The CEO «nsn'1 the only enrplinve at North Tampa Behuvinrill who lacked the related yludlfieat'Ions, according to the inslectinn report onlg foraof the gfi coployus ivho perCrented urine tests and other laboratory Work hall the proper nnhring. The Iced cook 'vas filling ht as the director of (In tap'servim, menthough in was rat yoallfied. btemwhile, the kitchen did lilt properly make items fm' patients who needed spacial duts Iannul ho it a1vtus and suicidal patlmts who shouldn't use tensile, Thu hospl4tl's gmuuds wcrcci Rel fur alaunllnese issues. In three of Ihn hospitals tour units, Ivspeclors (bund sink farwets "dripping with buildup of greenish yellow brmvn" snlwtatme; and flouring stained with a *hlack/brown biogrowth,"The air maul' for tie lea muahice wins coated inn "gray army residua" Regain Iors also referred to n high number of citations in rile prat 12 modes and nn "nn -going putro'n nYnon-compliance with ]oxer and ixgulatious." The IN,, ]nuestgstiun found that tarts 2014, North'Houl" Beh. imahvas cited 92 times I'or i nanfc conditions rod egde violations —mere than all but one other psychiatric hospital in Florida. That hospital is also awned by Acadia I heahl Bare. NorthTnmpa Behavioral Hetilth had until Dee.I to sunndt it detailed plan to fix the ales[ severe prub]uus. Federal regulalvrrs sold they had received We plan and were ract ew!as it, The letter from the Curlers for Med note and Medicaid Ser, ac.ssnid Nnith 9Lmpn Behavioral would boss public fundbrg on 4ch, 19 if I egulatoa ween not wdlafird with the fixes. https:l/www.tanepabay.com/investiaatlons/2019/12103 /former-nil-player-not-actually-nualiFii... 3/2/2020 Fortner NFL player not actually qualified to run hospital, fads find alll}aa �tayi11IR8 he federal agency rarely takes that step, Just throe hospitals acmes the country lost funding last fisenl year. North Tampa Behavioral Is also under scrutiny fmm the state Agency for Health Care Administration, whichhaerse hospitals across Florida and checks for compliance with m to standards. The agency conducted its own inspections of the facility, but the reports have not yet been made public. Additionally, the Florida Depertmerd of Children and Families hue time oversight because it authorizes hospitals and mental health centers to receive pntlema under the Baker Act, Aspoksa, o aan declined to say if the agency was investigating. YOU MIGHT ALSO LIKE Thle m.lor amend truck anpaar teak daegwe.s sber[cuu. NayMm ydbmN. veererdar IMx99aaum 04 corponlbne OWN epammkg. Fbdd. Pok. 0." But medy Wye tebm moose, Jen 29 Rodd. Ne mit 0.. 0f the ddee boys IN how cies. N n.nteda Way for Ckierac 0.e. 16, 1019 Asa Poten Wil A Tnwe a 1a. k..k to hey the pw .ant to o"GOP domfs suvaryecht mwku Nov. 16, W19 , Gpe9kl R,p o kienmbgr spread ramodeakm swa n ckaraata. WevWevw .ron't kwPr WIL NMI ImW48tive Repadw B..d BxtlaWwld'a reapo... to baesNotion Yxierdry mvestlgesoos Th" pn.duro Wp lavAl" fakes 411howe, Be Nmf r. mostly MINN INenmrkNers. Mo. 27,, 2019 • wv W 9.awu PonnerW deyerntxtu* gudNNd to ea WWII, Leda W sec a,aar9 •Yraera9anoru Nandi Tmmp'e nemest NNeer, Pwla White, BN ha wmt u Tmrym W .a, 2019 samw sem Grieatdow dwddW its domataam Ckannla loo"I to 9 waw Page 4 of 6 i� 1 all I/MIF.».,.«—o-1,.,---.-1 x,.11..—.114 QN/,non Plan to construct youth treatment center nulled 61' """o, NEWS WEATHER PIO TRAIL NATION CONTESTS COMMUNITY GOOD DAY NWA ADVICE NETWORK KNWA Land nulled for youth treatment center A treahnent center designed to help kids with sexual behavior disorders will not be built in Springdale as previously planned. In, Cryenal Marline, Posted: Nov la, 2010110:12 PM CST I Updates: Nov u, 2010110:14 PM CST SPRINGDALE, Ark, (KNWA) —A treatment center designed to help kills with sexual behavior disoods A will not be built in Springdale as previously planned. Connie, Whiteley lives in Springdale, lost a few yards train where Acadia Healthcare was supposed to build Piney Ridge 'rreat lent Center to help children with sexual behavior disorders and mental illness. "Having something move in there that's commercial, I don't have a problem with that," Whi eleysaid "With all the churches and schools put in, 1just thought the location was a pretty bad mix." The racfllty would be like the one In Fayetteville - which is being investigated by the Department of I broad Services for alNgatons or neglect, abase mid sexual misconduct a econg residents. "Facilities like this do need to be bolt probably but I do think they need to be away from the regular population and especially from concentrations of children;' Whiteley said. planning and Community of Development Dh eetor Patsy Christie says In 2016, the planning com nisslon gave the green Ilghl for construction on the center to stmt, 'if they have net started construction within a yen', the plan would be null slid void," Christie said. Fast forward three years and other tion a little bit of work on stormwater mitigation -no major construction has been done, halting the development, ChHste says she hasn't heard from anyone with the healthcare provider in over a year but It they were still Interested in building on the lot- they'd have to go through the process all over again. Whiteley says the news is it sigh of relief - for now Page t of 5 TRENDINGSTORIES OLa S2Hetralm/mdnp sophomore Ed Croswell Hears from the Hogs ..... ........ ® ..... ............................�.............,......,... PTN's'Ask Mike' fm Mach gid OEirMmsbareanenselormom 1-1....11.........__ OVielimst ...............- .............................. and dancer hags" Son" bringing tour to Wolmnt AMp ® 1.1._11.... ..... .. .......................... Weelhm Get the mobile app! M Plan to constl3lct youth trcatrnent center nulled "WeVn lost some really good neighbors because they were so concerned that they sold their propm'ty,' Whiteley said. She says If ICs proposed and reviewed by the board again, she plans to take the same action she took in 2016. "I'd he pretty upset and yes, I would fight,' Whiteley said. We, reached out to the health group - a spokesperson told us they are aware of the development being voided but didn't provide a clear pial on what they will do next. oopylall 0020 allt Nodi xre.Il0.a11011""I'dli-1.111 In Iel 1. pul h"xmA rcMl., or r.®ellbubtl. SHARETHISSTORY e AROUND THE WEB Online Jobs Might Pay More Than Lose Weight with These Amazing You Think Homemade Drinks The Favourite Female Actresses of We Bet These Will Cheer You Up Ina the Current Age Second You Won't Believe the Amounts All Truth Behind Couple Therapy These Celebs Spent on Their Motors 1110 11 Ir LATEST VIDEO Page 2 of 5 kin— n...,d......,.«..,.., —/— ... a,....... /1....,1 —11-4 F. ... ..... n, n1 1 1111 ". Caroline Youn From: Miss M Sent: Saturday, February 22, 2020 9:03 PM To: Mary Sales; John McCann; Steve C. Padilla; Mike Diaz; Jill Galvez; Caroline Young Subject: Re: Investigative Review of for-profit facilities Warning: E>tternal Good evening, �r . I'm not sure if you have seen these series of articles regarding for-profit psychiatric hospitals. The need for mental health services and the rapid building of for-profit facilities. Daniel Gilbert an investigative reporter in Seattle, WA conducted research to find out more... https://www.seattletimes.com/se attle-ne ws/ti mes-watchdog/behind-the-public-crisis-private-tol I -investigation -a- m u Ititude-of-i n to rviews-tho usa n d s -of -pages -of -records/ Gilbert's investigation (part 1) focuses on Point Behavioral Hospital owned by US Healthvest a for-profit company: http://p rojects.sea tt letim es,com/2019/p ubl i c -crisis -private -to I I -pa rt1/ Next, Gilbert investigates the lack of reporting by Cascade, an Acadia Healthcare owned facility (Part 2): https:Hprojects.sea ttletim es.co m/2019/p ubl is-cris is -private -to I I -pa rt2/ Finally, Gilbert examined various for-profit admissions and holds in part 3 of his series on mental health facilities: https://www.sea ttlet i m es.co m/seattle-news/times-watc h d og/pu b l is-cri sis-priva to -to I I -free -to -check -in -b ut-not-to- leave-washington-mental-health-care/ We do not need a company like Acadia in Chula Vista l Behind the Public Crisis, Private Toll investigation: A multitude of interviews, thousands ... Page 1 of 4 Times Watchdog Behind the Public Crisis, Private Toll investigation: A multitude of interviews, thousands of pages of records 011.62o,s a' Fgonm I UIahuetl MI R 1o19 n„o.57— By Seattle Tinos stall f m +r This project began with a surprising discovery. After years of chronic shortages of mental-health care options in Washington state, for-profit companies were competing to build new psychiatric hospitals, and state regulators had approved a. major expansionof inpatleni beds. How would these new hospitals, geared to make money, serve people who arrive there at their most vulnerable? TIMES WATCHDOG Public Crisis, Private Toll: Read the full investigation Major andings uF'ITie Seattle Timm plv44agxl Ion of privnta psychiatau hosrttalx Ikldnd dre Invpsngatbn: a mnllieule of Intcrvlewa, lhnusmuls nrpngus nl','ewrds Reporter Daniel Gilbert spent months pursuing this question. He Interviewed about a5o current and former employees of psychiatric hospitals, patients and their family members, regulators and mental-health professionals. He filed more than i8o public-recatds requests, obtaining thousands of pages of regulatory complaints, inspection reports, emergency - dispatcher notes, police reports, death records, gar calls, video footage from inside hospitals and other public documents. Patients and family members also shared their medical records. So far, our Investigation has revealed how one company's aggressive expansion put patients in peril; how patients and hospital employees suffer harm far more often that is reported to regulators; and how private hospitals regularly refuse to release palienis who checked in voluntarily until forced to by mentabhealth officials. h(tps://www.scattletimes.contlseattle-tiewsltinies-watclidog/behind-the-public-crisis-private-.., 3/2/2020 Behind the Public Crisis, Private "Poll investigation: A mtdtihrde of interviews, thousands ... Page 2 of Since these articles began publishing, a Massachusetts health-care system has launched it review of its partnership with a company we profiled, and Gov, lay mains has directed the state Department ofhfaahh to draw up new legislative and regulatory hots to improve oversight of private psychiatric hospitals. Our reporting continues. Read Public Crisis, private Toll. Seattle Times staff Most Read Local Stories 1 A second person in U.S.—and King County -dies of novel coronavirus; Inure cases likely Flow It unfolded: King County death first in U.S, linked to novel coronavirus a As schools summers closures for coronavirus, Seattle -area parents wonder whit's next 4 King Can try patient is first in U.S. to elle ofCOVID-oi as officials scramble to Stem spread of novel coronavims ei watcu 5 Working to quell fears, Seattlearea offlclaIs shift their strategy or coronavirus IP Clew3 Gin "n a. Fir Recommended in r �. r - } Y r � c Seattle Mayor Durkee. Take Space Needle out of Virus limits next Tokyo Supreme Court won'thear allows winter eviction ban Seattle's skyline and most Olympic test event to case brought by author Jan to become law, proposes... think we're a certain... tapanew-only Krakauer NNER[ISIMG L ...... rr__.....___,.1..n:......--,.._.L--,,I-__.....L:» .............m..._..u:.. .__:...... xnnmll Public Uresis, Private'I oil Page 1 of 35 ac$CO leMmes PUBLIC CRISIS, PRIVATE TOLL The hidden costs of the mental-health industry's expansion http://projects.seattletimes.com/2019/public-crisis-private-toll-pard/ 3/2/2020 Public Crisis, Private Toll Page 2 of 35 How a company's push to expand psychiatric care brought peril Marjorie Erickson holds a photograph of her mother; Rosemary Torgesen, 0 Shoreline. (Erlko Schanz / The Seattle Times) By Daniel Gilbert Seattle Times staff reporter Published August 25, 2019 —/In 10/-,,1 : +-II.,,..,I/ 111PVYln Public Crisis, Private'roll t'age 3 of 35 On the first of Rosemary Torgesen's 99 days as a patient at the Smokey Point Behavioral Hospital, her children felt the placement was especially promising — even providential. Rosemary, 78 years old, had come to the brand-new psychiatric hospital in Marysville in a state of delusion, believing that a divine voice was instructing her not to eat or take medication. She had been involuntarily committed at least 17 times before and had always stabilized, returning to a routine centered on church and prayer. Smokey Point was the first newly built psychiatric hospital in Washington state in decades, drawing patients from all over the state. It happened to be a short drive from where Rosemary lived with one of her seven children. Gov. Jay Inslee himself had attended Smokey Point's ribbon - cutting, praising its executives for expanding access to mental-health care. "Isn't it a joy that we know that hundreds of Washingtonians are going to get better because of the Smokey Point Behavioral Hospital?" Inslee said at the July 2017 event. The Torgesens couldn't have known that a week before Rosemary was admitted, in March 2oi8, state inspectors had found problems so grave that they Governor speaks at Smokey Poi... 0 (Douglus Buell / The Arlington Times) created a "high risk of serious harm, inigM aizd death " They didn't know about patient -safety lapses that authorities had documented at other hospitals run by the same company, a for-profit firm called US httn://oroicets.scattletimes.coin/20 t 9bubi ic-crisis.nrivate-tol I-nart t / V9./2020 Public Crisis, Private Toll Page 4 of 35 HealthVest. But as weeks turned to months, they grasped that something was profoundly wrong with their mother's care. Rosemary had arrived high-stepping around the hospital. Three months into her stay, she couldn't walk, had developed a dangerous wound from being bedbound, and appeared alarmingly gaunt. As the Torgesens pressed for more treatment options, the hospital's staff suggested hospice care to allow her to die at home. Her family was stunned. "I got her in there when she was perfectly healthy," recalled her son Douglas Torgesen, who had been her primary caretaker. Now, he said, "She just looked half dead right there." "I got her in there when she was perfectly healthy. She just looked half dead right there." - Douglas Torgesen, son of Rosemary Torgesen US HealthVest is at the vanguard of a quiet transformation in how patients receive care for mental health and drug addiction in Washington. Since zotz, the state has approved or expanded to private psychiatric hospitals, nine of which are for-profit. This expansion will add more than 85o inpatient beds in a state with one of the highest rates of mental illness and least capacity to treat it, holding the promise of specialized care for patients who often land in jails or hospital emergency rooms. Without doubt, the addition of Smokey Point has provided much-needed mental-health care to httD://t)roiects.seattletimes.con 2Ol9/public-crisis-l)dvate-toll-oartl/ 3/2/2020 Public Crisis, Private'Tolt patients in an underserved area. Yet the state's early embrace of US HealthVest, after Washington's own failures to meet patient needs, has brought a new peril into the system: a model proven to deliver profits that has routinely failed vulnerable patients, an investigation by The Seattle Times has found. Stookey Point's first chief executive, with no medical Page 5 of 35 Primers Washinaton's mental-health care crisis license, would weigh in on which patients to admit. Patients with serious medical conditions worsened while waiting for treatment that the hospital couldn't provide. Executives failed to boost staffing despite pleas from employees and findings by regulators that conditions were unsafe. As Smokey Point executives prepared for inspections, they repeatedly instructed nursing staff to fill in records .that were incomplete or missing from patient files — even when it would have been impossible to accurately recall details, according to internal records and interviews with staffers. At another US HealthVest facility in Georgia, law enforcement accused the staff of "covering up their own neglect of patients" and "fraudulently documenting care." The problems at Stookey Point — and three other of Resources for mental-health the seven psychiatric support hospitals US HealthVest • ILI-asrisis'? Public Crisis, Private Toll operates across three states — surface in a review of thousands of pages of state • tLe( sum it7 • Ayi r ecl t J)Out Ineoue ynu knob ? health and law-enforcement records, internal documents, hospital records shared by patients and their families with The Times, and interviews with roughly two dozen current and former employees. Page 6 or35 Last year, Smokey Point's own incident log showed 88 assaults, 33 discoveries of contraband and 26 employee injuries. It's hard to compare this record with other private hospitals, which don't publicly disclose incident rates, but it stood out to regulators for what was missing: other assaults, suicide attempts and medication errors that weren't logged into the system or investigated. Smokey Point's own incident log showed 88 assaults, 33 discoveries of contraband and 26 employee Injuries. Many mental-health facilities are struggling to recruit and retain qualified staff. Ensuring the safety of patients — who are often at risk of harming themselves or others — can be hard even in ideal circumstances. But no private mental-health care operator in Washington state in recent years has pushed to expand as rapidly