Drugs, Solitary confinement, torture and abuse

Diagnosing (pathologizing) troubled children as mentally disordered is a huge industry—whether incarcerating them in behavioral or psychiatric facilities, wilderness camps or subjecting them to psychological behavior modification programs. In the minds of those abused in this system, they’ve suffered child abuse, punishment and torture. Many of them are silenced, however, out of fear, or because of damage—too scared to speak out.

This is exacerbated by the lack of oversight and accountability in the behavioral/psychiatric industry—putting children’s welfare at risk, traumatizing them, then labeling that normal reaction to an abusive abnormal situation as “Post-Traumatic Stress Disorder.” Approximately one-third of UHS’s Behavioral Division’s revenues are derived from taxpayer dollars, such as Medicare, TRICARE, and Medicaid, with the remaining two-thirds from commercial payers.

In July 2020, Modern Healthcare reported that 19 individual complaints were made public after being kept under seal throughout Federal Department of Justice fraud case that alleged Universal Health Services’ psychiatric hospitals had a range of techniques to “Maximize payment by admitting as many patients as possible and keeping them as long as possible.” “Each describes a methodical scheme whereby administrators pressured staff to admit patients even when it wasn’t necessary and hold them for as long as their insurance paid out. From there, the allegations detail a hodge-podge of contrasting methods and effects on patients and government programs.”

When such practices involve children, it is even more egregious. The following is but a small example of abuses documented from Universal Health Services (UHS), with similar abuses found in other chains of behavioral facilities. It shows patient sexual abuse, suicides and restraint assault, even death. Some of the facilities were shut down, but too many still remain open.

Video: Cumberland – A New Kent County children’s hospital at the center of a Virginia State Police investigation is being sued for $127 million, WTVR-CBS 6

An October 2020 lawsuit against UHS’s Cumberland Child and Adolescent behavioral hospital in Virginia exemplifies such risks: Twenty former patients from the hospital alleged sexual abuse, physical assaults and attempts to deceive public and state health officials. Seeking $127 million in damages, attorneys for the plaintiffs alleged that Dr. Daniel N. Davidow, the former medical director of Cumberland since 1996 inappropriately touched young female patients during routine medical exams and that employees and fellow patients physically struck or sexually abused other residents. Twelve female patients alleged sexual abuse, including some as young as nine. It was reported that Davidow was under police investigation.  Herschel C. Harden III, a former psychotherapist at Cumberland was also indicted on two counts of object sexual penetration by force of a former patient in 2018 and 2019 while Harden worked at the hospital. [See entry October 2020]

In the cases below, at least 32 relate to sexual abuse, including several convictions of staff responsible; about 18 abuses involving seclusion rooms or restraints use in children as young as 6, and including 3 deaths; wrongful deaths, assault; breaking a patient’s arm and fracturing the nose of another; and, at least 6 suicides that may have been preventable.

August 15, 2003: 12-year-old Ronald Hamilton committed suicide at The Pavilion behavioral facility in Champaign, Illinois by wrapping a bed sheet around his neck and attaching it to the door of his room. Ronald had become upset upon hearing that he was to be transferred to another foster home the following day.

2004: At Spring Mountain Treatment Center in Nevada, a 14-year-old resident was put in seclusion and defecated on the floor. She told state investigators she had repeatedly requested to be taken to the bathroom, but staff ignored her. Investigators found no evidence the child was continuously monitored while she was in seclusion.

In a separate incident, a 15-year-old girl was restrained at Spring Mountain by five members of staff and forcibly administered the antipsychotic, Thorazine.

2004: At Rockford Center in Delaware, a child complained about being “thrown to the floor” and forced into a seclusion room. The child had a fresh, bloody injury on the right side of the face and bruises around the eye.

March 24, 2005: Charles Sarao said his son, Joshua, was injured twice during restraints at Westwood Lodge in Massachusetts. The 14-year-old cut his knee during the first take-down. Mr. Sarao filed a report with Westwood police after his son said he was also punched in the face during the second restraint.  

July 2005: Daniel Jeudin and Andre Currie, former counselors with Westwood Lodge pleaded guilty to statutory rape, admitting they had sex with a 15-year-old patient in the summer of 2001. Jeudin was sentenced to 2½ years, with one year in jail and the other 18 months suspended; Currie was sentenced to 10 years’ probation. Both were required to register as sex offenders.

2005-2007: UHS acquired CHAD Youth Enhancement Center in Tennessee in the fall of 2005. The juvenile detention center housed about 90 troubled youth between the ages of 7 and 17, of which a large number were African American.

  • 2005: CHAD fired an employee after he allegedly slammed a boy to the floor so hard the child fouled himself.
  • September 2005: 14-year-old Linda Harris, an African American girl, collapsed and died while being escorted to a “time-out” room. She died of heart failure. While an investigation cleared CHAD of blame, New York and Tennessee stopped sending children to the residential treatment center.
  • 2006: The state of Tennessee complained that CHAD wasn’t reporting serious incidents to regulators, following a boy going to an emergency room for cuts sustained in a restraint.  In another case, Tennessee officials disclosed that staff broke the left arm of a 16-year-old boy during a restraint. Another teenage resident was “taken to the floor” in a restraint that required four stitches for cuts on the lips. In May, Edith Ruland pulled her son, Dennis, 10, out of CHAD after she found numerous bruises on him, which the boy said staff had inflicted in a restraint hold.
  • 3 June 2007: 17-year-old, Omega Leach, died after CHAD staff pushed him face-down to the floor, apparently cutting off his air, investigators said. According to the autopsy, the youth had “multiple superficial blunt force injuries” to his body as well as injuries to his neck muscles. He had sustained scrapes and bruises to both shoulders as well as a bruise under his left eye.  Omega Leach’s family subsequently sued UHS. In 2010, UHS settled with the family for $10.5 million.
  • A September 25, 2008 report by the Disability Law & Advocacy Center of Tennessee found “that Chad staff members use restraint/physical holds too frequently and without sufficient grounds (e.g. restraints are implemented in non-emergency situations in violation of federal law and facility policy).”
  • CHAD is now known as the Oak Plains Academy.

