It was supposed to be a refuge for troubled adolescents and foster kids who had run out of other options. But at Hill Crest Behavioral Health — part of UHS, America's largest psychiatric hospital chain — a culture of violence flourished. Internal videos show staff members beating and dragging their young patients. And many say the worst abuses happened beyond any camera’s view. A BuzzFeed News investigation.

This is part of a BuzzFeed News Investigation. Other main stories in the series include:

Locked On The Psych Ward

A Six-Year-Old Gets Locked Up

The Dark Side Of Shadow Mountain and related video

Nothing To See Here Hayden Vice was walking down the hallway of the psychiatric hospital when a mental health technician instructed him to go take a shower. Pausing on his crutches, the 15-year-old patient 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 that he was going to take a shower. “No, the hell I’m not — I’m going to do what the nurse told me to,” he recalled responding. Surveillance video shows what happens next: Doughty walks toward him waving his right index finger in the air, then brings both of his hands down on Vice’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. For a few moments the hallway is still, strewn with loose papers, scattered chairs, and Vice’s crutches. Then Vice stumbles out again. His face is now bloody, and his white shirt is soiled with large crimson drops. Bending over to retrieve his crutches from the floor, he tries to strike Doughty with them. But Doughty, bigger and quicker, shoves him and pulls him back into the room, once again out of the camera’s sight. Minutes later, the hallway swells with patients, but Vice does not emerge 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. “I’m surprised it didn’t paralyze my leg, the way that he was slamming it,” Vice said. Contesting Vice’s account of what happened in the room, Doughty, who reviewed the footage at BuzzFeed News’ request, repeated several times, “I didn’t do anything wrong.”



Cristian Rossel / BuzzFeed News Hill Crest Behavioral Health, a UHS hospital.

Videos show patients — including foster children — being tackled, dragged, and choked by staff members. Employees sometimes hauled patients into bedrooms where, beyond the view of surveillance cameras, they doled out their most vicious beatings, patients and staff members said. Interviews and documents show that the hospital’s management did little to halt the abuses. “They don’t treat those kids right. They treat them like they’re animals in a zoo,” said a former nurse. “I wouldn’t send my dog there.” In a written statement, the facility said that the videos show “isolated incidents” that are “not indicative of the quality of care provided at Hill Crest.”

“We regret and are disappointed in the instances of inappropriate conduct by our employees, which was inconsistent with the facility’s policies and their training,” it continued. UHS declined to make any comments of its own. Hill Crest, a 219-bed facility that has several state contracts to care for Alabama’s foster kids, touts superior patient care and rigorous staff training. But interviews with current and former workers, as well as patients, reveal that training is so cursory and staffing levels are so low as to be dangerous. Not all employees said they witnessed abuse, and many said they did the best they could, even spending their own money on snacks for patients when the hospital was in short supply. But other employees resorted to using chokeholds or twisting the arms and legs of patients to control them. And those who were caught on camera hurting patients — such as Doughty — continued to work there with little discipline. In addition, the facility was run down; the County Health Department found roaches and dead rodents rotting in traps in the facility’s kitchen. Hill Crest has gotten high marks from Alabama’s Department of Mental Health and Department of Human Resources, the two state agencies that oversee the facility, and has been accredited by The Joint Commission, a national non-profit. But a BuzzFeed News investigation reveals that Hill Crest withheld crucial information from government regulators, falsified patient records, defrauded insurers, and lied to the families of its young charges.

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More than a half dozen employees say that hospital administrators helped floor workers cheat on exams that state contracts require them to pass. Several families of patients who incurred injuries said hospital officials lied about what actually happened. Five employees said they were told to backdate or falsify patient charts, including those for patients not in their care — a seeming violation of fraud statutes. And despite state and federal rules about how hospitals report serious injuries, Hill Crest filed no documents regarding an adult patient who died the day after being restrained by staff members. The most shocking of these incidents — in which children, some so vulnerable that the state has placed them in the care of a special institution, are physically abused by the very people who are supposed to be caring for them — are captured on closed-circuit video. After obtaining these videos, BuzzFeed News used interviews and documents to confirm the events they capture. We shared them with the families in question, as well as with UHS. Portions of the videos are presented here as BuzzFeed News received them, though some of the individuals’ faces have been obscured. Hill Crest told BuzzFeed News that its investigation “relies upon a limited number of isolated, cherry-picked, non-representative, and in some cases wholly inaccurate accounts.” The hospital’s “goal is to help and heal those who come to us at their most vulnerable times in their lives,” and if patients said they were mistreated, administrators would conduct a thorough review. But Hill Crest's statement added, “it is important to note that many patient allegations are ultimately revealed to be unsubstantiated, inaccurate or incomplete.” The experiences of former residents and employees, however, tell the story of a very different hospital. They suggest that Hill Crest often did not help its young patients, among the most powerless people in the state. Some patients and families say the violence and mistreatment they received there ruined their lives and have haunted them ever since.

