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Strategic Behavioral Health's sanctions in five states

Strategic Behavioral Health's sanctions in five states


Strategic Behavioral Health, a for-profit company in Memphis, Tennessee, has had nine immediate jeopardy violations at four facilities in Colorado, North Carolina and Texas since 2014, along with other serious actions in other states.

The company, which has 10 psychiatric hospitals in six states, plans to build a 72-bed hospital in Middleton.

Here are summaries of the sanctions, according to public records:

Strategic Behavioral Center, Charlotte, North Carolina:

•In January, the 60-bed hospital got an immediate jeopardy violation for failing to keep the facility secure. Ten patients, ages 12 to 17, escaped through a broken window Jan. 1 after some used wooden boards from furniture they destroyed to attack a worker.

The ordeal amounted to a “riot,” a nurse told inspectors. But staff delayed calling police, even though they said there weren’t enough employees to control the situation. “We have been short staffed for two months,” one worker said.

Police returned the patients to the facility after about two hours. Strategic Behavioral Health said it would stop taking patients with felonious behavior, get more durable furniture and encourage staff to call police promptly when emergencies arise.

Strategic Behavioral Center, Garner, North Carolina:

•In December 2016, the hospital, which today has 116 beds, got an immediate jeopardy violation for failing to have enough nursing staff to monitor a patient who was possibly sexually assaulted by another patient.

Each unit was supposed to have at least one registered nurse. But inspectors said only one registered nurse was scheduled for three units, and that person left in the middle of night, leaving no registered nurse on any unit.

•In March 2014, the Garner facility, which then had 92 beds, got an immediate jeopardy violation for its handling of three incidents involving teenage patients.

The facility didn’t seek emergency medical help when a code was called, it failed to find a lighter used by a patient to set a fire and neurological checks were not done after a patient had a head injury.

Peak View Behavioral Health, Colorado Springs, Colorado:

•In February 2016, the 112-bed hospital got an immediate jeopardy citation after inspectors said nursing staff failed to properly assess patients’ risk for falls and take steps to prevent falls.

Several patients fell multiple times, with one breaking an arm and another sustaining a “big bump” on the head.

Rock Prairie Behavioral Health, College Station, Texas:

•In October 2015, the 72-bed hospital got five immediate jeopardy citations. Officials said the facility didn’t have enough licensed staff, and nurses failed to properly assess patients for medical issues and before and after using physical or chemical restraints.

Two patients were restrained or put in seclusion without proper explanation. Another patient injured her finger in a seclusion room, requiring six stitches. Nurses failed to give medications as ordered 11 times to a fourth patient.

Montevista Hospital, Las Vegas, Nevada:

•In January 2017, the 162-bed hospital got two level three citations, a step down from immediate jeopardy.

In one citation, the state said staff failed to prevent or properly investigate: alleged sexual contact between two girls, ages 6 and 8; sex involving two teenage male-female pairs; and physical abuse by staff, including a worker hitting a patient.

In the other citation, investigators said staff failed to prevent a 9-year-old boy from escaping, and did not notify police.

Peak Behavioral Health, Santa Teresa, New Mexico:

•In December 2015, Disability Rights New Mexico, a state-designated protection and advocacy agency, said in a report that the 119-bed hospital had 80 incidents of “resident-on-resident violence or aggression,” with “numerous injuries,” between September 2014 and September 2015.

Police were called to the facility 21 times and patients escaped 23 times, and the facility provided an “unsafe environment,” the report said.

Nancy Koenigsberg, senior attorney for the New Mexico group, told the State Journal she’s not aware of recent problems at the hospital. That could be because of how Strategic Behavioral Health responded to the group’s report, she said.

“After we had concluded our investigation, they decided to no longer take young people with challenging behaviors,” Koenigsberg said.


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