2006:  A counselor at Hermitage Hall, a behavioral treatment center for children in Nashville, used excessive force against a boy. Staff pulled the counselor off the boy before the child was injured. The counselor was later fired, but was not prosecuted for battery, nor was Hermitage Hall punished or fined by state regulators.

February 2006: 14-year-old Monique Payne died at Westwood Lodge. Payne, who had a brain tumor (which the hospital was aware of) began complaining of pressure in her head and was vomiting and hyperventilating and begged for help. A Westwood nurse thought she was faking and gave her cold medicine. Monique was found dead the next morning.

March 2006: An 18-year-old committed suicide at Westwood Lodge by slashing his wrists.

November 22, 2006: A 15-year-old patient at the Meadows Psychiatric Center in Pennsylvania committed suicide, by hanging himself in the bathroom.

2006 – 2008:  Following significant publicity about restraint and psychotropic drug use on youths at the Hermitage Youth Hall, Tracey Robinson-Coffee, Department of Mental Health and Developmental Disabilities (DMHDD) director of licensure, said there was no rule that required facilities like Hermitage to report the number of times it administers psychotropic injections as a form of restraint. Further, her department was only concerned with whether the shots were ordered by a doctor and administered by a nurse, not “the way the medication is actually administered.”

September 2007: The Nashville Scene newspaper reported further abuses at Hermitage Hall in Nashville, Tennessee: “In September, the facility’s counselors were having trouble getting a boy in the Eagles group, the facility’s youngest unit, to take a seat. According to staff reports filed with the state, the boy finally sat after numerous directives. But it didn’t stop counselor Byron Keith Brown from grabbing the boy by the back of his shirt and tightening his grip until the boy said he was choking. That complaint prompted Brown to slam the boy against a wall—a confrontation that didn’t end until staff called a ‘code blue’ to break up the fight. A DMHDD investigation found that the unnecessary force constituted abuse. Hermitage officials fired Brown.” Further, Hermitage employees said restraints had “almost become a sport to Hermitage counselors, who congregate at night and say things like, ‘Yeah, I got this kid. I got him good.’”

October 2007: Hermitage Hall records showed an incident report in which a boy became upset when staff wouldn’t allow him to sleep in the facility’s day room. He agreed to move to the “quiet room” to calm down, but refused to take off his belt and shoes upon entering. Staffers then placed him in a hold to forcibly remove the items. The boy began yelling, “I feel so violated. You are raping me!” The employees held the boy in a horizontal position on the floor, where he told staff, “I don’t like people standing between my legs.” The employees, unmoving, held the boy in the restraint for more than 20 minutes.

October 2008: Two 16-year-old female patients told staff, including a therapist, at Old Vineyard Behavioral Health in North Carolina that they had been sexually abused by their roommate while sedated. Their therapist did not initiate a required incident report or notify the administration, risk management or the Department of Social Services (DSS). In an interview, the therapist said, “I wanted to make sure everybody was safe. I didn’t believe it happened.”

2010:  In 2010, UHS acquired the National Deaf Academy (NDA) in Florida, a facility for the deaf with emotional and physical disabilities. According to a lawsuit filed against NDA, a deaf patient on suicide watch fled the school grounds and was hit by a car. Florida’s Agency for Health Care Administration (AHCA) alleged that NDA had failed to meet the “minimum criteria required by the level for which the facility is licensed, which is contrary to law.” NDA paid a $6,000 fine.

  • Three NDA patients died between 2009 (before UHS acquired the facility) and 2014 in allegedly negligent circumstances, and one former NDA employee told reporters she called an abuse hotline a dozen times in just one six-week period.
  • As the Bazelon Center reported to the court, “While UHS might try to dismiss violations like these as ‘technical’ or ‘obscure,’ the children at NDA experienced much more than technical harm.

April 2010:  A 14-year-old boy at Old Vineyard Youth Services in North Carolina, accused his 17-year-old roommate of forcing him to have oral sex and trying to rape him while staff members were preoccupied with a disturbance in the unit, a state report showed. Investigators reviewed video footage that showed the boys engaged in sex acts. The facility, which did not admit wrongdoing, agreed to improve monitoring procedures and training for staff. Several other problems were uncovered, including medication errors and an allegation that a patient had engaged in oral sex with a staff member, reports showed.

25 October 2010: The Keys of Carolina paid a $26,500 penalty to the state of North Carolina to settle an investigation which began with the report of a 15-year-old patient who was stabbed in the eye with a nail by another resident in 2009. The attack occurred after one of the residents gossiped about the other having been raped as a child—information he’d gathered from the other resident’s records, which had been left unattended by Keys staff. The Keys failed to report the incident to the state, as required. Further investigation uncovered use of improper restraint techniques and other incidents of violence, including a patient requiring staples to close a gash in his head that occurred while he was reportedly “horse playing” with a staff member. CLOSED, 2013

December 2010: Hundreds of serious incidents at The Meadows Psychiatric Center were not reported to the Patient Safety Authority and the PA Department of Health (DoH), as required by law. During a three-month period, there were internal incident reports of 13 escapes, 370 physical confrontations, 62 attacks on patients by other patients resulting in 26 injuries, 25 sexual allegations, and 12 self-inflicted injuries, including 6 suicide attempts. Only three reports were submitted to the health reporting system for the entire year. Among those incidents, a 14-year-old female patient reported she had been forced by a male peer to have sexual intercourse. The DoH also found violations of cross-boarding regulations, including younger children sleeping in the adolescent unit which housed two “known pedophiles.”

March 2011: A patient committed suicide at Two Rivers Psychiatric Hospital in Missouri after staff failed to conduct appropriate 15-minute checks to make sure she was breathing while asleep. When staff checked the patient at 5:00 a.m. for vital signs, she was not breathing and had a nylon strap from a medical device and a stretchy rubber toy wrapped around her neck. It took staff several minutes to begin resuscitation procedures and cut the items from around her neck. Center for Medicare and Medicaid Services (CMS) declared it a case of unabated Immediate Jeopardy. When the facility was found not to have corrected the jeopardy by April 2011, CMS terminated Two Rivers from Medicare and Medicaid programs, but later agreed to a plan of correction.