no ideas / BuzzFeed News

"I didn't want to live no more"

A few hours after the altercation with Doughty, Vice was sent to the emergency room for stitches above his eye. Hill Crest didn’t notify his mother, Trecia Gilmore, until the next day, she said, when they told her that her son had fallen in the hallway. She didn’t buy it. By that time, Vice had been at the facility about nine months. She had seen bruises on her son before, she said. So that afternoon, after she picked up her other kids from school, she made the 90-mile drive to Hill Crest. She arrived in the early evening, in time for visiting hours. “Now, Hayden had a pretty nasty fall, but it looks worse than it is,” she recalled a manager telling her as she waited to see her son. “Hayden’s just being overdramatic.”

She recalled a manager telling her, “Hayden’s just being overdramatic.”

She also recalled being told that the facility’s security cameras weren’t working that day. She started getting nervous. When her son finally came down from the unit, she immediately spotted the fresh bruises on his arms and throat, and the row of half a dozen stitches above his left eye. “My heart dropped, and my eyes filled up and I started crying,” Gilmore told BuzzFeed News. She demanded to see Burney Johnson, the clinical director, but recalled being told that he wouldn’t speak to her. “I'll tell you what, get his shit together because we're leaving,” Gilmore said. Staff protested, but the hospital released Vice that night. Stephanie Jenks, who had until recently been Vice’s therapist at Hill Crest, said it wasn’t the first time that staff members assaulted him. On another occasion, a few months prior, she had found him “all scuffed up and red-faced and scratched and bleeding,” she recalled. “His neck had finger marks around it,” she added. “He was crying and shaking.” Hill Crest records show that Vice had a “history of violent, destructive threats,” as well as “severe and dangerous agitation.”

BuzzFeed News Hayden Vice in his bedroom.

But along with several other nurses and employees, Jenks said staff members “would just antagonize. They would just push these kids’ buttons.” They did it to Vice “so they could restrain him or put him on restriction or take something away from him,” she said. “It was just abuse.” Vice said he felt constantly under attack at Hill Crest. “I kinda felt like they didn’t care or anything,” he said. “It just made me feel like I didn’t want to live no more.” The day after Vice was released, Gilmore took him to a medical hospital, where a doctor diagnosed him with a contusion, records show. Photos she took two days after the incident show brown and purple bruises on his bicep, his knees, and his elbows, and long red scratches covering his chest and neck. Hill Crest’s employee handbook says physical or verbal abuse toward a patient can be punished with corrective action or immediate termination. “Of course I got talked to about the incident,” Doughty said. “That’s protocol.” Hill Crest said Doughty “received mandatory retraining” and the incident was reported to applicable state and regulatory agencies. Doughty said he continued working part-time at the hospital until just a few months ago. He said he quit only because he is currently in school, and his schedule got in the way. He is studying to become a psychiatric nurse. “My experience with Hill Crest,” Doughty said, is “the patients have been treated fairly. I’ve never seen a patient treated badly.” Jenks, Vice’s former therapist, no longer works at Hill Crest. She said she left the hospital after that incident, which Hill Crest acknowledges, because of how badly Vice was abused and how eager everyone was to say it was his fault. “I was not going to go along with the lies,” she said. “Not about this — not about abuse.”

“They picked me up like some sort of animal”

UHS has operated Hill Crest since 2010, but the hospital has a much longer history, having opened nearly a century ago as a 25-bed sanitarium in the mansion of a former Birmingham sheriff. Today, it has expanded to more than 200 beds across nine programs that serve both adults and adolescents. As of September 2017, Hill Crest’s one- and two-year contracts with the state’s Department of Human Resources, or DHR, to house foster kids in its adolescent units and group homes are worth more than $20 million in state and federal funds.