as US HealthVest or racked up as many serious violations as quickly, records show. Government inspectors have found violations at Smokey Point on 12 separate visits over 15 months. After meeting with senior US HealthVest executives and their attorneys, the Department of Health in lune agreed not to take action against Smokey Point's license in exchange for the company hiring a state -approved consultant, analyzing its failures, III I,, anmuu L.,imFu --/11) 1 _I/ 111 /Inn. Public Crisis, Private "roll Page 7 of 35 submitting an improvement plan and undigoipgste )jj -uD monitorirf for a year. Separately, the Department of Health dented U5 HealthVest's apphca_ti n to build a new psychiatric hospital in Bellingham. "They've demonstrated that they don't have a good track record of being able to care for patients safely, so we're not going to allow them to do that," Nate Weed, director of the Department of Health's Office of Community Health Systems, said in an interview. Yet the limits of this statement were on display Note Weed is director of Community Health Systoms at the state Department of Health. (Steve Ringmw / The Seattle Times) just a 15 -minute drive away from the regulator's offices near Olympia, where US HealthVest recently opened a second psychiatric hospital. The department approved it before Smokey Point had opened its doors. Richard Kresch, US HealthVest's chief executive, did not respond to requests for an interview or provide answers to written questions. In a general response, he wrote in an email: "At Smokey Point, we care for many of the sickest members of our community. Our patients turn to us in crisis and we take our responsibility to provide the highest level of care in the safest of therapeutic environments with the upmost seriousness. We are first and foremost caregivers and the health and safety of our patients is our top priority." He added, "all of our hospitals have been fully compliant with all state and federal regulations." http:/iprojects.scattletimes.com/2019/public-crisis-private-toll-part I / 3/2/2020 Pablie Crisis, Private Toll Page 8 of 35 Many of the Stuckey Point employees asked to remain anonymous because they were warned by executives not to speak to a Times reporter, or they worried it could hurt their ability to work in health care. One common complaint, confirmed by state inspections, was that the hospital was too thinly staffed to adequately care for patients. In March of 2or8, a nurse told state inspectors that there had been "many suicide attempts," including three on a single recent day. "It was only a matter of time until someone dies," the nurse said. because when patients need more staff to check on them "there is no one available." Inspectors asked the chief nursing officer about staffing and recorded this exal na ioir "corporate leadership asked him to be within budget." "They've demonstrated that they don't have a good track record of being able to care for patients safely, so we're not going to allow them to do that." _NataWwari 8irartnr nffha rtanar+mant of r-rwalth'c /lffirn of rnmrnnni4v Health Systems 6w..•/M.,,{e..te o�...,iI f;----/On1—4-4. 1-11 .,. If III Public Crisis, Private Toll Page 9 of 35 Washington's severe shortage of inpatient bods for psychiatric patients put pressure on state officials to acid more capacity, Smokoy Point Behavioral Hospital, a for-profit hospital In fvlarysville operated by US Health Vest, aimed to address the need, (Erika .Schultz / The S©ottle Times) "Immediate jeopardy" Kresch, US HealthVest's founder, has made a career developing psychiatric hospitals and selling them for a profit. A psychiatrist by training, Kresch ran Ascend Health before selling it to industry giant Universal Health Services in 2012 for $503 million in cash. US HealthVest was incorporated four months later, drawing well-heeled investors like Polaris Partners, which reportedly earned to times its investment by backing Ascend. US HealthVest has raised more than $r8o million so far from investors and lenders. Mery//nrnir+rra eF,tr l mim nam/7t11Q/nuhlb._, a��_nn.,�rt�_r..11_,...�rI/ LM/IAIn POUllo Cnsis, Private toll Page 10 of 35 Washington state was one of the first places where US HealthVest looked to establish a presence, and its timing was good. The state was in the midst of a mental-health crisis, with so few inpatient beds that emeigencv rooms were holding-aatLents who had been involuntarily committed. The state Supreme Court in 2014 found this practice illegal, ratcheting up pressure on state officials to add more beds. Smokey Point directly addressed this need. we take our responsibility to provide Otl%erape�*110rl0"knitits:with the To open the hospital, US HealthVest's proposal had to pass muster with the Department of Health. Given that US HealthVest was a new company, the regulator considered the track record of Ascend, which had been run by the same executive team. The department conducted a limited review of Ascend that turned up no red flags. Had the regulator looked a little further, it would have discovered serious violations that government inspectors found at an Ascend hospital in Houston in 2011 and in Salt Lake City in 2012. In one case, in Houston, a man admitted for "aggressive homicidal behavior" was accused of sexually assaulting a female patient and briefly transferred to a male -only unit. The next night, a staffer found him assaulting another female patient in her bathroom, covering her mouth as she yelled for help. The male -only unit had been closed that day due to a "cost saving measure," according to an inspection report, At Smokey Point, staffers have become accustomed to measures designed to save money, http://projects.seattletini".cont/2019/public-crisis-private-toll-partt/ 3/2/2020 Public Crisis, Private Toll according to employees and internal records. Last January, Smokey Point's nursing staff received a directive on US HealthVest's approach to monitoring high-risk patients who needed to be watched at all times, Such monitoring is called "one-to-one" or "line -of -sight" — abbreviated as r:r and LOS — and often requires additional staff. Page II of75 "Our corporate offices do not subscribe to the philosophy that rn and LOS are needed for ongoing days at a time," John Beall, Smokey Point's chief nursing officer, wrote to his staff. A couple of nights later, a nurse asked Beall for an additional staffer because two patients on a unit needed one-to-one observation. He responded that one patient was asleep and that sleeping patients do not require such monitoring. "That's not a staffing model US HealthVest uses," Beall wrote back, according to screenshots of the correspondence that another staffer provided to The Times. "Please keep her well medicated & we will re- evaluate in the morning." Beall declined to comment. At Smokey Point, a staffing plan calls for one nursing employee for every four to six patients, depending on the unit. Still, a staff member can be alone on the floor with a dozen or more patients for at least an hour, according to current and former employees. While hospitals in Washington can be fined if they fail to staff aooro rp iately, the law doesn't apply to psychiatric hospitals like Smokey Point. Christina Perry, a former Smokey Point nurse, often found herself alone tending to as many as eight patients for hours. "Every day I worked at ..«.�., n4 ..... r r, 11 -.,1/ onnrcnn Public Crisis, Private Toll Page 12 of 35 Smokey Point Behavioral Hospital, I was afraid for my life and the lives of my patients," she later said, Play full video (3:08) ► Christina Perry was a nurse at Smokey Point Behavioral Hospital from September 20q through May 2018. "1 felt helpless working there,"she said. "I felt like 1 didn't have enough resources to make sure everybody was safe."(Erika Schultz, Gabriel Campanario & Louren Frohne / The Seattle Times) There is no question that some patients have benefited from care they received at Smokey Point, which has provided Snohomish County residents with a treatment option much closer to home and their support networks. One man, whose 17 -year-old daughter spent three weeks there, said she left in much better health. "They definitely helped her, and they provided something that I don't think I could have," said the father, whom The Times is not identifying to protect his daughter's privacy. "I feel like it was definitely a positive experience." http://projects.seattletimes.cotn/2019/publiccrisis-private-toll-partl/ 3/2/2020 Public Crisis, Private Toll Mary Hintz, 26, spent about 10 days at Stookey Point in February while her medications were adjusted. She felt safe and well - attended by staff. "It was just a great experience for me," she said in an Page 13 of'35 You can support watchdog journalism Make a tax-deductible donation to The 3-c,t1le.lkn-es Lm%,g 'it*itiveJQua aIistn Fuocl and subscribe to The Seattle rte, interview. "The doctor was amazing." Yet other patients complained of the lack of therapy, according to interviews and complaints filed with the Department of Health. Group sessions were often cut short or canceled, in some cases because there weren't enough staff to run them. Patients passed time between meals playing with cards, puzzles, board games and coloring books. One of the first hospital staffers to take his concerns public was Chris Lurvey, a mental-health technician, who emailed elected officials and the Department of Health in February 2018 to report numerous suicide attempts and fights between patients. Cammy Hart -Anderson, a Snohomish County official whose division oversees mental-health services, also filed a eomnlaint with the Department of Health. Patients had testified in involuntary commitment hearings that they didn't feel safe, she wrote, and neither did county staff. The next month, in March 2018, the Department of Health dispatched six inspectors to Smokey Point. Among their findings: A suicidal patient was checked on with the same frequency as patients who were not suicidal. Six days into his stay, he was found unresponsive hanging from his bed sheets and taken to a medical hospital. Three days later, back at Smokey Point, the man made a second suicide attempt. htto:llproiects.seattlethnes.com/2019/oablic-crisis-private•toll-oairtl/ 3/2!2020 Public Crisis, Private Toll Page 14 of 35 • Another patient had a plan to kill herself by "banging her head as hard as she can into the wall." She had been slamming her head into a wall, a nurse had written, but inspectors found no evidence that staff intervened to stop her. • A staff member threw away the catheter that a "wheelchair bound" patient used to manage a urinary condition, only for another staffer to remove it from the biohazard trash, wash it off and return it to the patient. • One diabetic patient had a foot ulcer and had a referral to a wound -care clinic "as soon as possible." Instead, the wound worsened for another nine days until the patient was sent to a medical hospital. • An aggressive patient was found having sex with a developmentally disabled woman, hours after he was ordered to stay five feet away from all female patients. When a mental-health worker asked if the encounter was consensual, the woman said it was. "He was sent by God to have babies with me," she said, according to state investigative findings. US HealthVest didn't respond to whether the matter was referred to law enforcement. The inspectors declared a state of "immediate jeopardy," the most serious kind of violation that can put patient lives in danger, triggering a process to cut off the hospital's access to federal funds. For facilities like Stookey Point that rely heavily on reimbursement from taxpayer -funded Medicare and Medicaid, such a penalty could have had a dire financial impact. A week after the inspectors issued their findings, Smokey Point admitted Rosemary Torgesen. htti)://Proiects,seattletimes.com/2019/public-crisis-nrivate-toll-t)artl/ 3/2/2020 Public Crisis, Private Toll A more appropriate place Rosemary stood 5 feet tall and weighed barely into pounds, a diminutive stature that contrasted with an exceptionally strong Will. She had lived most of her life with schizophrenia while raising seven children. When her kids were grown, she volunteered for Catholic Community Services, helping seniors and disabled adults do household chores. She knew seemingly everyone's name at the St. Mary's Church in Arlington, and Page 15 of 35 Rosemary Torgesen is seen on Christmas Eve in 2017. Jost three months later, Torgesen, who hod schizophrenia, was it committed and admitted to Smokey Point Behovloral Hospital. (Courtesy of Jeffrey Torgesen) rarely let a kindness go unrecognized; one friend who gave her rides to church would later find money left in her car console. A county mental-health worker who evaluated Rosemary in March 2018 determined she was "gravely disabled," meaning her disordered mind presented a serious threat to her physical health. A judge agreed she met the criteria for involuntary commitment. The question was where to send her. At Stuckey Point, whenever there was a question about whether it was appropriate to admit a patient, the chief nursing officer would consult with the hospital's chief executive, Matt Crockett, who held no medical Mt,,tlFrimr.c nmPotll9/n,ihlI,.,_t,.l I_no.e I/ to II Ain Public Crisis, Private Toll Page 16 of 35 license, according to slue records. A physician assistant told inspectors last year that some patients were admitted after a doctor had_rulecl_thcln too medically fra ile to accept. Rosemary, who also had a heart condition, was the oldest patient Smokey Point had ever admitted. A county mental-health worker later reported to the state that Crockett had ordered her to be admitted over the objections of a medical doctor. A state investigator found "no evidence" of this, but made no attempt to identify or interview the doctor. Crockett, now the interim chief executive of Wellfound Behavioral Health, a new psychiatric hospital in Tacoma, didn't respond to emails and phone messages seeking comment. Almost as soon as Rosemary arrived, Smokey Point's nursing staff recognized that they lacked the ability to care for her. Staffers said she refused to let them check her vitals, which prevented them from giving her an antipsychotic medication. Two weeks into her stay, a nutritionist recommended that she be "sent to a more medical psych unit" due to "not being able to monitor pt appropriately," using the shorthand "pt" for patient. The Torgesen family had another facility in mind: Northwest Hospital in Seattle, operated by UW Medicine. Rosemary had been there for electroconvulsive therapy, which sends electric currents through the brain to alter its chemistry, and had responded well. The procedure is performed under general anesthesia and could not be done at Smokey Point. Her children asked the hospital to transfer her to Northwest. http:Hprgiects,seatttetinies.com/2019/public-crisis-private-toll-para/ 3/2/2020 Public Crisis, Private'l'oll Page 17 of 35 Smokey Point's staff made several efforts to contact Northwest, Rosemary's medical records indicate. But for reasons that are unclear, no appointment was made, A month later, on May 8, a Smokey Point psychiatrist finally sent Rosemary to Northwest Hospital's emergency department to evaluate her for admission there. A mental-health counselor examined her with some confusion. Rosemary's family wanted her to be treated there, he wrote, but "Smokey Point staff present in ER are unaware of why pt came from Marysville to Seattle to be seen in the ER." He added, "Pt has not been discharged from their facility." Rosemary herself was frustrated. "This is a waste of money," she told the counselor, rattling off the lab costs, the ambulance rides and the staffs time. It was, in fact, a wasted effort. Northwest said its geropsychiatric unit was full and couldn't admit her. She was sent back to Smokey Point. "Hundred percent success rate" Kresch, US HealthVest's chief executive, has spoken candidly about the company's focus on profitability, boasting of a "hundred percent success rate in turning around all of the distressed hospitals we have acquired." The company's flagship hospital, Chicago Behavioral, was such an example. The facility had been run by a nonprofit 'Health and safety of our patients is our top priority': Read the fall response from US HealthVest V that was losing money and planning to close when US HealthVest acquired it in late 2014. By the end 6r,...O..«..:............d N...:.«un...._Ml n/....61;.. ";....t.,. Inu . I/ Vl ill19n Public Crisis, Private poll Page 18 of 35 Of 2o16, it turned a $7.3 million profit, according to its l nanchIl statements. A different picture, though, emerges from regulatory and court records. Regulators found serious violations at Chicago Behavioral four times in less than two years, including an immediate jeopardy to patient s&jKLn May,. Inspectors found the hospital Failed to co_ di safeiy checks on patients, pltQyide indtvidp�lized-etre and invesaate alleged sex.Il- abuse. The company is contesting two wrongful -death lawsuits filed by the families of patients who died of medical emergencies within a four- month span in 2m6, Similar problems emerged at the company's two hospitals in Georgia. At the Ridgeview Institute in Smyrna, on the outskirts of Atlanta, regulators found the hospital was providing"gpI Qtic non�7dividUalizec. 