April 2011: A young patient died at Peachford Behavioral Health System in Atlanta after using towels and a bedsheet to hang himself in the bathroom. Video surveillance showed that other patients and staff were attending a group activity at the time of the suicide and staff had failed to observe the boy for 47 minutes.

April 2011: A boy said he was sexually abused by a resident of the Pines Residential Treatment Center in Virginia. The Department of Behavioral Health and Developmental Services said that it had conducted more than 150 investigations at the center, which provided in-patient treatment for more than 400 youths. (Pines is now known as Harbor Point Behavioral Health Center.)  From March to mid-April, 2011, according to incident records, there were 50 fights or assaults among kids—sucker punches, biting, outright brawls. There were also two suicide attempts and 15 incidents of self-harm. At the end of March, two boys, aged 8 and 9, admitted to engaging in oral and anal sex. The Department suspended admissions to and downgraded the license of The Pines and its three other facilities in the Hampton Roads area of Virginia.

July 2011: At Coastal Harbor Treatment Center in Savannah, Georgia, the Centers for Medicare and Medicaid Services (CMS) found that seclusion or restraints had been initiated or continued without adequate documented justification, stating: “These failures expose patients to potential harm from unnecessary restraint. They also violate patients’ rights to safe treatment in the least restrictive manner possible.” The facility treated youths with emotional problems.

July 2011: Millwood Hospital in Texas was cited over the physical restraint of a 6-year-old boy who had been placed in seclusion. A staff member attempted to restrain the boy without assistance and while no other staff members were present to observe the patient for signs of distress. Video surveillance showed that the staff member was sitting on the bed with his legs wrapped around the patient while the boy wriggled and struggled. Due to the incorrect hold, the boy fell face down and sustained a nasal fracture.

Millwood also failed to provide a safe setting for two adolescent female patients who were threatened and forced to engage in improper sexual activities with a male staff member. According to CMS, “none of the nurses or staff questioned why a male staff was on the adolescent unit.”

July 2011: The Florida AHCA fined National Deaf Academy (NDA) $3,000 in response to an Administrative Complaint against the facility. AHCA found that:

· “an employee utilized a bedroom closet as an intervention of seclusion and/or time out on a resident on multiple occasions.”

· NDA “…did not include a system for monitoring the employees for practices that placed the residents at risk.”

· NDA failed to ensure the rights of its residents and the appropriate use of proper seclusion procedures.

2011: The Chicago Tribune documented that juvenile state wards and other youths were sexually assaulted at Riveredge psychiatric hospital in Forest Park.  

February 2012: The mother of Bryan Demetrius Montgomery, a developmentally disabled 17-year-old boy, filed suit against NDA for wrongful death and abuse and neglect of a child. She alleged that Bryan was under the permanent care of NDA when he was pronounced dead. The listed causes of death were refractory cardiogenic shock, possible myocarditis, anemia and diabetes mellitus—conditions which were caused or exacerbated by the negligence and lack of supervision by personnel at NDA who were responsible for his care and well-being.

March 2012: UHS Inc. and two of its Virginia subsidiaries, Keystone Education and Youth Services LLC and Keystone Marion LLC, agreed to pay $6.85 million to the U.S. and the Commonwealth of Virginia to settle a False Claims Act lawsuit that alleged they provided substandard psychiatric counseling and treatment to adolescents in violation of Medicaid requirements, falsified records and submitted false claims to the Medicaid program.  UHS closed the Marion facility shortly before the settlement. CLOSED, 2012

April 2012: A lawsuit was filed on behalf of J.A.C., a child, who was an inpatient at River Point in Florida, and J.A.C.’s mother. J.A.C. alleged he was sexually and physically assaulted by D.W., another minor patient at River Point. It was alleged the facility knew or should have been known that D.W. had a “propensity to physically and/or sexually assault other inpatients.” The plaintiffs alleged that the defendants were negligent and in breach of their duty to their inpatients in not properly monitoring these patients and allowing D.W. to physically and sexually assault J.A.C. The case was settled in mediation in September 2014.

May 2012: When state agency officials visited University Behavioral Center (“UBC”) in 2012, they found that UBC had failed not only to report suspected child abuse and to provide front-line staff with effective communication equipment but also to employ enough staff to care for its young patients. One nurse described a “near riot” among boys in the facility during a period of under-staffing. The facility’s CEO reported receiving calls about staff needing help but said he was frustrated that a nurse had called him rather than a weekend supervisor.

August 2012: In California, UHS paid $4.25 million in 2012 to settle claims that employees at one of its facilities were either inappropriately credentialed or not credentialed at all and that the facility “warehouse[d]” children while fraudulently billing for the provision of meaningful services.

November 2012 - April 2013: During this five-month period, the Nevada State Health Division substantiated four different complaints against Willow Springs Center regarding mistreatment of patients at a youth residential treatment center (RTC), including abuse, patient rights violations, and use of involuntary seclusion without clinical justification.

December 2012: Milton Girls’ Juvenile Residential facility in East Milton, Florida was closed according to the Florida Department of Juvenile Justice (DJJ), citing significant health, safety and security concerns.

  • The facility’s supervisor, Shannon Abbott, 33, was arrested in August 2012 on a misdemeanor child abuse charge, which was later raised to a felony. She bailed out and returned to work at Milton, forcing the DJJ to ask Milton’s director to remove her from all access to children. Assistant State Attorney James Parker described the injuries to the victim as, “carpet burns, bruising around the eye and swelling around the face.” In March 2013, Abbott was found guilty.
  • Following Abbott’s arrest, the facility’s director, Carol Andrus came under investigation after being accusing of grabbing the neck of a restrained client and throwing the 15-year-old to the ground. The DJJ report indicated the teenager received lacerations to her face and ear “that looked like it needed stitches.”
  • In April 2013, DJJ Secretary Wansley Walters told media, “I think there was a culture there that was really being kept secret and being hidden from our department. But it has emerged, and fortunately law enforcement has gotten involved and people are being held accountable—after the fact, because within a few months of that incident, that program was closed. And that will be our approach throughout our system.”  CLOSED, 2012
Video: Milton Girls’ Juvenile Residential Facility surveillance video shows girl being battered and restrained

February 2013: Ernest Parker, 55, a mental health technician at Milton Girls Juvenile Residential Facility was arrested on charges of sexually abusing at least six girls while he worked at Milton. Six of the girls were victims and another two witnessed his actions—which included digitally penetrating the girls and touching their breasts and buttocks. In March 2014, Parker was found guilty and in April was sentenced to 25 years in prison.