One of these contracts is to place foster children in the unit called RISE, which is located in one of the boxy, stand-alone trailers off the main hospital and is focused on treating adolescent girls with behavioral problems. “We had children that we could not place,” said a former nurse at the facility. “There was nowhere else for them to go.” Previous BuzzFeed News investigations have revealed how UHS pushed its executives to increase profit margins by boosting admissions while cutting staff. At Hill Crest, state contracts helped keep the adolescent units full: For the last few years more than 200 foster kids a year have been placed there.

“We had children that we could not place. There was nowhere else for them to go.”

Adryana Metcalf ended up in Hill Crest at 16. When she was 5, her father left a belt mark on her face because she hadn’t sat still in church, law enforcement records show, and the state took Metcalf from her parents. Her mother regained custody for a time, but Metcalf went back into state care as a teenager, getting shuffled among facilities around the state, several in the last year alone. She spent about a year on the RISE unit, she recalled. Many of the patients at RISE come from tough circumstances; some are violent. Among Hill Crest staff, it’s known as the place where no one wants to work. In contrast to nurses and doctors, mental health technicians at Hill Crest are only required to have a high school diploma, though experience working in a residential treatment center is preferred, according to a job description. Yet these floor workers spend the most time with the patients, doing everything from taking them on outings to intervening during fights and checking on them while they sleep. Despite receiving millions of dollars of public funds to house those patients, the hospital gave these employees minimal training, staff members repeatedly said. These workers are supposed to receive four to five days of classroom training on topics such as writing progress notes and making patient rounds, according to the facility’s contracts with the state. The hospital is also supposed to train its employees in how to physically restrain patients who are at risk of harming themselves or others. Such restraints are highly regulated by state and federal rules because of the “high-risk nature” and “potential for harm” according to Alabama’s administrative code. But employees said that training segments were rushed through or not completed at all. Several employees described watching a video or reviewing a workbook about how to place a patient in a restraint, but said their questions were dismissed by instructors, and the trainees did not have a good grasp of the techniques when they started working on the floor. “It’s so fast you don’t remember or really know what to do,” said a current worker at the facility, who added that he was nervous when he started working with patients. At the end of the training week, Hill Crest contracts say, new hires must score at least 90% on a test or receive additional training. But more than half a dozen employees who started at Hill Crest in different years and worked in a range of departments said that a supervisor read out the answers to them, ensuring everyone got the highest mark.

He saw some of his colleagues put kids in chokeholds “because they could.”

Hill Crest did not respond directly to allegations of cheating, but said, “If the Trainer notices that the employee does not fully understand why the answer is not correct, he intervenes to add clarity prior to the test being retaken.” The facility added that it provides ongoing training and mentorship for new hires who may not yet feel comfortable performing physical holds. One former RISE employee who said he didn’t learn much about physical restraints in the training was Tommy Horton, a heavyset man with close-cropped hair. Working on the floor, he said, he saw some of his colleagues put kids in chokeholds or twist their arms and legs. Staff did it “because they could,” he said. Last July, Metcalf was arguing with staff members in the common area because she wanted to sit closer to the television, rather than in her assigned seat, she said. Frustrated, she walked away and took a seat in the corner. Several staffers crowded around her and told her to go to her room. What happened next, captured on video, violates federal and state rules on how to physically handle patients. All at once, Horton and two other men reach for Metcalf’s arms and begin pulling her away from where she’s sitting. As they tug on her wrists, Metcalf scrunches up her knees to stop herself from sliding across the floor and lies down on her back, shielding her face with her arms. For a moment, she tries to wriggle away, but almost immediately Horton and the other two large men overpower her, flipping her over so she is facedown. With her legs flailing, Horton leans the side of his body on her neck and head. Restraints in which a patient is pressed facedown against the floor are considered especially dangerous because of the risk of suffocation. While Metcalf is pinned facedown, the video shows, a nurse gives her a shot. Horton and another worker then lift Metcalf up by her arms. As they take her to her room, her legs drag behind her until a third man pushes her ankles together and folds her legs at the knee. Together they haul her off. “They picked me up like some sort of animal,” said Metcalf.

“When they get off camera, they beat people,” one former employee said. “It happened on all the units.”