1`nZaLtlle t." The shortcomings were more serious at a second hospital US HealthVest opened 6o miles east, the Ridgeview Institute in Monroe. Last year, Georgia regulators received a complaint that nursing staff at the Monroe facility "are forced to provide minimal and unsafe care and monitoring to patients." The tipster expressed particular concern about an unnamed young woman, admitted to Ridgeview in January of 2o18. http://projects.seattleti nies.com/2019/public-crisis-private-toI kpart 1/ 3/2/2020 Public Crisis, Private Toll Page 19 of 35 Sarah Reum, 22, died by suicide Jon. a0, 2018, while she was a pabontat US HeaRhVest's Rldgeview Institute In Monica, Georgia. Loter that year, another pationt thoic killed himself. In both cases, security vidoo shows both pubents, on suicide watch, were left clone for more than an hour when they were supposed to be checked every 15 minutes. (Couratsy of the Reum family) The patient in question was Sarah Reum, a 22 -year-old with hazel eyes and a smooth voice that had won singing competitions, She had two young daughters, a tumultuous relationship with their Father and a mental illness she had struggled with since she was a teen. hrrn. fl—;.,nfn... rvJ1.....11I 111/on"n Public Crisis, Private Toll Page 20 of 35 Reum was admitted to Ridgeview under Georgia's involuntary treatment law and flagged as a suicide risk. She, like all patients, was to be checked on at least every 15 minutes. On her eighth day at Ridgeview, Reum called her mother and asked to speak to her 3 -year-old daughter. "`I love you so much, I love you so much,' she probably said it nine times," her mother, Stacey Jenkins, recalled. The next day, hospital records show that Reum was checked on as required. But its camera footage, reviewed by The Times, tells a different story. At q:oy p.m., a camera records Reum sitting in a chair in view of the nursing station, hands to her face, shoulders shaking. After two minutes, she gets up and walks down the hall to her room. Fifteen minutes go by without anyone checking on her. Thirty minutes pass. Forty-five minutes. An hour. At 5:12 p.m., a staffer enters her room, turns and runs down the hall to the nursing station, motioning for others to come. http://projects.mat(tetimes,com/2019/public-crisis-private-toll-pwll/ 3/2/2020 Public Crisis, Private Toll A nurse and another staffer accompany her, in no apparent hurry, to Reum's room. More staff come running, followed by police and paramedics, but they are too late. Shortly after 6 p.m., Sarah Reum was declared dead by suicide. Page 21 of 35 Health inspectors reviewed records of all four units at Ridgeview over 16 days, finding that they were inadequately staffed between 310/o and 690/o of the time. Jenkins and Reum's father, Ricky Reum, didn't know that n000ne checked on their daueliter for an hour until contacted by a Times reporter. They didn't know the unit where their daughter stayed was short-staffed the day she died. They didn't know that re ula oref,ybJeri 11e JraspJlsl for their daughter's death, or that the hospital had fir d two emnlovees as a result and hired a new head of nursing — all of which it described as "corrective actions." �AoNIA ;-- „n,.,/9 Al O/...,611n_,•rla L._nr;,...r„d..11 ......I / n m/nr»n Public Crisis, Private Toll Page 22 of 35 They were also unaware that Gina Holbrooks, a Monroe Police detective who investigated Reum's death, concluded that the hospital's observation log "was falsified as if staff was actually providing care to their patients." In May, Reum's parents and the father of her daughters Slued US HealthVest_ The company is contesting the lawsuit and denies that it falsified records, according to its legal re"vpse. Jenkins still chokes up thinking about milestones Reum is missing, like her older daughter's first day of school this month. "She didn't get to see it because somebody didn't do their job," she said. Her oldgr 4augbte;,'S first day of school was this month, but Reum "didn't get to see 3t?bk ase sumeboldivaidil' do their' itib "''Sa18 Lurl 'g riiU et- starpv The state inspectors who investigated Reum's death determined the hospital had fixed the problems by the time they showed up two months after her death. Six months later, law enforcement responded to another emergency at the hospital. Joseph Morris, a 46 -year-old patient admitted the previous day for suicide risk, was found dead hanging from a bedsheet in his room. While Ridgeview records showed that he had been checked on every 15 minutes, video footage revealed he was alone in his room for 93 minutes, according to a police report. When the coroner informed Morris' family of his death, his father slumped to the floor. "It is a lie," his mother said repeatedly, according to the police report. How, she cried, could someone on suicide watch die by suicide in a hospital? httD://Droiects,seattletimes.coin/2019/public-crisis-private-toll-pard/ 3/2/2020 Public Crisis, Private Toll Page 23 of 35 Holbrooks, the detective who also had investigated Sarah Reum's death, didn't disguise her anger in concluding her report. "Once again Ridgeview Institute has put more effort into covering up their own neglect of patients," she wrote, "by fraudulently documenting care." "A family's shock" At Smokey Point, some employees hoped US HealthVest would take Washington state's investigation to heart and improve conditions. Instead, the turmoil only intensified. Days after inspectors left the building in March 2018, executives fired three nursing employees — including one who had been promoted four months earlier — for violating a policy called "solicitation." The company didn't elaborate on the reason, but employees believe the message was clear: All three had discussed forming a union. The three employees filed a complaint with the National Labor Relations Board, and the hospital ultimately agreed to may each of them back pay, interest and $10,00o instead of reinstating them. Other employees left of their own accord. Christina Perry tendered her tesignation in mid-May. "I do not feel safe working here since there is not enough staff," she wrote to the chief nursingfficer. 6u... I I" W,L,.,I. ,,e,. u. I L,,.,.. ,.,,.«/9n l n/..,.61 L . ....:..:.....4..,.m +.,II ....., I / 11111111n Public Crisis, Private Toll Page 24 of 35 Christine Perry resigned from her position cis a out cat Smokey Point. 7 do not feel trio working here since there is not enough staff," she wrote to the chlof nursing officer. (Erlko Schultz /The Seattle Times) for joint Concern wasn't limited to staff tending to patients. Lejla Marusic, a senior manager whose job was negotiating with insurance companies, also resigned in May. She said of the hospital's executives, "They were only focused on passing the next audit, not the well-being of patients." One persistent focus has been on supplementing patient files missing required paperwork, a struggle compounded by short -staffing and turnover, according to internal memos and staffers. Public Crisis, Private Toll Page 25 of 35 Patient files, tagged with sticky notes to signal missing information, have at times been so numerous that they were deposited in the hospital's "yoga room," internal records show. Employees who failed to complete the charts would face disciplinary action, they were told as recently as March. A new chief nursing officer, who replaced Beall last fall, also told staff, "Don't sign for something you didn't witness." But several current and former employees said that too much time had passed to accurately fill in certain incomplete records, such as what a patient was doing in 15 -minute intervals days or weeks earlier. When inspectors have arrived, staff have been told to remove sticky notes to avoid signaling that files are incomplete, former employees say. The hospital had more serious problems than record keeping. On June 16, 2018, almost three months after she arrived, Rosemary Torgesen fell in the hallway and broke her arm. An emergency physician who examined her at the nearby Cascade Valley Hospital also noted a second possible injury: to her right hip. X-rays showed a deformity in her hip socket, but no fracture, and the doctor attributed it to arthritis. Listen to the lune 16th1c:1 Within days, though, Smokey Point's records indicate an abrupt change in her mobility. httn://nroiects.seattletimes.com 2019/nublic-crisis-private-foll-nartl/ 4 2/9.0211 Public Crisis, Private`Poll Page 26 of 35 On June 20, she didn't attend a therapy group due to being "bedbound" as a result of "fall and injury." On June 24, nursing staff found she had a bedsore, an open wound near the base of her spine from staying in the same position. The woman who never complained said of her pain, "It's terrible." Smokey Point's staff had become so alarmed at her condition that they sent her to Providence Regional Medical Center's emergency department in Everett, the fifth time they had done so since the beginning of her stay. An emergency -medicine doctor offered a strikingly different assessment. "Patient does not appear in imminent danger," the doctor wrote on June 28. "It appears she needs more mental health treatment." She was returned to Smokey Point. Smokey Point's staff suggested a new course: discharging Rosemary home to her family and referring her for hospice care. Only then did Rosemary's children suspect their mother had been neglected. "It was them admitting that they're incapable of caring for her," Jeff Torgesen, her oldest son, said. On June 29, Smokey Point held an emergency meeting with its medical director, chief executive and one of Rosemary's daughters. Rosemary hadn't had anything to eat or drink for at least four days. The hospital would send her to Providence and not accept her back. ho littn://Proiects.scittletimes.com/2019/public-crisis-private-toll-nartt/ 3/2/2020 Public Crisis, Private Toll Page 27 of 35 In July 20t7. Gov, Jay Insleo and Tilollp Tribes Chairwoman Murie Zackuse cut the ribbon at Che Srnokey Point Behavioral Hospital grond oponing. Since 2oi2, the state has approved or expanded in private psychiatric hospitals, nine of which are for-profit. (Kalvin Valdilloz / 7ulolip News) "A strong supporter" Despite Srnokey Point's struggles, US HealthVest benefited from a key source of support: Gov. Inslee and his administration. Since Stookey Point opened, the pressure had only mounted for the governor to expand mental-health care options. In June 2018, state-run Western State Hospital lost its Medicare certification after failing to resolve a litany of patient -safety hazards, forcing the state to make up for lost federal funds. With Smokey Point and its two other planned hospitals, US HealthVest would add almost 300 inpatient beds, all funded privately. 1,11_11/.....:..,,n. _..... �_ .q l ..,...e I I s M mann Public Crisis, Private Toll Page 28 or35 The company's plans were challenged by rivals that were also seeking to build psychiatric hospitals. Providence Health claimed US HealthVest had misled regulators about the scope of services at its proposed hospital near Olympia, and sued to block the project. Inslee's administration stepped in to broker a se(llernent in wlifch_both cmmp-nies would oven Pailities in the area. Support from the governor's office continued despite aides learning of concerns as far back as February 2018. On May 31 of that year, a Department of Health official sent two of Inslee's health policy advisers the March inspection report that found an immediate jeopardy to patients, A week later, Inslee's administration dispatched a cabinet -level official to Stuckey Point — to celebrate the opening of a new unit for veterans. As Alfie Alvarado -Ramos, Inslee's director of Veterans Affairs, emceed the dedication of the new unit on June 6, 2oi8, three inspectors from the Department of Health were inside the hospital conducting a follow-ua investigation. They completed a report the next day, finding serious violations including the failure "to ensure nursing staff were trained and available to provide safe and effective care." The next week, Secretary of Health John Wiesman sent a one-lJagg memo alerting the governor's staff to problems at Smokey Point and offering a series of talking points. He added: "Seattle Times inquired." US HealthVest has continued to leverage the governor's past support. http://l)rojects.seattletiutes.com12Ol9/public-crisis-private-toll-partl/ 3/2/2020 Publio Crisis, Private'rolt Page 29 of 35 An image of Inslee at Smokey Point's ribbon -cutting is prominently displayed on US HealthVest's website. As the company sought approval to open the hospital in Bellingham, US HealthVest reminded state health officials of the governor's support. "Governor Inslee is a strong supporter of our model," the companywrote ihj z memo for regulators last August, including a link to a YouTube video of his remarks at Smokey Point's opening. In an interview, Inslee compared Smokey Point to a promising athlete who "fumbles" and needs more coaching. "We can't just decide we're not going to open facilities because at one point there was care that was not sufficiently of quality, which we're now improving," he said. "We are experiencing what is frequently the situation when you have rapid expansion of any organizational pursuit, that you have bugs in the system." Fallout The staff at Providence Regional Medical Center seemed to be at a loss for how to treat Rosemary Torgesen. Her problem, some felt, was psychiatric and not medical, but Smokey Point wouldn't take her back. Doctors at Providence asked Northwest Hospital to accept her but they were losing hope. Rosemary had refused to eat or drink in life- sustaining quantities for I—_. u...:..............N,.a:..........-..... 101111 . LI!r . I -II I / 111 11.11, Public Crisis, Private 'roll weeks. She was sick and frail, the doctors told her children. The Torgesen family refused to give up on Rosemary's life. They authorized doctors to run a tube through her nose, down her throat and into her stomach to nourish her Page 30 ol'35 Click to see a fimellne of Rosemary Torgesen's last months ...,p POOWANnaxG[6Fw ni � i1 ll^ RAnop{eUi IYR App4Yv&e41AYID They "would like to proceed if she has `any chance' of recovery," a doctor wrote. Then Providence staff made an unexpected discovery while performing an X-ray of her abdomen: Rosemary's right hip was broken, apparently in a fall four weeks earlier while she was at Smokey Point, they wrote. Rosemary had told family members she had fallen several times at Smokey Point, but they weren't sure how reliable she was in her state. Her records showed only a single fall. Providence staff felt she would not survive the artificial feeding. The feeding tube was removed. On July 20, two days after the discovery of the broken hip, Rosemary Frances Torgesen died. The primary cause listed on her dea certificate was malnutrition. The secondary cause: "decompensated schizoaffective disorder" — the deterioration of her mental health. Contributing factors: "right hip fracture, right humerus fracture." http://projects.seattletimes.com/2019/public-crisis-private-toll-partt/ 3/2/2020 Public 0isis, Private 'roll Page 31 of 35 In just over three months at Smokey Point, her mental and physical health had deteriorated beyond survival. The Torgesens were bereft — and angry. Angry at Northwest Hospital, which had declined to admit her despite their wishes. Angry at Providence, which recognized only at the eleventh hour that their mother had a badly broken hip. Mostly they were angry at Smokey Point. Barely a week after she died, Jeff Torgesen began filing complaints with the Department of Health. Northwest Hospital had told Smokey Point that, as a King County facility, it was required to give priority to local patients, according to an email in Rosemary's medical records. A spokeswoman for UW Medicine, which operates the hospital, declined to comment about her case but said that family members and psychiatric hospitals "may not have the legal right to determine if a patient is transferred to another facility for mental health care." Providence also declined to comment on Rosemary's care. The Department of Health fauilt-cl Providence for sending Rosemary back to Smokey Point without documenting that the psychiatric hospital could provide the necessary care. A spokesman said Providence submitted an action plan to the regulator, which accepted it. Last August, a Department of Health investigator arrived at Smokey Point to review Rosemary Torgesen's file. The investigator found no record that a medical doctor was involved in reassessing her condition during her stay. The hospital was cited for Faiti r t_ transfer het"to a higher level of Ole in a timely manner when the hospital was not able to address the patient's health care needs." Less than a month later, on Sept. 13, the Department of Health determined that Smokey Point was back in compliance with state and federal standards, meaning its Medicaid and Medicare funding was safe. he..•//n...iA,.,o o—IiI --N)1 W—M❑....... im in.