April 2013:  A 15-year old patient of Timberlawn Behavioral Health in Dallas was restrained in violation of state procedures. A Dallas Morning News article in 2011 reported that regulators had cited Timberlawn for patient harm several times in recent years.  

May 2013: A lawsuit was filed in Orlando, Florida against NDA that claimed patients were involuntarily committed and kept longer than recommended for insurance money. Two former employees alleged horrible treatment, recounting one instance where a child with an injured leg was allegedly refused a wheelchair and made to crawl in her own urine to the bathroom.

May 2013: An employee at a UHS center in Pensacola, Florida, was sentenced to jail after she was caught on camera slamming a young girl into a wall and then sitting on her for 20 minutes.

May 2013: Lennox Seepersad, a mental health technician with The Vines Hospital in Florida was charged with aggravated felony abuse of a 13-year old resident whose arm he twisted to the point of causing a spiral fracture.

July 2013: A Miami Herald article reported that, according to estimates released by the Florida Department of Justice, 10 percent of youth at Bristol Youth Academy in Florida reported sexual victimization by staff in 2012.  CLOSED, 2013

December 2013: A mother filed a federal lawsuit alleging that Brentwood Behavioral Center in Mississippi failed to protect her 11-year-old son from being sexually abused by nurse Clifford Hough from December 2012 to January 2013. Hough, 49, pleaded guilty to a charge of “gratification of lust” in 2013 and was jailed for 10 years.

13 February 2014:  At Lakeside Behavioral Health near Memphis, authorities determined that the facility’s Governing Body (executive management) had failed to assume responsibility and provide oversight of the hospital to ensure all patients were free of abuse, neglect, restraints and seclusion and protected from injury. Findings included that patients with the intellectual capacity of young children—in one case the mental functioning of a 7-year-old—were not properly supervised and were put at risk of sexual behavior by other residents. On two occasions the facility inappropriately used restraints and seclusion resulting in a patient sustaining rib fractures.

2014:  David Jackson from the Chicago Tribune was a Pulitzer finalist for the 2014 investigative series about the perils faced by abused children placed in Illinois’s residential treatment centers, which included UHS facilities. Between 2013 and 2014, The Tribune published many of his articles regarding allegations against UHS behavioral facilities. Government inspectors found serious problems at 8.4% of UHS hospitals in 2014 compared to a nationwide figure of 3%—more than double the rate of other facilities.

September 2014: NDA came under Federal Department of Justice investigation. Three separate civil lawsuits were filed against the facility alleging negligence and abuse of children. The cases included one child being punched and thrown to the ground, another being doped up and a third coming down with scabies after being at the facility for four months, according to attorney, Bruce Maxwell. “My hope is that the NDA is shut down or significant changes occur,” he said. “This kind of conduct should not be tolerated.” An NBC News investigation also revealed that 10 patients at NDA alleged physical abuse to a government-funded advocacy group for the disabled.  

NBC News reported there had been complaints from staffers reporting runaways and patients alleging abuse. A list of 54 investigations by Mt. Dora Police between 2008 and 2014 included the following:

  • 15 involved alleged battery
  • 10 involved alleged abuse
  • 3 involved alleged sexual abuse. [NB: UHS acquired NDA in 2010 from the psych hospital chain Psychiatric Solutions]
  • On security videotape shot at the National Deaf Academy, a 19-year-old girl can be seen arguing with a staff member and exiting a room, and then reentering the room two minutes later clutching her left arm. She said, via sign language, “My arm hurts, my arm hurts,” and crumples to the ground holding her arm.

Earlier allegations also included:

  • Patient kicked in the mouth
  • Patient choked to death.
NBC’s story, “‘Mom, Please Help’: FBI Probing Alleged Abuse of Deaf, Autistic Kids,” was particularly disturbing. Through an interpreter, one teen, Daniel, told NBC News about having his hair pulled, being dragged into the shower and injections of powerful drugs that put him to sleep. “I would scream because it hurt,” he said. “They would take me down and then they’d give me the shot.”
Video: FBI Investigates Deaf Academy for Abuse Claims, NBC

January 2015: The Ocala (Florida) Police Department reported receiving 772 calls for service to Vines Hospital since January 1, 2011. Of those, 57 involved criminal activity including battery (35 calls), assault and petit theft (three each), and one each for attempted homicide and homicide. A former Vines employee was also facing prosecution, having been charged with breaking a juvenile patient’s arm.

April-September 2015: In April, Rock River Academy & Residential Center, residential treatment center in Rockford, Illinois for adolescent girls with emotional problems, closed after the Department of Children and Family Services stopped placing juvenile wards there. The Chicago Tribune found:

  • The residents suffered severe abuse during their stays
  • The Rockford Police Department fielded more than 700 reports “concerning victimization of girls under DCFS’s care including rape, aggravated battery and sodomy at the Rock River Academy,” during a four-year period.
  • The rate of physical restraints was nearly eight times the median for all Illinois facilities.
  • Staff administered psychotropic drugs like Thorazine at dosages which were far higher than doses at similar youth facilities.
  • Residents said they were knocked out for hours at a time from the meds.
  • In September a lawsuit on behalf of five plaintiffs was filed in Cook County Court against Rock River alleging sexual abuse and rape by staff. Each of the plaintiffs alleged staff “intentionally administered psychotropic drugs which they used to keep her in a semi-conscious state so that she could be more easily manipulated and sexually abused.” All five were minors at the time of being in Rock River.  CLOSED, 2015

April 2015:  A 10-year old was assaulted and suffered a head injury during a period when staffing levels were inadequate at Timberlawn Behavioral Health in Texas.