After Metcalf was carried into her room, “it got even worse,” she told BuzzFeed News. “When we’re in the room, there’s no cameras and they can do whatever they want.” The techs leaned her over so that her abdomen pushed into the edge of the wooden bed frame, she said. “They were forcing my head into the bed so that I couldn’t breathe. That’s what they do.” Horton said that he hadn’t meant to drag Metcalf and he told the other employee to stop when he realized what was happening. This is when the third employee grabbed her legs. While reviewing the tape, he said that Metcalf was kicking, which is why they held her down before taking her to her room. Staff members, he said, wanted Metcalf to go to her room because another girl wanted to fight her. The 15-minute surveillance video does not show Metcalf interacting with any other patients.

Horton said he recalled Metcalf was crying but was not in the room with her for long and did not see her pushed into the bed. Speaking generally, however, he said some staff members did hurt patients when they were escorted to their rooms. “When they get off camera, they beat people,” Horton said, referring to the other mental health workers. “It happened on all the units.” Hill Crest strongly denied any such pattern, stating that “no inspection or citation has ever alleged or revealed any evidence that improper restraints are conducted in patient rooms away from cameras.” Hill Crest said that the employees involved in the incident were assigned to mandatory retraining and that DHR investigated the incident and found that no abuse had occurred. Horton characterized that retraining as “no big deal.” He said it lasted about 30 minutes, after which he was asked to sign some papers stating that he knew how to do a proper restraint, he recalled. Later he was fired for what he said were unrelated reasons. Metcalf’s mother, Heather Todd, said she first heard about the incident at Hill Crest from her daughter shortly after it happened. “I got mad as hell, and I called up there and cussed everyone out,” she said. The hospital denied the incident had happened, Todd said. Her daughter was probably exaggerating, Todd remembered being told. A third parent, Meghan Parson, said she was on the phone with her son Jordan while he was at Hill Crest earlier this year. As they were talking, she heard a man, who Jordan said was a staff member, tell her son, “Give me the phone now before I beat the fuck out of you,” followed by muffled sounds of him shouting. The line went dead. Immediately she called back, but her concerns were dismissed. She spent the night in agony, she said, wondering if her son was OK.

“Give me the phone now before I beat the fuck out of you,” she heard someone tell her son.

Jordan told BuzzFeed News that on his side of the call, a tech pressed his face into the glass wall of the nurse’s station, punched him in his gut, and then restrained him. After that, he was given a sedative shot and taken back to his room. “At first they were telling me, ‘Jordan has a tendency to overexaggerate things,’” Parson said. But she knew what she had heard. “I’m not crazy. Jordan ain’t crazy. I was on the phone with him — I heard my child physically attacked.” When a reporter showed Adryana Metcalf’s mother the surveillance video of her daughter being dragged and then carried facedown by three large men, the woman’s breath drew in sharply. “Oh my god,” she repeated in a low voice. After a pause, her voice grew louder and more insistent. “They told me, 'Oh no, it didn’t happen the way she said it did.' And that’s exactly what she said happened! She said, ‘Mama, they dragged me across the room. They sat on me.’”

She couldn’t remove her daughter from the hospital because she didn’t have custody at the time of the incident. It was the same for Parson, who heard her son being attacked. They both said they felt helpless. Hill Crest called the account of what Parson heard during her phone call with her son “inaccurate, misleading and incomplete” but said the hospital could not provide specifics because it did not have a signed consent form to speak about his care. It added that the facility makes “good faith efforts” to communicate with parents, including “proactively updating parents” about “events affecting their child’s care.” Parson, who has since regained custody of her son, recalled that day: “It’s just the worst feeling in the world, watching your kid in pain like that.” She now owes nearly $1500 in child support to the state for the time her son was in its custody. Todd, who is still fighting the state to regain custody of Metcalf, her oldest child, couldn’t help but wonder aloud after watching the video: “What good have y’all done having my daughter in all of these places?” Referring to Hill Crest and the state agency that placed her daughter there, she said, “All they did was fuck her life up.”



“They would choke you”

When Nick Lafogg, 20, first came to Hill Crest after a stint in a juvenile detention center in 2014, everything seemed great. He could wear his own clothes, he said, and the food was pretty good. Lafogg recalled how Johnson, the clinical director, had told him things would be fun at Hill Crest, and they’d try to place him in a foster home within a few months.