-1,—lur-I1 —11 aro/IA,A Public Crisis, Private'Poll Page 32 of'35 The reprieve, however, was fleeting. In January, inspectors returned to Smokey Point and fond many of t11e sa nQ to 1,9 they'd identified last year. They cited serious failures again in February,, April_ and Lttne before reaching the corrective action plau with US HealthVest. Four of Rosemary Torgesen's so von children visit horgreve in Shoreline. From left: Marjorie Erickson, left Torgosen, Mouryo Smith unit Douglas Torgesen. (Erika Schultz / The Seattle Times) Jeff Torgesen, however, remains dissatisfied with the stepped-up scrutiny and has pushed law enforcement to open a homicide investigation, The Marysville Police Department is investigating Rosemary's death but not,. at this stage, as a homicide, a spokesman said, "I've been consumed," Jeff Torgesen said. "I feel responsible, not just to avenge my mom, but to show her treatment isn't being cast aside, being swept under the rug." httn://nroiccts,seattletimes,com/2919/public-crisis-nrivate-tnl I -hart I/ ¢nro(m) Public Crisis, Private Toll Page 33 of 35 His last correspondence with Smokey Point came in October, after the hospital mailed a bill to Rosemary. Smokey Point had charged a total of $297,000 for her 99 days of care. She owed $27,965.78. "Given the history of the above -referenced account, please see what can be done about an immediate forgiveness in full of account balance," Jeff Torgesen emailed hospital staff. "The patient is deceased." Smokey Point's chief financial officer responded within the hour, reducing the balance to $3,oi5. Two minutes later the finance chief emailed again. Rosemary had secondary coverage through Medicaid. There was no longer an account balance. The government would pay. Rosemary Torgesen's memorial plaque is prepared at a Shoreline cemetery. (Erika Schuttr / The Seattle Times) Readthe three-part investigation by The Seattle Times 1,N-//�ninor�..»Hlof;m mm /In Q/„1,1;—A.1—.4—fP_WI_.AI/ 1/O nrnn Public Crisis, Private Toll Page 34 oP 35 PART ONE: How a comnanv's push to expand psychiatric care brought Red Published on August 25 2019 PART TWO: A hidden safety record a human cost Published on September 8.2019 PART THREE: Free to check in, but not to leave Published on October 6 2019 Resources for mental-health support • In a crisis? • Meed sul)pog? • Worried aboutag11epn you ImQM? rte—_-- -- - Reporter: Daniel Gilbert Project editor: Ray Rivera Photographer: Erika Schultz Photo editor: Fred Nelson Video editor: Lauren Frohne 5 1-_ Developer and graphic artist: Emily M. Eng Illustrator: Gabriel Campanario Engagement: Taylor Blatchford Project coordinator: Laura Gordon You can support watchdog journalism kon-I/rii..;,M....tt I M;,d -- MI l_,—, II Qhronon Public Crisis, Privale T011 Page 35 of 35 Make atax-deductible donation to _T'he ceattlt_TinlEs ]nvlosti�ative aurnabsni Fund{ and subscribe to Dhe :ieadfle Times. If you're having trouble corrlmenting or viewing cornmerits, hit refresh on your browser and try again. _..._-- Vigw1g_Caarr it=.irt@ --� hltp://projects.seattletimesxoin/2019/public-crisis-private-toll-part I / 3/2/2020 Public Crisis, Private Toll Page 1 of 35 a4catfitaimes PUBLIC CRISIS, PRIVATE TOLL The hidden costs of the mental-health industry's expansion Public Crisis, Private Toll Page 2 of 35 At private psychiatric hospitals, a hidden safety record, a human cost PeterEdc Descalso checked into Cascade Behavioral Hospital In December 2016 for alcoholism treatment This document was pan of his admission paperwork, (Courtesy of the Descalso family) By Daniel Gilbert Seattle Times staff reporter Published September 8, 2019 https:/lproiect%seattletimes,cotn/2019/public-crisis-private-toll-Dart2/ 3/2/2020 Public Crisis, Private Toll Page 3 of 35 On Dec. 20, 2o16, health inspectors hand -delivered a notice to the chief executive of Cascade Behavioral Hospital, warning that conditions "posed an immediate and serious threat to patient safety." The next day, a patient in the throes of severe alcohol withdrawal was left to sleep unattended, went into cardiac arrest and died. Regulators made no connection between the two events, which came after a period of rapid expansion. by the psychiatric hospital, but Cascade's troubles were only beginning. Over the next 19 months, government inspectors found more violations at Cascade that put patients at risk, and at least six others died — by suicide, in medical emergencies or after an injury that caused or contributed to their deaths. They were men and women, aged 49 to 92: Diesel mechanic. Service -station owner. World War II veteran. Painter. Teacher. Mental-health professional. Advocate for the disabled. Together, they represent an unusually high toll for a hospital that is only supposed to accept medically stable patients and whose policies require staff to check on them at least every 15 minutes. It is also a largely secret toll. Patients and staffers at Washington state's private psychiatric hospitals suffer harm far more often than the facilities disclose to the Department of Health. While many states post hospital inspection reports online, Washington's default position is to keep them private. Despite repeated serious violations, Cascade and peer institutions have operated without any penalty, an investigation by The Seattle Times has found. The full scope of safety incidents at the private facilities is essentially invisible even to the officials who regulate them. When a patient or staff member suffers serious, largely preventable harm, hospitals are supposed to report it to the state as an "adverse event." The self- reported events, however, leave out dozens of incidents ranging from broken bones to sudden deaths, according to a database The Times built by obtaining workers' compensation data, emergency dispatcher notes and more than i,000 pages of police, regulatory and court records. https://prgimts.scattletimes.com/2019/public-crisis-private-toff-paf2/ 3/2/2020 Public Crisis, Private Toll In the past three years, the six private psychiatric hospitals In Western Washington that have been open at least a year reported a combined 15 adverse events to the state. The Times found 350 incidents in which patients or staff were assaulted, suffered an injury, attempted suicide, escaped or died suddenly at these hospitals over the same time — an average of more than twice a week. In interviews and documents, employees of the private institutions have said there weren't enough trained staff to Page 4 of 35 TIMES WATCHDOG Public Crisis, Private Toll: Read the full investigation protect patients or themselves. Some staffers have chosen not to report assaults to avoid entangling patients in the criminal -justice system, while others have said they were discouraged by their superiors from calling police. Even senior county officials overseeing mental health have been in the dark about problems at the hospitals to which they send patients. Jim Vollendroff, who was King County's top mental-health official before leaving late last year, didn't know about the deaths at Cascade Behavioral until informed by The Times. "That seems like a big, big red flag," he said. "That seems like a big, big red flag." - Jim Vollendroff, former director of King County Behavioral Health and Recovery Division r,.N:,rrlNKmnc nrn/901/in nn Public Crisis, Private Toll Page 5 of 35 Vollendroff also wasn't informed when state or federal officials found violations at King County hospitals, he said, adding he believes the reports should be public. "If I had a family member I was going to be sending to any one of those programs, I would want to know what their violation history has been," said Vollendroff, now director of the new Behavioral Health Institute at Harborview Medical Center. Speaking for himself and not the hospital, he said, "It helps drive good quality if hospitals understand people have access to this." Michael Uradnik, Cascade's chief executive, declined to be interviewed but said in written responses that serious cases of harm are rare and that Cascade strictly follows the law in reporting them to the state. "Many of our patients come to our facility experiencing some of Read the firll response from the most profoundly challenging Cascade Behavioral CEO behavioral and medical health Michael Uradnik challenges of their lives, including being turned away or transferred from other hospitals that are unwilling or unable to provide the highly intensive, specialized services offered at Cascade," Uradnik wrote. He added, "The small number of isolated incidents referenced provide a highly incomplete, inaccurate and non -representative depiction of Cascade that is not at all reflective of the overall quality of care, patient experience and community public health benefit provided by our clinicians to thousands of patients annually." It Is relatively rare for patients to die or suffer fatal injuries at a psychiatric hospital. In 2014 and 2oi5, there were seven and eight deaths, respectively, at psychiatric hospitals statewide, according to Department of Health data. At BHC Fairfax Hospital in Kirkland, there has been a single death since 2016 under the jurisdiction of the medical examiner, which determined the man died of natural causes. At Navos in West Seattle, the county medical examiner has no record of any deaths in the past three years. https://proiects.seattletimes.com/2019/Dubuc-crisis-private-toll-Dart2/ 3/2/2020 Public Crisis, Private Toll Page 6 of 35 A hidden toll Safety incidents at private psychiatric hospitals in Washington state, 2016-2018 When patients or staff suffer serious, largely preventable harm, hospitals in Washington state are supposed to notify the Department of Health. Between 2016 and 2018, private psychiatric hospitals reported a combined 15 "adverse events," which are exempt from public disclosure. Over the same period, The Seattle Times found 35o assaults, injuries, escapes, suicide attempts, sudden deaths and other incidents that harmed staff or patients. Many likely didn't meet the state's high, narrow criteria for mandatory reporting, but The Times included them to give a more complete picture of safety at these facilities. Below are incidents for which The Times located a public record. To see information for each event, explore this graphic on a larger screen. (Warning: Some reports contain graphic descriptions.) O REPORTED ADVERSE EVENT Q INCIDENT FOUND BY THE TIMES FOUR PEOPLE HARMED ONE PERSON All incidents Incidents by facility Incidents by type httns://Proiects.scattletimes.com/2019/public-crisis-orivatc-toll-Dart2/ 3/2/2020 Public Crisis, Private Toll Page 7 of 35 Note: Incidents at Novos aro through 313112018. 'Includes incidents at Fairfax hospitals in Kirkland, Eve;ettand Monroe bttps:llnroiects,seattletiines.cum/2019/public-crisis-private-tol I-oart2/ 3/2/2020 Public Crisis, Private Toll Page 8 of 35 -Includes sudden deaths, injuries, overdoses, sexual assaults of encounters where there was a question of consent, and medication errors that required medical follow-up or were recorded on internal incident log. Source: Times reporting GRAPHIC: EMILY M. ENG / THE SEATTLE TIMES REPGRTING: DANIEL GILBERT / THE SEATTLE TIMES It isn't clear if all of the deaths of Cascade patients could have been prevented. Many families interviewed by The Times expressed anguish over the care their loved ones received at Cascade, but not all. Don Kay, whose wife, Marilyn, died suddenly at Cascade last year, was happy with the hospital's service. "She was cared for extremely well by the employees," he said. Uradnik said a private survey conducted for the hospital found that 780/0 of patients surveyed over the past year — representing about r8% of total admissions — described their overall experience as good or very good. There is no question that Cascade provides a badly needed service and that its staff has helped patients. One woman who was assaulted by another patient there in 2017 said she still benefited from the therapy she received. "Overall I think they helped me realize that I had a reason to live," said the woman, who requested anonymity because she didn't want her assailant to know her identity. "I felt like the staff was doing their job, I really do." Uradnik added Cascade has "never been subjected to any licensure restrictions, fines, admission freezes, patient suspensions or facility closure orders." That isn't unusual in Washington state. The Department of Health hasn't taken an enforcement action on a psychiatric hospital since suspending the license of a facility owned by Pierce County in 2oo6. "Our role in this structure is to really work with the facility to help them be successful in doing their job better." - Nate Weed, director of the state Department of Health's office of Community Health Systems https://i)roiects.seattle6mes,com/2019/public-crisis-private-toll-l)art2/ 3/2/2020 Public Crisis, Private Toll Page 9 of 35 "Our role in this structure is to really work with the facility to help them be successful in doing their job better," Nate Weed, head of the Department of Health's Office of Community Health Systems, said in an interview. The lack of enforcement action "is not because we don't think that's a tool available to us, but there's a process that happens after you do that, too, within the legal world," he said. "What we're really trying to balance, often, is how do we get that facility to behave better right now," In a demonstration of the department's enforcement philosophy, agency officials earlier this year met at the state Attorney General's office in Olympia with senior executives of US HealthVest, which operates Smokey Point Behavioral Hospital, records show. The regulator had found violations at the Snohomish County facility on ra separate visits over 15 months, including failures that put patient lives in danger. Instead of restricting Smokey Point's operations, the officials reached an agreement that required the hospital to submit to stepped-up monitoring. The hospital's failures that gave rise to this deal are nowhere to be found online and are only available through a public -records request to the Department of Health or its federal counterpart. While health regulators in at least 18 states, from West Virginia to Wyoming, post inspection violations publicly, Washington state doesn't. Hospital inspections by state At least 18 states publish hospital inspection reports online. Click on a state CANADA MM1*■ beIt httna//nrnirnt, c,,Ot +tim..rnnd701 Q/niihlin-oriuiemrivaf._tr,lI-..a,•t7/ 71719!19!1 Public Crisis, Private To11 aACiINSPECTIONS Pnrifir States with public report Source: Individual states Page 10 of 35 L,gaOgIIGQ i raiftVapuonIdbulors,a.gprLv GUYANA COWMAIA EMILY M, ENG / THE SEATTLE TIMES In response to questions from The Times, the Department of Health says that it "intends to develop the capacity" to post inspection reports online, enabled by new funding, but does not have a firm date to do so. The Centers for Medicare and Medicaid, a federal agency, has made thousands of inspection reports available for download, and the Association of Health Care Journalists has tblicly on sted many of them. But neither database is complete. When Eric Descalso started looking for help and settled on Cascade Behavioral, there was no record online of the repeated violations identified by state inspectors. He had no reason to expect anything other than the "world-class treatment" the company promised on its website. A gem of a hospital An Army veteran who maintained diesel trucks for a living, Descalso, 49, loved telling jokes but struggled to get to the punchline without cracking up, His laugh, beginning as a grunt that he tried to suppress, shook his barrel-chested littps://projectsseattletimes.com/2019/public-crisis-private-toll-part2/ 3/2/2020 Public 0isis, Private Toll Page I I of 35 frame until he couldn't speak. But as he sank into depression in the fall of 2or6, the drinking that anchored his social life became a problem. One morning he woke before dawn and stared at the clock, watching the minutes go by until the supermarket would be open so he could replenish his vodka supply. It was then that he understood the alcohol had taken control. Eric Descalso holds hlsdaughter Danielle in no April 1998lumpy photo. (Courtesy of the Descalso family) https://projects.scattlQtimes.com/20191public-crisis-private-toll-oart2/ 3/2/2020 Public Crisis, Private Toll Page 12 of 35 Codi Branson, his ex-wife with whom he remained close, and Carol Descalso, his mother, both worked in health care and encouraged him to get treatment. When Branson learned he was going to Cascade Behavioral, she felt reassured. The facility used to be known as Riverton Hospital, where Branson's oldest daughter from another marriage was born. "This is a hospital," Branson thought. "They've got doctors, they've got an operating room." The hospital had undergone some big changes. It treated only patients with mental-health and substance -use disorders. There was no operating room, In late 2013, Acadia Healthcare, a publicly traded company based in Tennessee, purchased the facility from Highline Medical Center and renamed it Cascade Behavioral. The acquisition 1s; absolutely, going to be a gem for us,' Acadia's president told financial analysts the following spring. The acquisition "is absolutely going to be a gem for us," Acadia's president told financial analysts the following spring. "Because of the way we were able to extract it from a not-for-profit," be continued, Acadia bad acquired it at a "very attractive valuation," according to an event transcript produced by S&P Global Market Intelligence. Acadia's acquisition was part of a broader transformation in how patients in Washington state receive care for serious mental health and substance -use disorders. In 2oi8, private psychiatric hospitals treated 350/a of people admitted to a Resources for mental-health suonort • Ina crisis? • Need support? • Worried about someone you now? Public Crisis, Private Toll Page 13 of 35 hospital with such conditions in Washington state, up from 17o/o in 2012, according to a Times analysis of hospital -discharge data. By the end of 2016, Cascade Behavioral was delivering on its financial promise. It generated $3.7 million in net revenue that year, a striking reversal from 2014 when costs exceeded revenue by more than $i million, the company reported to the state. But inside the hospital, conditions had deteriorated to an alarming degree, records show. In June of 2oi6, a police officer arrived at the hospital to investigate an assault. One patient had been hit in the head several times by another patient and was taken to a nearby medical hospital to be evaluated. "The staff just watched," the victim told the officer. The staff, for its part, "reported that because of the lack of security that they are afraid," the officer wrote. Cascade Behavioral Haspaui in Tukwila, once known as Riverton Hospital, was boughr by Acadia Healthcare in 2013 It Offers treatment for psychiatric and addiction disorders. (Erika Schultz / The Seattle Tomes) httr)s:Hproiccts,seattletimes.com/20l9/public-crisis-private-toll-t)art2/ 3/2/2020 Public Crisis, Private. "Coll Page 14 of 35 The next month, a registered nurse reported he had been assaulted by a patient and suffered a dislocated shoulder. He was calling from home, he said, because a supervisor "did not want the police called." Ten days later, officers again arrived at the hospital to investigate a report that two patients were punched in the jaw by a third patient. "Cascade Behavioral has no on-site security so the only reason both assaults stopped was because the suspect stopped on his own," the officer wrote. Three days after that incident, a nurse went to a police station to report that a patient had choked him, explaining that "there is an unwritten rule at Cascade Behavioral that staff should not call Sir for these type of incidents." Police officers were responding to Cascade Behavioral so often that in October Of 2016, Tukwila's police chief designated it a "chronic nuisance propel." according to records reviewed by The Times, the first step in a process that can lead to revoking a business license. A police spokesman said the matter has been resolved but declined to elaborate. Police officers were responding to Cascade Behavioral so often that in October of 2o16, Tukwila's police chief designated it a "chronic nuisance property." The Times identified 65 assaults from 2o16 to 2o18 where a Cascade Behavioral patient or staff member was injured, including several where the victim was knocked unconscious, or suffered a concussion or a broken bone. The Department of Health requires hospitals to report assaults that result in "serious injuries." Cascade hasn't reported a single physical assault as an adverse event in its history. Uradnik, Cascade's CEO, wrote to The Times that "not all incidents (including ones that could reasonably be deemed undesirable) necessarily meet the hrrr,v t/„r„L.