January 2016:  NDA closed in the wake of allegations of patients complaining about similar abuses. Two former employees told CCHR and an NBC News investigation that they personally saw bruising, black eyes and chokeholds used on residents at the facility in 2012, but they felt pressure to cover it up. The Orlando Sentinel also reported: “The National Deaf Academy, a residential treatment facility that has been hit with civil lawsuits alleging abuse and neglect of clients” was closing. “In the past two years, Mount Dora police were dispatched to the academy 162 times, records show. Twenty-three calls were for child abuse and seven were for sex crimes, records show.” CLOSED, 2016

20 November 2016: Austin Skidmore, a 19-year-old with autism died during an incident with staff at Laurel Heights in Atlanta. Austin was subjected to a manual hold in “a manner that would potentially impair the patient’s ability to breathe resulting in the death of the patient,” an investigation found. He choked on his own vomit but the medical examiner also classified the crime a homicide.

7 December 2016: BuzzFeed News published an exposé on UHS, headlined, “LOCK THEM IN. BILL THEIR INSURER. KICK THEM OUT. HOW SCORES OF EMPLOYEES AND PATIENTS SAY AMERICA’S LARGEST PSYCHIATRIC CHAIN TURNS PATIENTS INTO PROFITS. At least one employee alleged her supervisors at UHS’s The Ridge in Kentucky told her “If we didn’t have beds, it doesn’t matter — just go ahead admit them anyway.” She said that there was “every bed filled on the kid unit, teenagers boarding on the child’s unit, and kids sleeping in the dayroom on rubber mats. And also in the seclusion rooms—they would be sleeping in there as well.” Senator Charles Grassley, Senator Elizabeth Warren and Rep. Joe Kennedy III supported the need for a federal investigation into allegations of patient abuse and fraud at UHS’s behavioral facilities.

January 2017: Children at Palmetto Pee Dee Behavioral Health facility in Florence, South Carolina were allegedly hurt after altercations with staff. The State Department of Health and Environmental Control had cited the facility for 18 violations, including two that were considered by the agency to be among the most serious types of violations. The Greenville News reported that workers at Pee Dee alleged that “children at the facility have been hurt after altercations with staff, were given inadequate food and programming, and children there have been subjected to verbal abuse by staff.” Staph infections, scabies and mold (that can pose health risks) were also found at the facility. South Carolina State Department of Health and Environmental Control (DHEC) officials cited the facility with 19 violations including abuse and failing to adequately watch over children.  CLOSED, 2019

February 2017:  Police investigated a case of sexual assault involving two teenage patients at Cedar Ridge Psychiatric Hospital in Oklahoma City. The most concerning part was the facility’s response to the police investigation: According to law enforcement sources, Cedar Ridge’s CEO told officers they don’t call police for incidents of sexual assault. Instead, they conduct an internal investigation because “they didn’t want to upset the children or interfere with their mental health treatment by getting the police involved.” Oklahoma statute requires reporting all of such incidents.

2017: Internal surveillance videos and interviews with patients and staff revealed “a culture of violence” at Hill Crest Behavioral Health Services in Birmingham, Alabama. Videos showed staff members choking, dragging and endangering adolescent patients. In one video, 15-year-old Hayden Vice is seen walking down the hallway of the facility when a mental health technician instructed him to go take a shower. Pausing on his crutches, the teen replied that a nurse had told him not to get the cast on his lower leg wet. When he refused to go to the shower, the nurse “walks toward him waving his right index finger in the air, then brings both of his hands down on Vice’s neck,” BuzzFeed News reported. The crutches fell as the nurse spun him around against the wall and then pushes him down to the floor. With the help of another worker, the teen was hauled into a nearby room—and out of the camera’s view. Off camera, Vice said, the tech smashed his head into the dresser and then picked up his right foot, the one that was in a cast, and slammed it down to the ground. “I’m surprised it didn’t paralyze my leg, the way that he was slamming it,” Vice said. 

February-September 2017:  A teacher’s aide who worked at Behavioral Education Services, a subsidiary of UHS, in Florida was accused of sexually assaulting a 14-year-old troubled special needs student.  

April 2017:  Senator Charles Grassley drew attention to serious allegations against Shadow Mountain psychiatric facility in Tulsa, Oklahoma. This followed a report that police records, state inspection reports, and lawsuits, as well as more than 15 current and former employees all declared that Shadow Mountain was “a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as five are separated from their parents and held in dangerous situations, and where wards lack adequate staffing….” In a letter to the inspector general of the U.S. Department of Health and Human Services, Senator Grassley said reports “portray a pattern of conduct that is extremely concerning and cast a dark cloud over UHS’s ability to properly care for its patients and whether it is properly billing federal programs.” In April 2017, Oklahoma’s Governor Mary Fallin and Senator Jim Inhofe asked the Oklahoma Department of Human Services to investigate Shadow Mountain Behavioral Health over allegations of systemic abuses of patients. CLOSED, 2019

Video: Shadow Mountain – BuzzFeed Investigates Troubled Youth Psych Facility

June 2017:  The mother of an 11-year-old girl filed a lawsuit against Shadow Mountain, alleging negligence, assault and battery and intentional infliction of emotional distress. The child was frequently seen with large bruises and welts during her stay, the lawsuit alleged.

June-August 2017:  Authorities closed Okaloosa Youth Development Center in Crestview, Florida after state authorities terminated its contract because of “serious deficiencies that potentially could threaten the health and safety of the youth placed at the program.” CLOSED, 2017

11 July 2017:  A lawsuit was filed against Laurel Heights Hospital in Atlanta, alleging employee negligence after a 12-year-old patient was sexually assaulted by another boy. The suit, filed by the preteen’s mother, detailed an alleged pattern of lax supervision at Laurel Heights, including the assault by a 14-year-old boy in July 2016. Had supervision been better, the assault wouldn’t have happened, the mother contended. The suit said a security camera recorded the assault, but “no one at Laurel Heights Hospital observed the assault on available monitors or bothered to check video surveillance recordings until several days following the sexual assault.” Melvin Hewitt, the mother’s attorney, noted in the complaint that there had been 11 other incidents in the last five years at the hospital. Those include incidents of alleged child molestation, abuse and patient escapes.