“After a week or so you start seeing the bad side,” said Lafogg. “You start to see staff being abusive.” Kids in state custody, as Lafogg was, may get sent to Hill Crest if they have a history of behavior issues. Some have been in juvenile detention. Others were victims of trauma and abuse. “They could not find me a foster placement that would take me because of what was on my juvenile record at the time, and they had to put me there,” he said. But some employees responded to the kids with more violence, said both staff and patients.

“I've seen them twist” a patient’s “foot sideways until they get the answer that they want.”

Staff members “just see these kids as badass kids who don’t have home training and need things beat into them,” said one former Hill Crest employee. “I've seen them throw them on the bed and bend their leg up like over their head. I've seen them twist the foot sideways until they get the answer that they want.” Several employees pointed out that their young patients tended to have troubled histories. “We were working with kids off the street, kids who were in gangs, kids who have been abused since day one,” said Alison Bigham, a therapist who said Hill Crest gave quality care. “You can get in some violent situations with our kids because they’re very violent.” Other staff members said these were kids who had “nothing to lose,” who were “manipulative,” or who threatened staff — or actually hurt them, a point that some former patients confirmed. But young patients, who spent months or sometimes years at the facility, described Hill Crest as a place they were trying to survive. Some spoke about staff members they liked, often someone who had listened to their problems and made their time at the facility better. “I tried to pick out the staff who were trustworthy,” said Jessica Williams, 20, who came to Hill Crest after a foster family she had lived with for a couple of months decided to give her up. “They didn’t want me there, so they took me to Hill Crest. I was really depressed.” She said she learned to watch how the staff members interacted, avoiding the ones who fought with other employees or who “told lies on kids.” Many of the other patients interviewed and nearly a half dozen workers agreed that some employees picked on patients, looking for ways to provoke them in order to dole out punishments. Some of those sources said staff members also drugged patients to make them easier to manage — a violation of state rules — or resorted to violence.

Some workers said staff members drugged patients as a means of control — a violation of state rules.

Staff treats patients “like members of an opposing football team,” said Jordan Parson, Meghan’s son, who was released in July. “If you don’t act right, you get restrained. Basically that means they’re going to come in your room and get the crap beat out of you.” Fighting also broke out often among patients. When a code purple was called, alerting all available staff to an out-of-control patient, staff members sometimes escalated the conflict. “They would choke you, put you in a chokehold, they would sit on you,” said Jessica Evans, 19, who left Hill Crest earlier this year. “It happened a bunch of times.” She recalled seeing an employee break the arm of a resident during a restraint, an incident echoed in state reports. “There were some staff who thought they could do whatever,” she said. Hill Crest said “it does not condone nor tolerate utilization of chokeholds or intentional twisting of patients’ arms or legs during physical restraint episodes” and that its policies are consistent with applicable regulations. Sometimes these restraints — either a physical hold or a shot of sedatives — happened with little provocation, according to interviews. “There are kids that said one wrong thing and got kneed in the stomach,” Lafogg recalled. Other times, workers deliberately antagonized the residents, patients and some staff members said. “They would call us stupid, they would call us lame, they would call us all kinds of stuff,” said Parson. Staff members saw it too. If patients “came in from school in a bad mood,” nurses “would pull up a shot and give it to them,” said one nurse who recently worked at the facility for a year. “The techs would come in: ‘So-and-so is getting me on my nerves watching TV and won’t quit talking; come over here and give her a PRN’” — a shot that could contain a sedative such as Ativan or an antipsychotic like Haldol. The nurse said she would decline these requests since under Alabama regulations, so-called chemical restraints are to be used only as a last resort — and never as a tool of punishment or as a substitute for treatment.

The shots had powerful effects. Often they’d make kids go to sleep for the rest of the day. For Parson, they were torture. “My tongue would get really, really thick,” he said. “Every time I tried to move my mouth there will be 13 or 14 seconds where I’m struggling to swallow so I can speak.” Drinking water helped, but sometimes the sensation would last for an entire day. He estimated he got as many as five or six shots a week. Hill Crest said it “wholeheartedly rejects any allegations that it inappropriately administers medicines for any non-clinically justified purpose and it has never received a citation alleging or revealing such conduct.” Because of the powerful shots and the daily medications, some patients said they missed days of school. Parson said he was sedated so often that after he was released from Hill Crest, he had to attend summer school to make up for the education he had missed.