�•i� c,"rrl ;" "� ¢n/loon Public Crisis, Private Toll Page 15 of 35 formal legal criteria" for reporting to the state. "Cascade strongly disputes and rejects any inference that our staff improperly or purposefully misclassifies or omits required adverse incidents from any state mandated reports," he wrote. The chief executive contended the nuisance designation was inappropriate but added, "We continue to work collaboratively with the City and Tukwila Police Department to reduce the overall number of calls from our facility." On Dec. 12, 2016, five inspectors from the Department of Health arrived at Cascade Behavioral to investigate complaints. One inspector noticed that a patient received emergency medical care and follow-up specialty You can support watchdog Journalism Make a tax-deductible donation to Ilie Seattle Times Investigative Journalism Fund and subscribe to The Seattle Times. appointments after being assaulted. When asked by an inspector why the hospital neglected to report this to the state, a manager claimed to be unaware that the incident should have been reported, records show. The inspectors spent eight days on site, cataloging a series of violations. There was mold under the caulking in a shower. There was a leak in the ceiling of a room where patients were put in seclusion. Door joints and window handles posed hanging risks for suicidal patients. Emergency carts were stocked with expired medical supplies. Staff had failed to follow doctor orders for treating patients with alcohol withdrawal. And, most alarmingly to the inspectors, Cascade had expanded the number of patients it treated by nearly 600/o from a year earlier without adding pharmacy staff, sharply increasing the chances of medication errors, The pharmacy director told inspectors, "I don't have enough pharmacy staff to do what we should." https://prgiects.seattletimes.com/2019/public-crisis-private-toll-l)art2/ 3/2/2020 Public Crisis, Private Toll Page 16 of 35 "Something is going on in the hospital" Eric Descalso was in bad shape when he checked in Dec, 19, 2or6, with a blood- alcohol level of 0.28 at intake. But he walked steadily and was calm and cooperative as he answered the staffs questions. Codi Branson reflects on her ex-husband's last days, "I thought he was more cored -for in that setting, that it was a hosteltot'(ErINuSchultz, Gabriel Companodo & Lawon Frohne /The Seattle Tlrnes) "I've got grandkids now and I'd like to see them grow up," he told hospital staff. "I'm here to quit and get healthy." The hospital put him on a plan for alcohol withdrawal, initially assessing his symptoms as mild. On the morning of Dec. zo, his second day, a staffer noted that Descalso's hands had begun to shake, his medical records show. That same morning, the hospital's leadership was facing a problem of another order: State inspectors declared an 'immediate leopardy" to patient safety, concluding Cascade "failed to provide sufficient pharmaceutical services to meet the scope, complexity and needs of the patients served." It was the most serious finding the regulator could cite, setting in motion a process to terminate the hospital's access to Medicare funds — a sanction that https://proiects.seattletimes.coin/2019/public-crisis-private-tol I-nart2/ 9/9,0020 Public Crisis, Private Toll Page 17 of 35 is rare but not unprecedented, with Western State Hospital losing its federal certification last year. Cascade staff were still trying to address the findings by the time the inspectors left the next day. staff. That day, Dec. zr, was Descalso's third at the hospital. He was delirious from withdrawal. His blood pressure spiked to 187 over iii, just shy of what the American Heart Association defines as a hypertensive crisis, which can cause a stroke, heart attack or organ failure. A doctor ordered a series of drugs for blood pressure and agitation, and Descalso fell asleep shortly after noon. He had been under continuous monitoring by staff, but a nurse left him sleeping in his room, according to his discharge summary. Descalso's 20 -year-old daughter, Danielle, was trying to call him but couldn't get through. "All they kept saying was, `Something is going on in the hospital, we can't talk right now,'" she recalled. Danielle called her mother, Codi Branson, at work. Branson, a nurse, called the hospital to check on her ex-husband. She was put on hold. Cascade Behavioral kept a record of Descalso's condition and whereabouts every 15 minutes, initialed by a staff member. According to this record, Descalso was lying or sitting to bed in an agitated state during checks at noon, 12n5, 12:3o and again at 12:45 p.m. But according to his discharge summary, Descalso was already unresponsive by 12:45, his skin bluish from lack of oxygen. FMna /1nrn:nrFa �P�»1P6,,,Pa �nm/9e1 1MMAIn Public Crisis, Private Toll Page 18 of 35 As Codi Branson waited on hold, a doctor came on the line. He had some really bad news, he said, Peter Eric Descalso was dead. When her fonner husband needed treatment for alrohralism, Cod! Branson felt confident shot Cascade Behavioral Haspltol in Tukwlto would be a good fit. He died three days after checking in, (Erika Schultz /The Seattle Times) Branson made her way home in a daze. She remembers finding Danielle in her bedroom and telling her that her father would not be coming home. Danielle ran out of the room and collapsed in the hallway, sobbing. When inspectors reviewed the case months later, they cited Cascade for Ejuing to document how staff responded to the cardiac arrest. It was a minor violation on the regulatory scale, but it was also a failure that left the hospital "unable to evaluate the effectiveness of emergency response," inspectors wrote. In response, Cascade pledged it would retrain staff within two months, and annually perform drills responding to medical emergencies, known as "Code Blue" events. 6er�•//...,.: �..,o o—ff laN — n...../I11l tN—hh.,_...t,�i.._...6..,m ..,II —.1/ III nn In Public Crisis, Private '1'oil Page 19 of 35 An autopsy determined that Descalso's heart failed due to alcohol abuse. His mother consulted a lawyer, who hired a nurse consultant with expertise in mental-health care to review Descalso's medical records. The consultant came to another conclusion about the care he received from Cascade's staff: "Their failure to meet their duty resulted in his unfortunate and premature death." The family settled with the hospital on terms that weren't disclosed. Citing patient confidentiality, Cascade didn't respond to specific questions about Descalso's care. In his statement, Uradnik said that settlements "do not constitute admissions nor findings of liability or wrongdoing." He described the hospital's rate of serious events as low but acknowledged that "regrettable negative incidents do invariably occur," adding "In these rare situations, we do our best to provide support and compassion to all those affected." For Descalso's ex-wife and mother, their sense of loss has been compounded by guilt at having encouraged him to seek treatment at Cascade. "Maybe I should have checked into it more," Branson said. "It's, like, what did I miss?" https://projuts.scattlettimes,cotn/2019/public crisis-private-toll-Wa / 3/2/2020 Public Crisis, Private Toll Page 20 of 35 Doniollo Descalso and herdad, Eric Descoiso, "were best bionds,"says her mother, Codi Bronson They're seon heroin 2012. (Courtesy of the DeSaa150 family) Adverse events If Descalso had died at a hospital in Pennsylvania, the facility likely would have been required to report it to the state health regulator — or face a fine of $z,000 a day. Pennsylvania health regulators have to investigate deaths in "unusual circumstances," such as when the cause isn't immediately clear. If they find any violations, they post them in a public database online, as at least 17 other states do. hfincJ/nrnienl'a cenMefi,nec enni/7019/nnhlir•.rricia_nriunY.+-MII_nnrf7/ 7/9/9(19!1 Public Crisis, Private Toll Page 21 of 35 In Colorado, hospitals have to report everything from unexplained deaths to threats of physical harm, which regulators must investigate and "disseminate ... to the public in a form that will assist people in malting informed choices among health care facilities," according to state law. When a patient dies suddenly at a hospital in Washington state, there is almost no trace of it. Descalso's death surfaced in an inspection report, which described him only as "Patient #9," after regulators learned of the cardiac arrest and faulted Cascade for failing to document how its staff responded. The hospital didn't report Descalso's death as an adverse event to the state, and it isn't clear that it had to. Hospitals have to report adverse events — including when a patient falls, gets assaulted or dies -- but only in certain circumstances. They don't have to report a death unless it was caused by specific types of mistakes, such as a device malfunction or medication error. They don't have to report assaults, suicide attempts and escapes unless they result in death or "serious iniurv," defined as loss of limb, bodily function or harm that requires surgery. There are no penalties for failing to report. httned/nrniPnta anaHlm;i nnm/?O1 'im/lcoa Public Crisis, Private'I oil Violation reports for private psychiatric hospitals b Vpl: oenJ• Uv:Yona+ ""I" 5f Inn® race+na. V'JASh11NG101q CLynyeia. Y.nnrn.o 4,pglpoll+ Salnrr'r CV9�W c M,al ,H- OIdEGl,tl+l N" ,nil,• uoi.P• arab Illano s lm�.11m� Page 22 of 35 ...LtL11211 10Ooen51 IN—g COIItnbtIt.B, 0 Gert a Click on a facility to read its inspection reports Note: The Serittle Times is providing thews reports of violations identified by governrnent in.spentors of private psychiatric hospitals in Washington store. rhe reports include violotions found during annual licensing surveys and complaint investigations. In sono cases, inspectors produced two separate reports for the sorno inspection to cite violations under distinct state and federal standards. Those records rlo riot Include inspections where a regulator Found no violations. They rnoy, not include every violation report, and this database will not be updated In real-time You con also request statements of deficiencies directly from the Washington state Department of Health and the Centers for Medicare and Medicaid Services https://projects,segttletimes.com/2019/public-crisis-private-tol I-part2/ 3/2/2020 Public Crisis, Private Toll Page 23 of 35 Sources: Washington state Department of Health, Centers for Medicare and Medicaid Services EMILY M. ENG /THE SEATTLE TIMES "The adverse events program aims to facilitate quality improvement in the health care system, improve patient safety and decrease medical errors in a non -punitive manner," the Department of Health said in a statement. The agency publishes a list of adverse events, summarized by a few words that don't reveal basic details such as whether a patient was injured or died. Over a decade, private psychiatric hospitals have reported a total of 23 events to the state in categories that can include death. When The Times asked in June which events proved fatal, department officials didn't know. They were still working on an answer as of last week. Even if hospitals reported every event as required, this tally would leave out many near -misses, like patient escapes, as well as serious injuries that fall short of requiring surgery or loss of limb. The Times found cases of sexual abuse, patients who received medical care after suicide attempts, and employees who suffered concussions and broken bones. Among the safety incidents that apparently were not reported to the state: • At Navos, a nonprofit hospital in West Seattle for patients who have been involuntarily committed, at least 17 patients escaped over three years. One patient who escaped was found unresponsive, with a blood-alcohol concentration of 0.57 — a level that can be fatal — and was taken to Harborview Medical Center where he survived, records show, • At BHC Fairfax Hospital in Kirkland, there were at least 14 escapes and 133 assaults over three years. Last August, there were two escapes, one apparent suicide attempt and four incidents in which a hospital staffer was assaulted or hurt trying to restrain a patient. • At BHC Fairfax's Everett facility, which hasn't reported any adverse events, one patient seized another patient by the back of the head and "punched him in the face repeatedly with the other hand." A police officer wrote of httns•//nrarvnfs ceaftleKmag cpm/2019/m,hlir-nri cia.nrivate_tnll-nart9/ 2/7/909(1 Public Crisis, Private Toll Page 24 of 35 the October 2018 incident, "Staff at the facility stated they did not have adequate resources at the facility to prevent any further incidents of violence." • At Smokey Point Behavioral Hospital, which opened in June 2017, The Times was able to identify 28 unreported assaults through law enforcement and regulatory records. But that represents only a slice of the violence occurring inside the hospital. Its own incident log recorded 88 assaults in 2018 alone, according to a state inspection report, which didn't provide details of the incidents. Navos was acquired by Multicare Health System in 2017. After reviewing documents of two incidents provided by The Times — the escaped patient who was found unresponsive, and a nurse whose hip was broken in an assault — a Multicare spokeswoman said, "We agree that these events should have been reported to the Department of Health and we will be filing those reports." The incidents predated the company's acquisition. Fairfax Behavioral Health, owned by hospital chain Universal Health Services, said that incidents identified by The Times were "regrettable and unfortunate" but not severe enough to report to the state. The company disputed that its staff lacked adequate resources but acknowledged that the needs of its patients have intensified over the past five years. "We believe this relates to the placement of highly acute patients who once would have received treatment at state hospitals returning to or remaining in community-based hospitals such as Fairfax, as well as to an overall underfunded and overstretched behavioral health system," Beckie Shauinger, Fairfax Behavioral's chief executive, said in a written response. Three assaults at BHC Fairfax Hospital in Kiridand https://projects.seattlefines.com/2019/public-crisis-private-toll-part2/ 3/2/2020 Public Crisis, Private I oil Page 25 ol'35 Oct. 31, 2077: The victim was Oct, 17,2018: The victim lost a taken to Evergreen Medical front tooth aad suffered an Ceaterfar hiSmiunos. Tice afacirent broken nose. Tile assailant was chartled with assrdlonr was onested and the misdemeanor ossaulh raise wassent to the prosecutor: Dec, 27, 2oi8/ The staff member, who hodiust been panchod in the face, was then bitten on the hand. Police referred the assailant for prosecution. While some staffers in psychiatric hospitals felt there was an unwritten rule not to contact law enforcement, there