25 August 2017: The Massachusetts Department of Mental Health closed Westwood Lodge psychiatric hospital due to “issues concerning patient safety and quality of care.” The closure was amid a sexual assault investigation. Westwood’s psychiatric unit for children was earlier ordered shut down following a surprise inspection. CLOSED, 2017

Video: Psychiatric hospital shut down, WCVB Channel 5 Boston

September 2017: Massachusetts suspended admissions to Lowell Treatment Center after finding “serious issues involving patient safety” with the facility. In February 2018, Lowell permanently closed its doors, after the Massachusetts Behavioral Health Partnership ended its contract with the center “due to quality concerns,” according to MassHealth. CLOSED, 2018 

September 2015: Anchor Hospital in College Park, near Atlanta, was accused of negligence after a 16-year-old sexual assault victim said she was raped. The teen’s attorney, Chris Stewart said: “This is just inexcusable because they have cameras. They’re supposed to have round-the-clock nurses and medical staff monitoring the patients.” Further, “Once we started digging into it, we just saw how bad their history is over there.” The lawsuit said the hospital had a history of failing to have adequate staff and has been cited by the federal government for violations.

October 2017: A 13-year-old girl at Timberlawn Behavioral Health was allegedly raped. The girl’s father told the Dallas Morning News that his daughter had been raped by a 17-year-old patient and stated, “This can’t happen to anyone else. The place needs to be shut down.” In response to the outcry over this and other sexual assault allegations, James Miller, Timberlawn’s chief executive, stated: “We believe our rate of serious incidents associated with the patient population treated at Timberlawn is within industry norm.” Further, “…we are mindful that over the course of successfully treating thousands of patients per year, isolated and regrettable incidents may occur.” [Emphasis added]

October 2017: The Oklahoma Health Care Authority canceled its contract with Shadow Mountain. It had opened several dozen investigations into the treatment of patients at the facility. At least five lawsuits had been filed in district and federal courts. Incidents under investigation included:

  • A 12-year-old who gained access to the medication chart and swallowed powerful antipsychotic drugs.
  • A staff member grabbed a patient and pushed her onto a stool on her back and in a second incident with another patient, held her in a headlock and wrestled her to the floor.

25 October 2017: The Dallas Morning News headlined its investigative report about Timberlawn: “Raped, fondled, flashed: What female patients say happened to them at Timberlawn psych hospital.”

7 November 2017: WFAA-TV (ABC, Dallas) exposed allegations against Mayhill Hospital in Denton, Texas. Jason and Govinda Hough said their teenage daughter, Madison, entered Mayhill voluntarily for depression on a Friday night. By the next day, she told staff that she wanted to leave. However, the staff threatened her and said they were going to put her on a 24-hour hold in solitary confinement. A Denton Police report appeared to confirm Madison’s concerns, saying: “Madison was not allowed to sign an AMA (‘Against Medical Advice’) that day and was not released from Mayhill.” The Houghs agreed to meet with staff to voice their concerns. Minutes before entering the conference room, Madison had signed an official letter requesting release. But a video showed the Hough family’s efforts were met with a hospital staffer saying the facility was seeking to detain her. The parents questioned their daughter’s treatment, including her placement in a geriatric ward. The meeting turned violent when Mrs. Hough attempted to take a picture of her daughter’s wrist band. A staff member jumped up and blocked her from taking another cell phone photo of her own daughter, citing HIPAA (The Health Insurance Portability and Accountability Act about privacy) concerns. The family tried to flee from the facility. “My wife and Madison started getting out that door when another staff member from behind tackles me to the floor,” Mr. Hough, a licensed peace officer, stated. “And then...there’s like three people on me.” Further, “The reason they held Madison is because we have fantastic insurance benefits, and they can bill over $1,000 a day, and they can keep her for up to what, 30 days?” Mrs. Hough told WFAA-TV.

Video: Voluntarily checking into psychiatric hospital, easy. Checking out? Not so much, WFAA

11 November 2017: BuzzFeed News disclosed continuing allegations of patient assault and abuse at Hill Crest Behavioral Health Services in Alabama. In particular, there was the case of 15-year-old Hayden Vice who was walking down the hallway of Hill Crest when a mental health technician instructed him to take a shower. Pausing on his crutches, he replied that a nurse had told him not to get the cast on his lower leg wet. But the worker, Isaac Doughty, told Vice again to shower, then walked towards Vice, placing his hands around the teen’s neck. “The crutches fall at Vice’s side as Doughty spins him around against the wall and then pushes him down to the floor. Briefly, Vice lifts himself onto his hands and knees, but Doughty grabs him around the middle and, with the help of another worker, hauls Vice into a nearby room—and out of the camera’s view.” When Vice stumbled out of the room, his face was bloody, and his white shirt soiled with large crimson drops. Bending over to retrieve his crutches from the floor, he tried to strike Doughty with them. But Doughty, bigger and quicker, shoved him and pulled him back into the room, once again out of the camera’s sight for about 30 minutes. Off camera, Vice said, the tech smashed his head into the dresser and then picked up his right foot, the one that was in a cast, and slammed it down to the ground. Doughty, who later watched the video said he hadn’t done anything wrong. As of September 2017, Hill Crest’s one- and two-year contracts with the state’s Department of Human Resources to house foster children in its adolescent units and group homes were worth more than $20 million in state and federal funds.

Video: Hayden Vice – They Were Kids. And Hospital Employees Beat Them, BuzzFeed News

Adryana Metcalf, under state care, argued with Hill Crest staff members because she wanted to sit closer to the television, rather than in her assigned seat, she said. What happened next, captured on video, showed three staff reached for Metcalf’s arms and began pulling her away from where she sat, and while she struggled to get away, the staff overpowered her, flipped her over so she was faced downwards, and one leaned the side of his body on her neck and head. A nurse injected her and she was dragged to her room. “They picked me up like some sort of animal,” said Metcalf. According to the teen, the techs leaned her over in her room off-camera. “They were forcing my head into the bed so that I couldn’t breathe. That’s what they do.” One of the staff who restrained her said that some staff members did hurt patients: “When they get off camera, they beat people,” he said, referring to the other mental health workers. “It happened on all the units.”  Hillcrest denied any wrongdoing and no action was taken by the County’s Department of Human Resources.