Being at Hill Crest “has eradicated every ounce of happiness that I’ve ever had.”

When residents did make it to class, they attended Higdon Hill School, which consists of a few classrooms in the basement of Hill Crest’s main building. Alabama’s Department of Education paid more than a million dollars to the hospital over the last two years to provide specialty education for children in its care, according to figures provided by the department. But several former patients said the school did not provide any real education at all. “There were books but they were rarely opened,” said Lafogg. “It really wasn’t class — it was more like crossword puzzles and coloring sheets.” Hill Crest said Higdon Hill adheres "to stringent curriculum requirements." Both Lafogg and Williams, like others interviewed, tried to run away. Lafogg said he tried to bust through the window of his room to get out. (It didn’t work.) Williams said she managed to escape with a piece of glass tucked in her bra to defend herself. After a few hours, the cops picked her up and took her back to Hill Crest. The hospital told BuzzFeed News it was not required to report the incident because she was brought back to the facility before midnight, but they voluntarily notified her case worker.

Parson said he just tried to get through his time there without getting too depressed. But after a few months, he said, all he could think was that being at Hill Crest “has eradicated every ounce of happiness that I’ve ever had.”

“An expectation to doctor the charts”

Many current and former employees interviewed said they didn’t see incidents of outright abuse of patients by staff. But most said the demands of their job made it impossible to properly supervise patients or offer proper care.

Several former nurses described overseeing as many as 30 — and in one case, 70 — patients at a time on their own, sometimes spread across multiple units. And since several of the adolescent units are located in stand-alone trailers out of the main building, for some this meant running back and forth between different buildings to make sure medicines were administered properly. “All you were doing is passing medication as fast as you could open it and then running to another unit and doing the same thing,” said one former longtime nurse. Ultimately, several nurses say, staff levels were not high enough to keep either patients or employees safe. “I was scared every weekend that something would happen to one of my patients,” said another nurse. Hill Crest did not answer specific questions about nurse-to-patient ratios, but said “Staffing is maintained at appropriate levels consistent with state and federal rules governing the levels of care at Hill Crest.” In addition, facilities were dirty and crumbling. In August 2015, county health department inspectors found roaches and gnats as well as dead rodents in traps. The following March, federal inspectors listed nearly two dozen items in the adult units that needed repair, including a hole in the wall, rotting wood in the windowsills, graffiti, and rust. They also cited the hospital for storing expired medication and not labeling some medications properly. Hill Crest said that any facility maintenance issues were “standard-level” and were promptly addressed. It also added that it has contracted weekly pest control services. Several staff members said they had stayed at Hill Crest for years because of kids at the hospital who needed help, even digging into their own pockets to provide appropriate supplies when the hospital came up short. A floor worker said she bought underwear for an adolescent girl who didn’t have any that fit her properly. Multiple nurses said they bought snacks because there often wasn’t a lot to hand out between meals. “The poor children would be hungry on the weekends,” said a former longtime nurse of the facility, who started bringing in boxes of apples. “I would tell them it’s bedtime, and they were crying and saying they’re hungry.” Hill Crest denies any shortage of supplies or food. Without proper supervision, patients also had greater opportunity to hurt themselves. In another 15-minute surveillance video, an adolescent walks into a small common area room alone. He throws a hoodie over the surveillance camera, but it slips off. As he takes a seat under the camera, his left wrist is still visible, and he begins to make stabbing motions at his arm and then his left leg. Blood spurts onto the floor and one of the chairs. After several minutes, a group of staff members come in, stop him, and begin cleaning up the cuts on his arm and leg. For much of the video, which also shows a view of the hallway outside of the room, no staff members are visible anywhere. Hill Crest said that patient rounds were properly conducted. State agencies that oversee Hill Crest rate the hospital highly. Alabama’s Department of Mental Health, which licenses the main hospital, awarded Hill Crest a score of 100% across six of seven areas in its most recent site survey in May 2017. Among the areas where Hill Crest was awarded a perfect score was for the use of restraints and seclusion on its children's and adolescent units. And the Department of Human Resources, the state agency that licenses Hill Crest’s two group homes and oversees the state’s foster care system, found no major deficiencies in a recent site visit in May 2017. The Joint Commission, a national nonprofit that accredits hospitals, named Hill Crest as a top performer until 2014, the last year that designation was in use. But those outside assessments may not reflect the true conditions at Hill Crest. When the “Joint Commission came in, they’d pile the people in there and put so many people on the schedule to make it look like there was tons of staff,” said one former nurse, “but as soon as Joint Commission had come and gone it’d go back to the usual staffing.” A spokeswoman for the Joint Commission declined to comment about Hill Crest. The Department of Mental Health directed BuzzFeed News back to its most recent site survey of the facility. The Department of Human Resources told BuzzFeed News it could not comment on specific patients or complaints of abuse. Meanwhile state rules require Hill Crest to file a report any time a child in state custody is injured in the hospital’s care. Through a public records request, BuzzFeed News obtained the nearly 100 incident reports Hill Crest submitted to Alabama’s Department of Human Resources between 2014 and 2016. Only two of the reports suggested that employees had been responsible for any patient injury.