was an explicit policy at Smokey Point, operated by a for-profit company in New York called US HealthVest. "Before calling the police, please contact Matt Crockett, CEO," John Beall, then the hospital's chief nursing officer, emailed his staff in January 2oi8. "There is a process we utilize in talking thru the need and of corporate notifications." Beall declined to comment and Crockett didn't respond to requests. US HealthVest's chief executive, Richard Kresch, didn't respond to a question about this policy but said in a statement that "Smokey Point has been and continues to be, fully compliant with all state and federal regulations." A cycle of violations At Cascade Behavioral, inspections followed a familiar pattern. Inspectors often found violations they had cited in past surveys, notably for the hospital's readiness to respond to medical emergencies. The hospital would submit a plan of correction, the regulator would approve it, and the cycle would repeat at least annually. The severity of the violations in December 2016, however, dramatically raised the stakes for Cascade. State inspectors now were acting on behalf of the Centers for Medicare and Medicaid Services (CMS), the agency that determines whether a hospital qualifies for federal reimbursements. They gave Cascade a go -day deadline to comply with federal standards or risk termination from Medicare. In early March of 2017, the inspectors returned and quickly noticed a serious problem. https://projeets.seattletimes.com/2019/public-crisis-private-tol I-part2/ 3/2/2020 Public Crisis, Private Toll Page 26 of 35 A handheld metal detector for scanning patients appeared to be malfunctioning. One patient had hidden an X-ACTO blade in a sock, discovered only after a nurse found the 18 -year-old bleeding from cuts to the wrist, the inspectors wrote. They again declared a state of immediate jeopardy. The CMS operations manual spells out the consequences of a second such finding: The agency can terminate a hospital's Medicare funding. Instead, CMS extended the deadline for Cascade to comply for another month. With Cascade's status in limbo, on April 5, 2017, the hospital admitted a deeply depressed patient named Jim "Guy" Howell. Howell, 66, owned a service station in Arlington, lived on a farm and fixed up classic cars as a hobby. After a shoulder injury, though, he had spiraled into a suicidal depression. At Cascade, the hospital's staff noted that Howell had at some point expressed "plans to hang himself or use a gun to die," but he denied any current plans to kill himself. They determined he posed little risk of suicide. Every day he was there, Howell voiced his depression. "I miss Jim Howell, 66, fell into depression <rRera shoulder injury. For days, he talked about his hopelessness, and took his own life about two weeks after aroving at Cascade Behavioral Hospitol. (Courtesy of Bennie Jaeger) doing farm work," he said on April 7, his medical records show. "I am so sad," he told a physician on April 12. On April i9, he reminisced about working on the farm and told a therapist, "I will never have that again. There is no hope for me, no future," bttps://projects.seattletinies.com/2019/public-crisis-private-toll-part2/ 3/2/2020 fUDlle vnsis, rnvate toll Page 27 of 35 That night, hospital staff made a note of Howell's status every 15 minutes, as they had since his arrival. The record shows he was in bed all morning until 5:3o a.m., which is then crossed out with a large "X." Howell was not in bed at that time. In a note timed 4:45 a.m., a nurse wrote that a staffer had found him hanging from his bathroom door, with no pulse. This time, Cascade documented how its staff responded to the emergency. A nurse assistant found him and called for help. A registered nurse — the only one on duty at the time for the 15 patients on the unit — came to assist but doubted the two of them could get Howell down. The nurse ran back to the nurse's station and called a supervisor, then issued a hospital -wide alert and called 9rr. The situation called for using a manual resuscitation device — a self -inflating bag attached to a face mask — to force air into Howell's body. But the staff who responded to the alert struggled to assemble the device. They had never practiced it. Cascade Behavioral has a form for evaluating the staffs response to a Code Blue incident. Included on the form is a question of whether CPR was "uninterrupted and high quality." The staff left this question blank. "He was in a facility, he was supposed to be watched," said his sister, Bonnie Jaeger. "There's something there that is wrong." Cascade Behavioral appears to have reported Howell's death as an adverse event. The public record is limited to a date and a 7 -word description that doesn't reveal that the event was fatal: "Patient suicide, attempted suicide, or self -harm." https://projects.scattletimes.com/2019/public-crisis-private-toll-part2/ 3/2/2020 Public Crisis, Frivate'loll Page 28 of 35 Uradnik, Cascade's CEO, told The Times it was the only suicide in the hospital's history. "Our hearts go out to the individuals' loved ones," he wrote. As to the records that show Howell was being monitored after his death, Uradnik said "this was absolutely not a situation involving any bad faith or attempt to 'cover up' a death," adding that a staff member didn't know how to notate the event. "Cascade respectfully refutes as inaccurate any allegation that staff were not properly trained to respond to this unfortunate incident," he wrote. The inspectors returned in May and reviewed Howell's death. "The facility failed to ensure staff had the required knowledge and skills to respond to their patient's emergency medical needs," they found, according to the notice of immediate jeopardy. It was the third finding of immediate jeopardy in less than five months. Instead of terminating Cascade's Medicare funding, CMS gave the hospital reprieve after reprieve, extending the deadline to comply to the end of June and then to the end of July. CMS officials declined interview requests. The agency says that it evaluates each situation independently, along with the impact that terminating a hospital's funding could have on the community. "We will continue to strengthen oversight of health care settings and hold providers accountable for providing safe and effective care to patients," an agency spokesperson said in a statement. Uradnik said the violations cited by CMS were resolved two years ago. He added that the "overwhelming majority" of inspections by various entities have found Cascade complied with government requirements, but he declined to provide dates or copies of the reports. EO https://proj",seattlotimes.com/2019/publiccrisis-private-toll-part2/ 3/2/2020 Public Crisis, Private Toll Like most psychiatric hospitals that receive Medicare reimbursement, Cascade is accredited by The Joint Commission, exempting it from routine government inspections. The commission posts its accreditation decisions online but its inspection reports are confidential. A CMS website lists four inspections of Cascade since 2014, of which two found violations and two didn't, not including the immediate jeopardy findings in March and May of 2017. Washington state's Department of Health has Page 29 of 35 TIMES WATCHDOG Read the story 'Gold seal o approval' — and missed safety violations identified violations at Cascade in each annual inspection since 2014, as it has for every private psychiatric hospital in the state. On the day inspectors declared immediate jeopardy for the third time, an agency official filed a complaint about Cascade with his own department. This effectively triggered an enforcement action by the state, which has the power to restrict or revoke a hospital's license. The regulatory scrutiny was intended to force improvements at Cascade, but it didn't protect patients from harm. "I'm goingto die here" On June 22, 2017, the hospital readmitted a patient so violent he had been placed on a "do not admit list" after his last stay. "Patient #1," as he is described in an inspection report, sent another patient to an emergency room with a broken nose and wounds to his face and lip. He knocked another patient hill,,]M Il1PC Cfllltl7Ol OlnllhFn_nn ¢IC_I\YI v]I'P_h\II_,iq Y17I 11111mn Ya D11C Grids, nivate 100 Page 30 of 35 unconscious in an attack that drew a "significant amount of blood" and also required emergency medical care for the victim. Around this time, Tukwila police and fire responded to a reported assault at Cascade Behavioral but, upon arrival, "a nurse came out and said there was no assault and sent them on their way," according to state records. A police officer entered anyway and found a visibly injured patient, claiming to have been assaulted. State regulators reviewed these assaults, which weren't reported as adverse events, when they returned for an inspection in July. Though the inspectors stopped short of declaring a state of immediate jeopardy, it was the fourth consecutive survey in seven months that found Cascade's failures warranted terminating its Medicare funding. Once again, CMS extended the hospital's deadline to comply. On Aug. 29, 2017, two days before the deadline, inspectors returned to Cascade and declared the hospital had "substantially corrected" the most serious problems. CMS withdrew its enforcement action. The Department of Health had gone as far as preparing a "notice of intent" to modify Cascade's license, described in a handwritten notation as "no new admits until can demonstrate compliance," records show. After CMS found Cascade In compliance, the department dropped its investigation. But a disturbing pattern continued: Over 13 months, from April 2017 through May 2018, Cascade reported eight patient falls to the state that resulted in death or serious injury, The hospital itself flagged patient fall rates as an `outlier" in quality data, state records show. https:llprojects.seattletinres.conr120t 9/pablic-crisis-private-toll-part2I 3/2/2020 Public Crisis, Private Toll Cascade stuff told Carolyn Tornich's doughtar she'd hod it fall and suggested taking her Ocoee to soon doctor. Tomich had broken her hip, and the fracture contributed to her death a few weeks later (Courtesy ofTroceo Tomrah) lint Mason's farnlly aver foar'necl front Cascade how the w -year-old fell He rlled of a hernorrhuge and "blunt lot e injuries" to the head to May 2016 (Courtesy of Ten Johnson) Kenneth Turner, 82, fell four tunes of Cascade, his farnify said. "If they hod been walking with him, or taking care of hint like they're supposed to. how old he full four tirnes?" sold Barbaro Turnor, his wife of 62 years. (call? tosy of Judy Russo) Page 31 of 35 In one case identified by inspectors, an 85 -year-old dementia patient fell when staff wasn't watching. And her chart, which initially said she had been sleeping at the time of her fall, was later altered to acknowledge that she wasn't. State officials couldn't say how many falls contributed to deaths, but at least some did. https://projects,scattletimes.coin/2019/public-crisis-private-toll-p,lrt2/ 3/2/2020 Public Crisis, Private Toll Page 32 0l' 35 At about 3 a.m. on June 3, .2017, a 76 -year-old former teacher, Carolyn Tomich, experienced what hospital staff described as a "non -injury fall" In her medical records. Instead of sending her to a hospital, Cascade contacted her daughter, Tracee Tomich, and recommended she take her mother to see a doctor. With difficulty, Tracee Tomich loaded her mother into her truck and took her to a hospital. To her shock, her mother was diagnosed with a broken hip, When Carolyn Tomich died three weeks later, the medical examiner ruled it an accident with the broken hip listed as a contributing factor. That November, state inspectors faulted Cascade for inadequately monitoring patients at high risk of falling. Less than two weeks later, an 82 -year-old Cascade patient named Kenneth Turner fell at night. It was the fourth time that Turner, a retired commercial painter, had fallen during his time at Cascade, family members said they were told by the hospital. He died to days later. The manner of death was undetermined, according to his death certificate, but a contributing factor was "blunt force head trauma." The document lists Cascade's address as the location of the injury. "If they had been walking with him, or taking care of him like they're supposed to, how did he fall four times?" said Barbara Turner, his wife of 62 years. In May 2oi8, 92 -year-old Jim Mason arrived at Cascade Behavioral with a walker and worsening dementia. He had been in the Navy, a veteran of World War 11 and the Korean War, and was the father of seven children. On a Wednesday, he called his daughter Ellie Brown and asked her to come get him, a request he often made. "I'm going to die here," she recalls him saying.. A few days later, the hospital called to say he had fallen and was receiving emergency care. When she and family members arrived at his bedside, "His face looked like he had been hit with a baseball bat," Brown said. "It breaks my heart." He died of a hemorrhage and "blunt force injuries" to the head, according to skate death records. Brown said the family never learned from Cascade how her father fell. littps://Iirojects,seattletimes.com/2019/public-crisis-private-toll-part2/ 3/2/2020 Public Crisis, Private loll Page 33 of 35 Last July, police responded to a 911 call about a 74 -year-old dementia patient. Before the disease set in, Marilyn Ham -Kay had been an artist, painting in the Japanese Sumi style and making bronze sculptures, and a longtime advocate for people with disabilities. That July morning, Ham -Kay had gotten up to use the bathroom and was found unconscious and without a pulse a half-hour later, a hospital staffer told police. The Medical Examiner's office didn't investigate. Don Kay, her husband, said hospital staff told him she suffered a heart attack. He didn't request her medical records and doesn't question the hospital's version of the events. "They were the most attentive, caring, compassionate people," he said. "She was more at peace, more happy there than anytime in the last 15 years." That same month, a 52 -year-old mental-health counselor arrived at Cascade Behavioral as a patient, law-enforcement and state records show. The woman was diagnosed with psychosis, in addition to serious medical conditions including obesity, diabetes and high blood pressure. On the evening of July 16, a nurse found her lying on her bed, unresponsive, She died of a blood clot, according to state death records. When Department of Health inspectors returned last September to examine how Cascade Behavioral was dealing with medical emergencies, they found its practices wanting. Inspectors noticed that none of the emergency carts in the hospital's six units were stocked with IV fluids, as required by state law. When they reviewed the file of the mental-health professional who died, they found no documentation 1f https://projects.seattletirnes.com/2019/public-crisis-private-toll-part2/ 3/2/2020 Public Crisis, Private Toll Nage 34 of35 of how the hospital responded. There was no nursing or physician note describing it. No Code Blue form. No evaluation for the cardiac arrest. It was the same violation inspectors had cited in the death of Eric Descalso a year and a half before, a problem the hospital had promised to fix with more training and drills. Read the three-part investigation by The Seatfle Times PART ONE: How a PART TWO: A hidden safety PART THREE: Free to check company's push to expand record, a human cost in but not to leave psychiatric care brought published on September 8 Published on October 6 erfi 2019 2019 P bu lished on August 29 2019 • Maior findings of The Seattle Times investigation of private psychiatric hospitals • Behind the investigation: A multitude of interview thousands of pages of records Resources for mental-health support • Ina crisis? • Neeclsupoort? • Worried about someone you know? hfrna-//nrninete aenlllelimec rpm/7019lnnhlio_rri ¢i c_nri v;ita.hnll_nart9/ 4/9/OMn Public Crisis, Private Toll 16 Page 35 of 35 Reporter: Daniel Gilbert Developer and graphic artist: Emily Project editor: Ray Rivera M. Eng Photographer: Erika Schultz Illustrator: Gabriel Campanario Photo editor: Fred Nelson Engagement: Taylor Blatchford Video editor: Lauren Frohne Project coordinator: Laura Gordon You can support watchdog journalism Make a tax-deductible donation to The Seattle Times Investigative Journalism FFA and subscribe to The Seattle Times. If you're having trouble commenting or viewing comments, hit refresh on your browser and try again. yigw as Comments httos://oroieets.seattletimes.com/20 t 9lnublic-crisis-nrivate-tol I-nart2/ 3/2/202o Free to cheek in, but not to leave: Patients seeking mental-health treatment in Washington... Page I of 21 psanrt„ Times Watchdog I.og In I soboobol GantInmc,nfarmer Mero5cMoI Uo-; nmmbol, dldckad hot df il,InOnGF,lIdan Itolpnal A Hllklantlm Old op-gn Imap. Tftka Schulia/1110 Sldoole timet) f in V By Daniel Gilbert V S."fia iinld'odn,""t" Carol Jason had been a patient of BHC Fairfax Hospital for lust minutes when she began rethinking the decision to check herself into the psychiatric hospital. TIMES WATCHDOG Public Crisis, Private Toll: Read the full investigation hues://Www.sesttletimnH.cnm/scathe-news/ti mcs-waTrhdnn/nuhlir-rricic-nnrivah=_tnll_FrrN-tn 1/9/9fr)n Free to check in, but not to leave: Patients seeking infernal-hcalth treatment in Washington... Page 2 of 21 Muton Bndingx lei I he Seal Ile Time, ill V,,'AgaIto orp5vute psYcoatdc