State Representative Terri Sewell had recently commented that the allegations of abuse at Hill Crest were “disturbing and appalling.” She called for a probe into the facility, stating “These allegations should be thoroughly investigated by law enforcement and the appropriate licensing boards so that those responsible are held accountable and patients will be cared for in environments that are safe.”

Video: Hill Crest: Adryana, BuzzFeed News

10 December 2017:  The Dallas Morning News reported:

  • Timberlawn placed boys and girls in bedrooms near one another. Experts say this poses a problem when combined with poor staffing; inspectors cited this in their report about the alleged rape in October.
  • Inspectors found that in 2015, a 10-year-old patient went to another hospital with a head injury after two teenage girls assaulted her. The attack happened at a time when Timberlawn had only one mental health aide to oversee 14 patients on a unit.
  • Falsifying records: The night of an alleged assault on a 13-year-old girl by a 17-year-old male patient, Timberlawn had put 16 adolescents under the watch of just one mental health aide. The aide on duty that night falsified paperwork to make it look like the 13-year-old and 17-year-old were in common areas at the time of the alleged assault, staffers told inspectors. Video evidence showed that the teens were not there; Timberlawn fired the aide, according to inspection paperwork.
  • Inspectors saw no evidence that nurses gave any care to the 13-year-old after she reported the assault. The report noted that the girl was sent later that evening to an emergency room, where she reported abdominal and pelvic pain and got a rape exam.
  • Timberlawn voluntarily closed one week after state officials repeatedly because it was too dangerous for patients.  CLOSED, 2018

December, 2017: Parents of a 19-year-old boy with autism sued Laurel Heights behavioral hospital in Atlanta over the alleged wrongful death of their son during a staff restraint procedure. Records found that the facility was cited in 2015 for improperly restraining patients.

January 2018: William Herndon, a mental health technician at North Spring Behavioral Healthcare in Leesburg, Virginia was arrested January 16 on charges of involuntary manslaughter after the state medical examiner concluded that Jeremiah Flemming, the teenage patient he had restrained, died of positional asphyxiation. An internal facility report states that on the afternoon of the boy’s death, a peer was bullying and trying to provoke Jeremiah, who threatened to “fight and kill the peer” and tried to “attack” the person. Jeremiah was sent to a “cool down room,” but once there, he began punching walls and would not stop, according to the incident account. The report referred to “staff” and at least three nurses responded. Jeremiah and the staff were struggling while he was in a hold because he was “fighting and sliding on the floor in the doorway,” according to the report.

Almost all of the children accepted into North Spring’s residential program are referred from state and county agencies or school systems. During 2017, state records showed, North Spring said it terminated employees involved in three physical run-ins with patients, all confirmed by video. Staffers pushed a patient into a wall in one incident, stepped on a patient’s head in another and used restraints unnecessarily in the third, according to facility reports to state regulators between January and early December 2017.

January 2018: Parents filed a lawsuit against Kingwood Pines Hospital in Texas alleging the hospital was responsible for their 13-year-old daughter’s rape at the facility. The lawsuit alleged both the girl and her 15-year-old roommate were raped by two older teenage male patients who were housed on the same floor. Kingswood denied the allegations, indicating that they were “highly regulated” by Federal and state agencies. But in 2015, Kingwood Pines was cited for “patient safety” and “patient rights” violations. According to federal inspections reports, two male patients were assigned as roommates even though each had documented history of sexual abuse and victimization. The report says they engaged in sex. Kingwood Pines’ website says “we change lives.” Joe Mathew is the attorney who filed the lawsuit on behalf of the parents. “They change lives in a very bad way,” he said. “I want the hospital shut down so this never happens to another child again,” the girl’s mother said.

June 2018: WFAA News in Texas did an expose, “Against Their Will,” alleging that a mother took her 11-year-old son to Millwood hospital seeking help and the hospital detained him without her consent. As WFAA News detailed: “[T]he door locks behind you. You’re told you can’t leave. Stripped of your clothes, given a new bed. You have no idea when you’ll see your family again.” The facility billed his mother’s insurance company more than $11,000 for the unwanted stay.

Video: Against Their Will: Locked away in a mental hospital after voluntarily seeking help, WFAA

October 2018: Allegations that a staff member at Palmetto Pee Dee Behavioral Health in South Carolina facility grabbed a child in a headlock and punched him, while other children were repeatedly bitten, prompted the state’s regulatory agency to accuse the facility of failing to provide basic protection.

June 2019: The family of a 13-year-old girl was promised a safe environment when she was hospitalized for depression at Gulfport Behavioral Health Hospital in Mississippi. Instead, a 17-year-old male patient raped her, a lawsuit against Gulfport and UHS, filed in U.S. District Court in Gulfport alleged. The lawsuit accuses Gulfport Behavioral of negligence in hiring, training and supervision of employees and gross negligence because of a disregard for patient safety.

October 2019: WTVR-CBS 6 reported that between January and June, two dozen incidents involving ten patients at Cumberland Hospital for Children and Adolescents in New Kent County, Virginia, weren’t being entered into the state’s computerized human rights information system or CHRIS. Incidents are supposed to be entered within 24 hours of each allegation. “They found discrepancies, they found that there were many issues that the state should have been notified about but they weren’t,” former Cumberland Hospital Program Coordinator Kimberly Bass said. The hospital was cited with noncompliance with human rights regulations.

February 2020: Media reported that Dr. Davidow from Cumberland Hospital was under investigation for the allegations of patient sexual abuse and had originated a “leave of absence” from Cumberland at the time.

Governor Ralph Northam sent a statement to WTVR-CBS 6 saying that took “these allegations very seriously—not only as Governor, but as a pediatrician and father. While the Virginia State Police continues to investigate these claims, the Governor has directed Secretary of Health Daniel Carey to ensure we are doing everything possible on our end to protect the health and safety of patients.”

February 2020: Herschel C. Harden III, a psychotherapist from Cumberland Hospital was arrested and charged over sexual abuse allegations.  A trial date was set for February 2021. Virginia State Police conducted a criminal investigation and a grand jury indicted Harden on two counts of object sexual penetration by force of a former patient in 2018 and 2019 while Harden worked at the hospital. In July, 2020 Harden had his first court appearance to face two counts of object sexual penetration by force.