“There was an expectation to doctor the charts,” said a former Hill Crest nurse.

A former therapist at the facility said that in order to protect the hospital, incident reports didn’t always include the full story of what happened. A former nurse also told BuzzFeed News that when an employee was injured by patients on her unit, she was asked to omit details and make it sound as if the unit were fully staffed. “I think there was an expectation to doctor the charts,” said Layne Williams, a former nurse who worked at Hill Crest for more than a decade and was sometimes assigned to shifts in the medical records department of the hospital to fill in charts that were incomplete. The nurse told BuzzFeed News she wouldn’t jeopardize her license by falsifying the records and only filled in what she knew to be true about a patient’s treatment. Three other former staff members said supervisors instructed them to fill in charts for patients they had no knowledge of or could no longer recall. This could mean falsifying or backdating anything from the quick check-ins that floor workers are supposed to perform on patients every 15 minutes to official medical charts. Submitting false claims to federal payers, such as Medicare and Medicaid, violates fraud statutes. Hill Crest said it “strictly prohibits any employee from falsifying medical records.” It added that “it is the responsibility of each employee to use their professional judgment in ensuring their documentation is accurate and reflects the services they provided to the best of their knowledge.” UHS, which owns Hill Crest, describes itself as a management company with facilities that operate independently. But the company hires and oversees those facilities’ managers, controls budgets, and reaps profit margins as high as 28% last year from the hospitals. Its own corporate compliance policies state that it has the “responsibility and authority” to conduct any internal investigations into possible violations of state or federal laws, and it directs facilities to retain surveillance footage of any incident in which a patient is injured.

Courtesy Young Family Ed Young is seen in this undated photo.

An unreported death

It was still dark when Terry Young set out to make the 500-mile drive from his home in Jacksonville, Florida, to see his brother, who had recently been admitted to Hill Crest. Around 10 a.m., when he was just outside of Birmingham, a doctor called to tell Young his brother was dead.

Arriving at the medical hospital where his brother had been transferred, Young saw “black eyes and bruises on his body,” he recalled. “That’s not normal” was all he could think, he said, and he immediately requested an autopsy.

Arriving at the hospital, he saw that his brother had black eyes and bruises on his body.

Ed Young, Terry’s brother, had arrived at Hill Crest less than a day earlier — May 7, 2015 — after a referral from Birmingham VA Medical Center to regulate his medications. Years before, he had been diagnosed with schizophrenia, but was stable as long as he was taking his medication. Young still lived on his own in Birmingham and had recently put a down payment on a new Buick, said his brother, whose family is now suing Hill Crest for medical negligence, assault and battery. Hospital records say that after Young was admitted, he became aggressive. “Patient continues to be loud, disruptive, attempting to kick staff,” said a nurse’s progress note written around 2 a.m. When Young refused to get up from his chair, staff escorted him to his room, where a nurse gave him a shot to calm his agitation. Young only slept a couple of hours that night. Just after 7 in the morning, a nurse’s note said he was “loud, disruptive, combative, aggressive and non-compliant” and had been placed in a physical restraint for at least 20 minutes. As he was held down, Young was given another shot and then transferred to the psychiatric intensive care unit. Just before noon, he was given an ice pack for “eye swelling possibly from earlier altercation with staff.” At 12:30, a worker wrote in Young’s chart that he was lying in bed quietly. An hour later, Young walked out of his room and sat on the table in the day room, while holding a plastic bottle in his hand, according to a note written by a mental health worker. When staff members came toward him, he became loud and started to curse, and then went into his room, the note said. Another note said the patient was “attempting to stab a mental health tech with a crushed plastic bottle.” A police report on the incident said that Young had fashioned “a weapon out of a water bottle and was acting strangely.” Surveillance video obtained by BuzzFeed News shows that Young was sitting on the table in the common area, then hurried into his room as two workers approached him. But in the video he is not holding any plastic bottle; his hands are empty. The two workers then follow Young into the room and are alone with him for about 20 minutes, except for two occasions in which a nurse enters.