ho,i4)6 aehlel the ovexngnmmiz A oil lehala of Ill thooi,o, A of Pah, o(nmoatl, It was a Thursday evening In the spring of 2017, and Jason, a former elected official in Marysville, had come to Fairfax with contractions In her arms and legs that she worried might stern from a mental disorder. Though she had attempted suicide two months before, she told staffers at the hospital. in Kirkland that she wasn't feeling suicidal. The married mother of two was looking forward to celebrating her 54th birthday that weekend, and had scheduled an appointment with her psychologist the next Monday. By the time she was admitted, the jerking in her limbs had subsided and she suspected it might have been an allergic reaction — not a mood disorder. Jason decided to exercise her right to leave. Instead of letting her go, Fairfax started the process to involuntarily commit tier. For Jason and other patients who check in voluntarily, the revelation that they can't leave when they want to has shaken their faith in a system they turned to for help. The reasons for holding such patients vary, but the practice of doing so — sometimes for days — is a regular occurrence at some of Washington state's private psychiatric hospitals, an investigation by The Seattle Times has found. The question of discharging patients from a. psychiatric hospital is exceedingly fraught. Doctorsare only supposed to admit patients with serious mental-health conditions, and have to balance patients' right to leave against concerns about their welfare. Washington is one of just a few states where patients who check in to a hospital must be "released immediately" upon their requost, with no additional time for observation, according to state law. Yet many patients don't realize that even If they check in voluntarily, a hospital can legnily he Id them against their will. bttos:llw w,seattletimes.com/scattle-news)times-watchdouIpublic-crisis-nrivate-toll-free-tn._ 10nom Free to check in, but not to leave: Patients seeking mental-health treatment in Washington... Page 3 01°21 To do so, o hospital physician or nurse has to conclude that the patient poses an trained [aIs danger and then initiate involuntary -commitment proceedings. In Washington state, this begins with a call to county government, which then sends a rameablrealth professional to evaluate the patient. The county eValUmCo can Involuntarily commit patients for up to 72 flatus before pattents can make their case to a judge. Fairfax, the state's largest private psychiatric hospital, with 157 beds, routinely has held patients by claiming they wouldn't be safe If released, only to be contradicted by government evaluators who find no grounds for committing them. At Smokey Point Behavioral Hospital in Snohomish County, nurses were told to notify the hospital's chief executive any time a patient asked to leave early, internal records show, and several patients have complained that staff delayed their release or tried to intimidate them into staying, The Times, In a Bm4of-its-kind analysis, examined what happened each time a health facility in King County requested an involuntary -commitment evaluation since 2015. In more than 2g000 evaluation requests over four years, county officials usually agreed with the hospitals making the request, committing the patient 650Aa of the time. But at Fairfax and Cascade Behavioral Hospital, the county's two for-profit psychiatric hospitals, the trend was the opposite, In ago requests by Cascade Behavioral, the county committed patients 31% of the time. In more than 750 requests by Fairfax, county evaluators agreed 320/D of the it For commitment requests, private psychiatric hospitals stand apart Whena hmgtal Initiate that a patient needs to be Itinerary; committed, It stone the proeeee by selling III County 0181 and Commitment 5q,olpes to request an ewluatlan. While'moil IM, lale nommre ed paI]InIsafill 1111a,II" "I or the erne over so,y,a,,, they Iwad no vistr4la mmmlt PatenU In the malwlty or havinsts fron, the orange hw to, spin PoYNIeM4 apart nWIII COMMRAIM V IC itiou85 rl%cunmlLLN We iWM Catalog. aehuabral 220 ordination mural, taxa. Rums nospltAe 757 &ante VA hea,rilj j 1� 251 Nrrikells'Nal L901 pp�SStayttgh�ee Mchildren's hospital ' b{�:; 159 ; A:ARS,�eR41C!•1:.^fi Vi. rlNr51, w.onhwen aOphal role ,Ireeney hars.re Carl,, Medrol Centerfmv9enal 4,1)1 Narborvlew MaraialOre, enter Valley Madlenl Center 1.197 MbM1lina Community Hature, "ang "o'sMM`Wlvb. res W% 1W% " zo—nmailrosWWrtNeater, a 4naraferny an. x. axe r Tie,Pert. a tier Last year, officials declined to commit three out of every tour patients Fairfax held for an evaluation. Mins Hiview..sNittletimrc comLcl^.al'I' e•newc/timrc•wntrhdnvinnhlir-criai wnrivnYm•tnll_frnr_rn 4/9/9090 Free to cheek in, but not to leave: Patients seeking mental-health treatment in Washington... Page 4 of 21 When patients at Fairfax and Cascade ask to leave before the hospital wants to release them, physicians "have a habit of calling" the county"to bless It to let someone go," said Diane Swanberg, King County's coordinator for Involuntary commitment. There's no way of knowing how many patients drop their requests to leave after being told they could be involuntarily committed. Patients who proactively seek out help and are held Involuntarily —or who feel coerced into staying — might be less likely to seek treatment in the future, some psychiatrists say. If they are committed, they can be held for three days before they get a hearing in court — and potentially much longer, In Washington state, an Involuntary commitment on record also can increase a person's chances of being committed in subsequent evaluations. Fairfax is owned by Universal Health Services (UHS), one of the nation's largest pu ayor$ of mental-health care, with 188 Inpatient facilities. The company has expanded rapidly in Washington state, adding psychiatric hospitals In Everett, Monroe and Spokane since 2014. It is building an gybed psychiatric hospital in Lacey in partnership with Providence Health & Services, and recently won approval to double the size of its Everett hospital to 6o beds. UHS has been under lovesdgation by the U.S. Department of Justice for a range of issues, including "admission eligibility, discharge decisions, length of stay and patient care issues," securities filings show. The company disclosed in July that it will pay $tzy million to settle 00J's civil Investigaf ton, and that a related criminal inquiry had been closed. It has dented wrongdoing. In written responses to The Times, Fairfax said it holds patients for clinical and not business reasons, adding that patients' average length of stay there is comparable to psychiatric hospitals nationally. nevnen lwl littps://www.scattletimes,com/wattle-news/tunes-watelidog/public-crisi s -private -toll -free -to... 3/2/2020 Free to check in, but not to leave: Patients seeking mental-health treatment in Washington... Page 5 0l' 21 "Fairfax Behavioral Health is obligated to ensure the safety of patients and the community,"Heckle Shauinger, the hospital's chief executive, sold fn a statement. "It Is not uncommon in the mental health field for one professional to disagree with the assessment of another," she said. As far (lie state law that requires patients to be released immediately upon request, Shauinger wrote, it', s not an unqualified statement (hat literally means patients are immediately discharged." She offered no legal basis for this interpretation but said the hospital needs time to evaluate patients and prepare a safe discharge plan, "Any'delay' between a patient's request for discharge and assessment," she added, "is not for financial purposes but solely in the Interests of the patient and in conformitywith the law." "Fairfax Behavioral Health Is obligated to ensure the safety of patients and the community. It is not uncommon in the mental health field for one professional to disagree with the assessment of another." — Beckie Shauinger, CEO of Fairfax Behavioral Several current and former Fairfax employees, speaking on condition of anonymity to discuss internal hospital matters, said that a patient's insurance coverage regularly would come up In treatment, team meetings to determine when a patient would leave. But the staffers said they weren't pressured to hold patients longer than they thought necessary, Most Read Local Stories A second person in U.S.—and King County—dies of novel con avuus; more cases likely 1 How if Unfolded: King County dear, first in U.S. linked to novel coronavirus o Asschools announce closures forcomnavims. Seattle -area parentswondor what's next King County patient h; nod in U.S. to die of COVI6-r9 as officialsscramble to stem spread of novel coronavirus a a MUCH s Working equell fears, Sea Uh-areaeficiuls shin thelrshategywt coronavirus A medical professional who worked at Fairfax said that the hospital would call for an involuntary. commitment evaluation for the majority of patients asking for an unplanned discharge, but added there was no direct pressure from the hospital's management to do so. At Smokey Point, however, executives would yell at hospital staffers if they released patients whose insurance had authorized a longer stay, according to the medical professional who has also worked there. Flow come you let this person go?... the former employee remembers being asked by executives and billing personnel at Smokey Point, Richard Kresch, chief executive of LIS HeatthVest, which operates Smokey Point, said "protecting patient rights Is central to us" and denied patients are held for any reasons other than clinical ores. h ttp s: //www.scalt let imes.co ro/seat tle-newsIt i roes-watc lidog/p ubl i ororis is-private-tol I -free -to... 3/2/2020 Free to check in, but not to leave: Patients seeking rental -health treatment in Washington.., page 6 of 21 Cozy up for a winter get-together mm�"wo numo, oan u,. owa ",ion.q "Patients are never held beyond the clinical team's recommended discharge date," he said in a statement. "insurance companies and other payers routinely deny payment for patients when care is necessary. As part of our mission, we provide care to all patients regardless of ability to pay. If our clinical team determines that a patient can benefit from additional treatment, we will offer care to the patient without any reimbursement." "Patients are never held beyond the clinical team's recommended discharge date. Insurance companies and other payers routinely deny payment for patients when care Is necessary. As part of our mission, we provide care to sto patients regardless ofabiiityto pay." — Aicb4rd Kresch, do of U$ Healtlivest Michael Uradnik, chief executive of Cascade Behavioral, said that, "Due to the uniquely severe acuityof many Cascade patients, our clinicians generally err on the side of caution when making involuntary- commitment recommendations," adding that releasing n patient too soon can increase the risk of suicide. He said that the Tukwila hospital "rejects any allegation that our physicians' recommendations are based on anything other than good faith, clinically based findings. It isn't only private psychiatric hospitals where patients run Into resistance when asking to leave. In May, Suzanne Bolwell said she checked herself into Northwest Hospital, operated by UW Medicine, to treat her severe depression. The locked psychiatric unit where she was admitted was dirty, she said, with patients who were out of control. When she asked to leave, a doctor told her that he would try to have her involuntarily committed unless she agreed to stay. 'T was frightened, so I kind of gave in," said Bolwell, 71., who retired after more than Go years as a registered nurse. She said she was never Informed of her discharge rights. She stayed for about two weeks. A UW spokeswoman declined to comment on specific patient cases but said, "our policy Is to provide our patients and their families with information on their rights and we lel them know if we have any concerns about their medical or psychological condition." Carol Jason had initially sought help at Providence Regional Medical Center in Everett, before she was referred to Fairfax later that day. A Providence doctor had concluded that Jason wasn't suicidal, writing "discharge home is reasonable" if there were no psychiatric beds available, htins://www.seattletimes.eotn/seattle-news/times-watchdog/public-crisis-nrivate-toll-free-m... 3/2/2020 Fece to check in, but not to Leave: Patients seeking mental-health treatment in Washington... Page 7 of 21 Staff at Fairfax, however, cited concerns about her "mood instability and impulsivity," as well as her two suicide attempts since 2oi5, according to her medical records. Jason recalls a doctor telling her, with a smile, that she could be commilled If she Insisted on leaving. "That is a risk you will take," she remembers the doctor saying. RESOURCES FOR MENTAL-HEALTH SUPPORT • In a crisis? • Need support? Worried ahoulsomeone you know? "The scariest and most expensive hotel stay" Vickie Mutvany checked herself in to the Smokey Point Behavioral Hospital in January 2or8, looking for a safe place to focus on herself. The 48 -year-old homemaker had been caring for one daughter with chronic migraineswhen her other daughter was badly Injured in a river accident. She felt overwhelmed. One day white driving home along a two-lane road in Snohomish County, Mulvany's focus narrowed to the shiny grille of a logging truck approaching in the opposite direction. It "almost felt like it was just opening Its arms to me, like just six Inches over the line and It's, WE over," she later recalled. "You don't have to go home. It stops." Mulvany decided to seek out help. Her insurance company authorized a four-day stay at Starkey Point, where she was admitted for depression with suicidal thoughts, hitncd/www seaaletimea nnm/senttle-aewe/timec-watrhrino/ntihlir_rrieiN-nriv»tr_tnl I_frre-In 1011mn) Free to chock in, but not to leave; Patients seeking mental-health treatment in Washington... Page 8 of 21 WN rr M 0 1, I/ r 1 .ketl liver, W I lO 10 SO10keyPohRb h ,I No, Iai a It la q pnlmutl SN! I,U0-.1 veilfl I na Fr,nbtenBtl lty l rt,,3 P' 1h 20 m b, Jndr,ryloEl.. aOko IEr u/IM1eS-111, 1'iinm) Mom, Soon after she passed through the locking doors, Mulvany wanted out. Through the windows of a "quiet room," she watched as a patient, a big man, shouted andpushed another patient up against the wall of a common room. o®Imle Each effort by staff to placate the aggressive patient gave way to another burst of profanity laced demands — to turn off the television, to turn It back on. Then the man walked up to the room where Mulvany sat writing, and he pounded on the windows. "f realized there's one door in and out of this room," she saidin an Interview, "It scared me to death." Mulvany asked to be discharged. The staff members he spoke with said she wag new and didn't know the procedure. The next morning, Mulvany was so groggy from the medications she'd been given that she only wanted to go back to sleep. Still, she roused herself to ask how her discharge was progressing, This time, too, a nurse said she was new and didn't know how the process worked. Another staffer said she would send along a form to till out, but it never came. httnr//avow,, crnttirtimne rmn/araitle _nrwcRimre_,uat. hrino/nnhli...... 