February 2020: WTVR-CBS 6 reported that a girl named Astrid accused Dr. Daniel N. Davidow, the former medical director of Cumberland Hospital of sexually abusing her. Additionally, this report stated that the Virginia State Police had been investigating allegations of abuse and neglect and Cumberland Hospital since 2017.

February 2020: A staff member at Provo Canyon Behavioral Hospital in Utah was charged on February 6, 2020, with first-degree felony sodomy on a child and second-degree felony enticing a minor. Gabriel Michael Lima was accused of sexually abusing a 12-year-old girl he met at work at the hospital. The girl told police that days after she left the facility in September, 2019 Lima sent her messages on social media, including photos of his genitals and of himself shirtless. They arranged to meet up at a parking lot in Sandy on September 29, and Lima allegedly drove the girl to a nearby park and forced her to perform a sex act. Bail was set at $500,000.[132] Provo Canyon School came under scrutiny in late 2020 when Paris Hilton spoke of being abused there when the facility was owned by Charter Hospital but in September 2020, The Salt Lake Tribune reported that Provo Canyon was “placed on “conditional status” in 2015 after staff, on two occasions, injured students while holding them in restraints. “The Provo facility was also in violation for having a seclusion room with a lock on it, according to a notice of agency action.” It was also put on conditional status in 2013 after a girl was injured in a restraint, and the Provo campus had the same agency action taken against it in 2012 after staff did not properly watch students and a boy ran away. That boy stole a car and caused a car crash in Provo that killed a 65-year-old woman.”

Video: Provo Canyon School – 13 Former Students Allege Abuse at Boarding School

July 2020: The Legal Herald reported that Cumberland had placed Davidow, who had been medical director since 1996, on a “temporary leave of absence” following an investigative report that alleging he’d sexually abused one child. But the hospital’s CEO Gay Brooks, claimed Davidow was an independent physician and “has never been employed by either Cumberland Hospital or UHS. Cumberland Hospital does contract with Dr. Davidow’s group practice…on an independent contractor basis.” A New Kent County, Virginia police report dated 13 April 2017, revealed Dr. Davidow was questioned about several female patients’ sexual abuse allegation, with a copy of the police interview available online. Present was Suzanne Grable of Child Protective Services, who, despite the allegations believed a CPS investigation would be unfounded. Davidow had continued as medical director. The facility treats patients aged from 2 to 22.

7 October 2020:  A registered nurse who formerly worked at Cumberland hospital called for the facility to be shut down, after she said she witnessed child abuse at the facility, according to WTVR-CBS 6. “My soul will not allow me to continue employment within a facility where children are knowingly abused without appropriate action being taken” reads the resignation letter the nurse sent to the hospital's CEO. “Under no circumstances is abuse against a patient, much less a special needs child, appropriate in any fashion!” The nurse resigned about five months after a WTVR-CBS 6 investigation revealed the hospital had been at the center of a criminal investigation of allegations of child abuse and neglect since October 2017.

October 2020: Twenty former patients at Cumberland Hospital New Kent County, Virginia, filed a lawsuit alleging sexual abuse, physical assaults and attempts to deceive public and state health officials. Seeking $127 million in damages, attorneys for the plaintiffs also alleged that Dr. Daniel N. Davidow, the former medical director of Cumberland inappropriately touched young female patients during routine medical exams and that employees and fellow patients physically struck or sexually abused other residents.

“We have heard from children and parents that when no parent or other advocate was in the room, Dr. Davidow would say he needed to feel the female patients’ femoral pulse, located on their upper inner thighs, and he did so with the knowledge of some staff,” said Kevin Biniazan, an attorney for the plaintiffs. “Dr. Davidow would then place his hands beneath female patients’ undergarments and sexually abuse them by intentionally touching their intimate parts.”

The alleged victims’ ages in 2020 ranged from 10 to 26 and the abuse was alleged to have occurred over a period of at least 12 years.  

Other allegations in a 69-page complaint included:

  • Roommates or other patients sexually abused another patient without intervention from staff.
  • An employee scalded a patient with hot water.
  • Other patients were locked in rooms without access to toilet facilities and were forced to urinate in cups.
  • Staff members would pick one victim out of his wheelchair and throw him into a shower, knowing he could not physically brace himself to avoid injury.
  • Doctors and staff were encouraged to keep patients admitted for as long as the hospital could receive payment, “even when inpatient care or residential treatment was no longer medically necessary or beneficial.”
  • The facility made “bed-to-bed” transfers from the treatment center to Cumberland’s general hospital to increase revenue and profits and pressuring staff to “make fraudulent and materially false statements in medical records to justify longer stays.” Those included false statements to state health authorities and attempting to serve hundreds of children and adolescents, including the plaintiffs, without appropriate and necessary licenses from the Virginia Department of Health and the Virginia Department of Behavioral Health and Developmental Services.
  • Roommates or other patients sexually abused younger and weaker plaintiffs after hours, at times coming into their rooms, “without intervention from staff” and “sexually abused and battered” them by “groping and fondling” their “intimate body parts.”

“The defendants operated an unsafe facility that subjected the patients, including the plaintiffs, to constant threats to their basic safety, devoid of fundamental sanitation or humanity,” the plaintiffs allege.

From 2006 to 2016, the lawsuit said, “facilities owned and operated by UHS were cited or investigated for inadequate staffing violations on approximately 90 occasions, including Cumberland Hospital on at least one occasion.”

The allegations in the lawsuit included assault and battery, negligence, false imprisonment, reckless disregard and violations of the Virginia Consumer Protection Act. The suit sought $7 million in punitive damages and $120 million in compensatory damages for bodily injuries, physical pain and mental anguish, disfigurement, future lost earnings and medical expenses. The plaintiffs requested a jury trial.

Cumberland gave a typical UHS response when serious allegations are raised against it. "We are surveyed regularly, and like many healthcare facilities, address any deficiencies that may be cited. Further, any complaint or allegation is taken seriously, investigated thoroughly and addressed as appropriate."

However, the level of abuse recorded, in part, here demand state is evidence that oversight of the industry is poor, if not negligent, and that federal patient and fraud protections are needed with far stronger penalties for abuse and fraud, including CMS program expulsion and criminal accountability in the behavioral hospital industry.

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