While Young was in his room, a nurse administered a third shot — 5 milligrams of Haldol, an antipsychotic medication; 100 milligrams of Thorazine, another antipsychotic; and 50 milligrams of Benadryl, records show. Within minutes Young became unresponsive and was lying on his side on the floor near his bed. The nurses called a code blue, ran to get a defibrillator, and started chest compressions. Responders from the Birmingham Fire Department arrived quickly, wheeling Young out on a stretcher to take him to the emergency room.

One tech said colleagues who went to Young’s room later bragged about “taking time beating” him.

A nurse there told Terry Young that his brother looked so bad that medical staff had called the police. Horton, the worker who had dragged Metcalf to her room, said the techs who went to Young’s room later bragged about “taking time beating” him. Following a few high-profile restraint deaths of patients in the late 1990s, the Centers for Medicare and Medicaid Services, or CMS, now requires psychiatric hospitals to report any death that occurs within 24 hours of a patient’s physical or chemical restraint. These reports may trigger a federal survey to determine if there were any violations in standards of care or restraint and seclusion regulations. But federal surveyors never came to investigate Young’s death. They didn’t know about it. BuzzFeed News reviewed all reports of restraint-related deaths submitted by Alabama hospitals to CMS in 2015, the year Young died. There isn’t one about this incident. The federal agency confirmed the hospital did not report the death and that there was no investigation into the incident in 2015. The autopsy for Young showed that he had a black eye and contusions to the right side and the front of his head. It concluded that he likely died of hypertensive heart disease. The medical examiner classified the death as natural. Dr. Elizabeth Laposata of Brown University, an expert in restraint deaths who served as chief medical examiner of Rhode Island, reviewed Young’s records at the request of BuzzFeed News. She concluded that there was a glaring dearth of information. Laposata said a bad heart and manic behavior certainly are risk factors for cardiac arrest. But Hill Crest records give no details about how Young was physically restrained, nor do they include statements from staff about what happened in the minutes leading to his loss of consciousness. Laposata said the doses of drugs that Young was given were not inherently alarming, but that without those details, a standard part of a proper death investigation, it’s impossible to know what other factors could have contributed to Young’s death. Hill Crest referred questions about the incident to Martha Thompson, a lawyer representing the hospital in the lawsuit, who told BuzzFeed News that “Hill Crest denies the allegations in the Complaint, specifically the allegations of physical abuse or that Mr. Young’s death was caused by any actions at Hill Crest.” Cathryn Conn, the hospital's human resources director at the time of Young’s death, defended the care at Hill Crest and said that all incidents were investigated appropriately. She could not recall whether there was any investigation of this particular incident. “Just because he died in our hospital doesn’t mean that we did something wrong,” she said.

“They ruined his life”

On a blazing hot morning this past September, Hayden Vice — his leg no longer in a cast — appeared at the county courthouse dressed in orange sweats with “Property of Lamar County” across the chest. His wrists were in handcuffs and shackled to a chain at his waist. Now 17 years old, his dark hair had a shock of bleached blonde that tapered down to a V near the nape of his neck.

His mother sat up straighter when she heard her son’s name called, and craned her neck from the back of the courtroom to get a look at him. On the inside of her forearm was a tattoo that read “I can’t unlove you.” Vice had spent the last few weeks in jail after he lost his temper and destroyed a television set. His mother said she pressed charges to keep him out of trouble. She worried he might get too out of control and hurt himself or someone else.

His mother said Hill Crest left her son much worse off than when he was admitted.