1/9/9f10rr Flee to check in, but hot to leave: Patients seeking mental-health treatment in Washington... Page 9 of 21 On Mulvany's third day at Smokey Point, she was called Into a room to meet with a nurse practitioner. She'd spent the previous night reading the hospital's policy handbook, and painted out that patients must receive a psychiatric evaluation within 24 hours. The hospital had failed to meet its own standards, Mulvany recalled saying: She demanded to be discharged. The nurse practitioner agreed to discharge Mulvany, writing that she had made "good progress,' according to her medical records. Mulvany tried to stay calm as she walked through each set ofdoors, terrified someone would stop her. When a staffer returned her boots, she didn't pause to put them on. She walked in her socks out of the building Into the cold February air, Of the go hours she had spent there, she attended only two go-mluute group sessions, spending the other 49 hours eating, sleeping or passing the time. Stuckey Point charged $6,000 for two days of "Adult Psych R&B," according to her bin, with insurance covering a little more than half, "It was literally listed as room and board," Mulvany said, "And all I could think was it was the scariest and most expensive hotel stay I've ever had." httnN[//www_ sentflefimrsnnm/senYtle-new-s/fimec-wnfnhdna/nuhlir-nrieic-nrivate_rnll-free.Yn IMM IN) Free to check III, out 1101 to leave: Patrf.Illg Seeking metrial -health treatnnent in Washjngt... Page I11 of 21 PURI. I C CHISIs, 4m VATe TOLL • Major findings mitre Seattle Times investigation arpdvafc psychlahic hospitals • Behind the Investigation: A multitude oFintervlews, he""nde of pages afronmds What Mulvany didn't know was that a case likehers — a voluntary pallent asking to be discharged with additional days authorized by private Insurance — caused acute anxiety fpr the hospital's executives, according to Internal records and former employees. Itsignaled (list the patlent was not responding welt to treatment, raised liability concerns and meant the hospital was at risk of leaving money on the table. The month before Mulvany arrived, john Beall, then Smokey Point's chief nursing officer, sent an email to his staff with the subject line "AMAs;" an abbreviation for voluntary patients who ask to leave against medical advice. He instructed staffers to notify the hospital's chief executive at the time, Mal Crockett, as soon as they received such a request, according to theemail reviewed by The Times. Beall declined to comment. Crockett didn't respond to repeated requests for comment, Twice a day, Smokey Point would send a list of patients scheduled for discharge to US HealthVest executives, who would demand explanations for additional, unplanned discharges, according to former employees. The reason for such close monitoring, the former employees said, was financial. they would say safety, but It was money," said Leila Marusic, a former manager at Smokey Point whose lob was negotiating with insurance companies. Marusic resigned in May 2or8, disillusioned with hospital executives' approach to patient care, littps:/hvww. seattl elimcs,com/seiittte-ne ws/tini os-watchdog/pLibI is-crisi s-pri vate-tol I -free -to... 3/2/2020 Tree to cliecK in, but not to leave: patients seeking mental-health ureatment in Washingt... Page I 1 of 21 Kresch, OS HeaIthVest's CEO, said dmt the discharge calendar "is a clinical tool developed by the treatment team in order to provide sufficient time for follow up care scheduling," adding that patients are treated regardless oftlreir ability to pay and never held longer than ell ricalty necessary. It isn't clear how often Smokey PolnI asks for its patients to be evaluated for involuntary commitment, as Snohomish County doesn't track requests by facility, One patient told The Times she appreciated that hospital staff made sure she was ready to leave before discharging her, Yet several other Stookey Point patients or their families have complained to the Department of Health or The Times that staffers tried to Intimidate them Into staying. One of them, a young transgender man, said he overheard nurses refer to him as "it" when he arrived last September and was later pushed to attend womemouly group therapy. When the patient told hospital staff his mother was coming to get film, they told him it wouldn't be that easy. 4 �wV2mnue: "I fell intimidated by one of the nurses as he threatened that my Insurance wouldn't pay for anything" If he left against medical advice, the patient wrote in a complaint to the Department of Health, The patient's mother, a nurse manager, called Smokey Point 47 times over a couple days but never received a call back, she told The Times. She made the four-hour drive from their home in Southwest Washington and spent hours waiting in the hospital's lobby, inside, a counselor told the patient that there was no record of his request to leave and that "she had no Idea how to file an AMA discharge," he wrote in the complaint. A nurse practitioner informed him that the hospital would start the process to involuntarily commit him if he insisted on leaving. Two crisis counselors tried persuading him to stay another day. Finally, to his bafflement, a nurse told him he could go. "That whole experience was everything I feared about going to inpatient," he said in an interview. Other patients who asked to leave opted not to press the Issue when they encountered pushback, https://www.se,qttletilnes.com/sm lttle-news/times-watchdog/pubIic-crisis-private-totI-free-to... 3/2/2020 Frcc to check in, but not to leave: Patients seekciltg mental-health breatmwtt in Washingt... Page 12 of 21 Monica Prader, a 38 -year-old nurse with bipo[It disorder, checked Into Smokey Point in fanuary 2018 for a medication adjustment. She was asking to leave by her title([ day, her medical records show. Then her agitation began to worsen, diagnosed as a bad reaction to an antipsychotic drug that Stookey Patna had ordered for her. While staff had scored horns a "very low" suicide risk three days before, n Physician assistant checker) a box that she was a danger to herself and others, One week into her stay, a nurse observed that Prader wanted to leave and was "tearful and scared due to misbehavior and load voices from another mate patient In the unit," On Poster's ilth day, a nurse wrote that she again asked to leave. Preder "was redirected to ask provider in the morning." gee, cnarxe„ms,"k"y vo ur r oarvnm n , a,vs.n. m" y,e io iwvc nu r �„eon.o�,, ay.(e ro, smnaixtn es�,ne The next day, a nurse wrote that Preder "shows no observable evidence of altered thought process.” She wasn't released that day, or the next, or the day after that. When Preder was discharged in February 2018, she had been at Stookey Point for t5 days, hthts'//unvw..cngtfletimes.mvn/ceartie-news/tiroee-wcrtrhdnrz/nuhiir_criaia_nriante_tnl l-froa_tn 1/1/1p9p Free to check in, but not to leave; Patients seeking mental-health LiVatmcnt in Washingt... Page 13 of 21 Preder said her experience gave her an empathy for patients that led her to seek anew Joln working as a psychiatric nurse. "Immediate" release Carol) ason served on the Marysville School Board for three years before her physical health forced her to step away In 2006. A series of surgeries and computations brought hey pain to an intensity that caused her emotional distress. Then, in January of 2017, she attempted suicide after a therapist she had gone to for years declined to see her. In the aftermath of (]its attempt, she found anew therapist Rod set regular appoint mems. By late March, she was experiencing physical ticks that scared her. Worried that her mentaldistress was causing the physical symptoms, Jason wenn to the emergency room on March 23, 2017, hoping a doctor could explain theYeaction and prescribe a medication to neutralize it. She asked to be referred to Overtake Hospital, where she had previously spent time in the psychiatric wing. A hospital social worker said Overtake had no beds available, but Fairfax did. When she arrived, Jason signed a series of forms consenting to be treated and received a document listing patient rights, On the second page, bullet point No. 34 of 58 stated that voluntary patients have the right to be released "unless Involuntary commitment proceedings are initiated." Jason, like many patients in a state of distress, didn't grasp fire implications of these forms when she signed them, But she discovered their effect soon after. As Jason was led to her room, she noticed that the bedding was rumpled, as if it hadn't been changed since the last patient to steep on it. There was food on the Boor, she later wrote in a grievance to the hospital, The toilet had a blackish substance on the back of the seat, Jason "expressed dissatisfaction with this hospitalization and immediately requested discharge," a Fairfax doctor wrote in her record. Though she denied any suicidal or homicidal thoughts, she wasn't allowed to leave. That night, she laid down on top of the blanket on herbed and fell into a fitful sleep, waking to the screams of another patient in the ward. httn0l,vonv ecsttletimre ,r,... sttly-na.uc/ti rune_..;aI,-hdnn/roJ.I ir•-rnae-nri rvarP_tnll_I?w�_tr. 7M/9!10!1 P7ae to check in, but Hot to leave: Patients seeking mental-health treatment in Washingi... Page 14 of 21 MISITIMMIll Fairfax would not comment on Jason's case "other than to state that we dispute the facts as presented by the patient." Understate law, patients like Carol Jason who cbeck in voluntarily "shall be released immediately" upon request. This law, passed in the mid-1970s, puts Washington at odds with a majority of states that allow for some period of time, often 72 hours, to hold voluntary patients —without Involuntarily committing them —for observation or while they make discharge plans, according to a 2oaq paper published by the Harvard Review of Psychiatry. There was only one way Fairfax could hold Jason: by Imliatlng the Involuntary-umnniitment process. And it could only take this step by concluding that Jason was likely to seriously injure herself or others at any moment, or that her mind had deteriorated to such a degree that she couldn't provide for her own safety. While hospitals have the option to seek involuntary commitments, their primary ditty -- "arguably the only duty" — to voluntary patients asking to leave Is to release them, a slate appellate court rulers in 2013 in a case involving a patient who died in a car crash soon after leaving a psychiatric unit. To be held liable forreleasing such a patient, a hospital and its staffers would have to be foundgrossly negligent, a high legal standard for failure to exercise even a slight amount of care. You can support local watchdog journalism blaleeotax 1r11ualiU,du,oi1 r kl eSataOe li r.I ltiysnvei Fu 0, nndsobaoihe u,I" Srtlin Ph"13. Washington state's deference to patient rights could trigger an unintended consequence, some experts said, Psychiatrists might feel more pressure to request an Involuntary evaluation in Washington, where they have no other option to hold a patient asking to leave, said Amir Garakani, director of education at Silver Hill Hospital in Connecticut and lead author of the Harvard paper. "By having an 'immediate discharge' requirement, providers have to choose between the risk of discharging a potentially unstable or unsafe patlent,"he said, or "holding a patient against their will, thereby infringing on their rights." Mips://www.seatdetimes.eoln/seattle-news/times-wate lido6/public-crisis-private-to I I •free -to... 3/2/2020 Free to check in, but not to leave: Patients seeking mental-health treatment in Washings... Page 15 of 21 It's not clear how frequently hospitals fail to act Inimedietely on a patient's request to leave. Fairfax said in a statement that It starts the discharge process as soon as a patient asks to be released. Yet when Carol Jason asked to leave shortly after checking in at 8:30 pan., the hospital didn't call King County's zq-hour commitment line to request an evaluation until the next afternoon, about 17 hours later, county records show. The evening before the call, a nurse had written that Jason appeared "anxious and Iff1table" but was otherwise cooperative. The county menial -health worker who took the call the next day got a somewhat different assessment. Jason was being "verbally aggressive with staff' and had said "I'm about to get violent" if she wasn't discharged, according to county records of the call. Jason denies saying this, and she questions the accuracy of Fairfax's records. One nurse's note refers to Jason widr the pronoun "he" three times. Another note in her record describes a patient with masculine Pronouns and as "being homeless," Jason and her husband have owner) their house In Marysville since zoor, "I am a'she' and I have never beenhomeless," she said. Jason isn't alone in complaining about unreliable documentation at Fairfax. In one case, two weeks before she arrived, Fairfax had sought to extend the involuntary commitment of a patient whose records stated "patient needs to be discharged" and "this is not an appropriate setting for the patient," according to a Snohomish County official's complaint to regulators. After a separate court hearing the next month, a Snohomish County official emailed Fairfax executives that "the question argued by both sides was tire reliability and credibility of your records.' haus✓/wwtvseanletimex.cnm/SeaLNe-new.ultimes-wainhdno/nuhlin.crisia-nrivnte_inll-frac-tn 4/7 /9!190 Free to check in, but not to leave: Patients seeking trental -health treatment in Washingt... Page 16 01'21 car"II ... ; II' " H- -, "', """ o1G Ff11H -?nYat heH 1. MaryNAIn. A VU„ tM ya e,,sLvhd Inwm.'.... Jtl-r11e, 35MInFl lu knVe. (ink., sdwl (me slneja rues) King County received Fairfax's request to evaluate Jason at 1:46 p.m. on Friday, March 24, Had the request come from a hospital's emergency toom, file county would have had to arrive within six hours, according to state law. But because the request came from a hospital where Jason had been admitted, the deadline wasn't until the nextcourt day, which excludes weekends. A request on Friday meant the county had until Monday to commit Jason or release her. Evaluation and aftermath Patthis's own psychiatric assessment of Jason, conducted the same day it requested an involuntary evaluation, didn't suggest a patient in crisis. "Thought content is appropriate without any sign of hallucinations, delusions or paranoia." a physician assistant wrote. "Patient's judgment is good," the evaluation states. "Patient's suicide risk is low." This didn't mean that Jason was free to go. "As she has requested discharge, she will be seen by the DMHP" — short for "designated mental-health professional," a county offieial —"for an opinion as to her suicide risk," the evaluation concluded, As Jason insister) on her right to leave, a physician tied her demand to a symptom of mental illness, "She is grandiose — feels she should be able to sign outright after she was admitted," the physician wrote, Jason was scared by the angry outbursts of other patients and felt her post-traumatic stress disorder spike. A staff member brought her to an empty mom for her to be alone, and she sat down on the bed and sobbed, "This act of kindness gave me the strength to endure my time at Fairfax," she later said. King County had until Monday to evaluate Jason. But at 11:25 P.m.lhat Sahnday night, a county officlaI contacted Fairfax to examine her. Fairfax said Jason was asleep and asked the official to come when she was awake, county records show. Jason was never told. haps: //wwwseattletimes. coal/seat tie-news/times-watchdog/publ is -tris is -private -to I I- free -to... 3/2/2020 Free to check in, but not to leave: Patients seeking mental-health treatrnent in Washingt_.. Page 17 of 21 Shortly after midnight on Monday morning, Jason was awakened by vahfax staff, A mental-health official for the county had arrived hr evaluate her for involuntary commitment, poster admitted to the official that she had been "difficult" with hospital staff. Yes, she said, she'd attempted suicide two months earlier. She seemed agitated and spoke rapidly, the official observed, but this also seemed consistent with her frustration that Fairfax wouldn't let her leave. It was 2:25 a.m. when the Official concluded his evaluation. Jason denied any suicidal thoughts, he noted, She had family support and a scheduled appointment with a therapist. "She Is not presenting with safety concerns," he wrote, fie had no grant d$ to commit her, It had been three days since Jason asked to leave. Fairfax billed $11,200 for her stay, receiving a $G,loo payment from Jason's Insurance. Soon after leaving, Jason lodged a complaint with Fairfax. The hospital apologized for the "unfortunate experience that you had" but contended it was within Its rights to hold her. Jason, after researching state law, believes Fairfax held her illegally. She filed complaints with the Washington state Department of Health, the Medical Commission, the Nursing Commission, The Joint Commission, the U.S. Department of Health and Human Services and the Washington state Attorney General's Office. Each declined to investigate or impose any penally. Jason has long been a believer in seeking out help, but her experience at Fairfax has shaken her faith in the system. "I would think twice about getting help because of this," she said. Vickie Mulvany, the former Stuckey Point patient, has struggled with the same question. In Match, a little more than a year after her stay, she again found herself in severe depression. "For the first time, I feel like I have no options as I realize I will never go back to a behavioral health facility," she told the Times. Instead, site gazes at four words she had inked into her forearm after her experience at Stookey Point: "I made a promise." hlfns�//www..¢uattlniimescnm/wattle. newafrimea.watt'.hdnn/mihlic_micic-nrivere.inll_Fre...tn 2h/7f190 Free to chock in, but not to leave: Patients seeking mental-health trcatment in Wosltingl... Page t if of 21 Mulvany made the promise to her daughters: To never try to kill herself. To seek help from friends, family and a helpline. To turn to her own personal support network. 'There are days I glance at those words and take comfort in them, and days I stare at them and feel trapped," she said, "Whatever their hold on me, they keep my head above water. They keep me alive." PUBLIC CRISIS, PRIVATE TOLL • Major findings of The Seattle Times investigation of private psychiatric, hospitals • Behind the Investigation: A nmltitude of Interviews, thousands of pages or records Daniel Gilbert: di tberi@seattletirnes.corm Twitter:@ ByDanielGilbee1 httl)s://www. seattletimes.com/seattl e-news/ti mes-watchdoizJnublic-crisis-orivate-toll-free-to... 3/2/2020 Free to check in, but not to Leave: Patients seeking mental-health treatment in Washingt... Page 19 of 21 Nc Nay, aa, I Ito, I F,.n.n. II al, too,n,imtM1 ata anal 1,, to, It o"', ..,I vnI tl � ne �rvJl zc/al .l, I n 'y„a m,rtl� mw Ir ,:, I„Iree I , io,In.. CREDITS Reporter Daniel allia., PI aditoo gory Rivera Photographer, Gdka Schole Photo edllob Pn:d Nahaa Video edlton tnurmi Ptohne Developer and graphic artist root, M, lino I11tofi tor: Gahrlel Gampanorio ragagemenb'la'k,r Dlmcha"I Rplect aoordia0 :terra Gordon You can support local watchdog journalism Makentay-0eductlglel'InnauI, In'II SuaUle I,,, Wm ttg,nat,IoomaliamFaad. andsobacal be to 1 he Senn 1, raoIa. PROLOGUE: A primer on the mental-health crisis in Washington state Published on August 23. 20:9 PART ONE: How a company's push to expand psychiatric care brought peril published on August 25, zot9 PART TWO: At private psychiatric hospitals, a httos://www.seattletimes,eom/seattle-news/times-watchdoe/niihl ic-rri.si.c-nrivabo-toll- free-rn V0090