Universal Health Services: Profits Over Patients In October 2007, news stories appeared on the death of a 17-year-old boy at the hands of staff members in a Tennessee psychiatric facility. The death was ruled a homicide. A month later, another story appeared, exposing the circumstances surrounding the death of a 14-year-old who was violently restrained by a 260-lb. staff member in the same Tennessee facility. That same month, Fox News broke the story of the death of another 14-year-old in a Massachusetts psychiatric facility, from failure to receive proper medical attention. Investigation of these reports by the mental health watchdog Citizens Commission on Human Rights (CCHR) found that the facilities these children died in are owned by Universal Health Services (UHS). Further research turned up numerous abuses in their psychiatric hospitals across the United States. UHS is a for-profit hospital corporation based in Pennsylvania. “For profit” means that it is a business, intended to make money and keep company shareholders happy. A visit to the UHS website bears this out, as it presents the visitor with much data about UHS’ business concerns: Their corporate strategy, capital strengths, investor relations, stock quotes and profitability, to name a few. UHS’ mission statement says, “We will never lose sight of the fact that we provide care and comfort to people in need. The patients and families who rely upon us are fellow human beings, and they will receive respectful and dignified treatment from all of our people at all times.” However, the cruel and violent deaths of three children in UHS psychiatric facilities—as well as an extensive list of abuses and violations that follows—seems sufficient evidence that perhaps UHS is not as focused on patient welfare as they are on the bottom line. CCHR is not the only agency to notice these troubles at UHS. In December 2006, the Service Employees International Union issued the report “ Failure to Care, A National Report on Universal Health Service’s Behavioral Health Operations,” which declares, “This report finds that UHS has disregarded the safety and recovery of the patients it serves, as well as the communities in which it operates.” A preface from the National Alliance of Professional Psychology Providers, states, “There is a crisis in our nation's mental health care system…of placing earnings and exorbitant profits above the public interest at the expense of quality services to those in need. Using Universal Health Services (UHS) as an example, this report clearly documents why mega healthcare corporations such as UHS need to be held accountable….” There is nothing wrong with for-profit business ventures but not at the expense of human life, health or sanity. As has too often been the case in the field of mental health, the many UHS patients in this report were not regarded as “fellow human beings,” but apparently as objects—numbers with which to create income by billing school districts and insurance companies. As you will see in the following pages, Universal Health Services has demonstrated in their actions that they have little concern for the health and welfare of patients in their behavioral health facilities. One only need read about the similar practices of other for-profit psychiatric hospital corporations, such as National Medical Enterprises (NME) to know that such practices need to be investigated. (NME came under federal investigation in the late 1980s and was found guilty of actually planning and carrying out the defrauding and of abusing patients for their insurance benefits and ended up paying over $360 million to the U.S. Justice Department.) CHILDREN WHO DIED IN UNIVERSAL HEALTH SERVICES FACILITIES Omega Leach, 17, a troubled teen from Philadelphia, was placed at UHS’ Chad Youth Development Center in May 2007. He died just one month later, on June 3. The coroner found that Leach had multiple hemorrhages of his neck muscles after a struggle with two Chad staff members. Tennessee child-welfare officials said staff should have given Leach space to calm down on June 2 when he retreated to a dorm after a fight with another resident. Instead, he was ordered to leave the dorm, sparking the confrontation in which police said he was pushed face-down to the floor with his arms behind his back. His death was ruled a homicide by the Tennessee medical examiner. Monique Payne, 14, was a patient at UHS’ Westwood Lodge in Westwood Massachusetts in February 2006 when she complained of pressure in her head. She vomited, began hyperventilating and begged for help. It was due to her brain tumor—something the hospital knew about—but a nurse thought she was faking and merely gave her cold medicine. By morning she was dead. Linda Harris, 14, was a resident of UHS’ Chad Youth Enhancement Center for only four days when she died in September 2005. According to her medical records, Harris, whose developmental age was close to that of a six-year-old, had been raped by a 20-year-old who she’d struck up a relationship with over the Internet when she lived in New York. The perpetrator was never caught. According to a police report following her death, Harris had been “flashing” boys (exposing herself). A Chad counselor responded by pulling her arms behind her back and escorting her to a “time-out” room, where it was reported that she “became limp and fell on the floor.” After a few moments, they called 911 and started CPR. However, investigator’s reports made public in 2007 paint a different picture: The counselor, 260 lb. Charles Garner, was reported by another Chad resident to have been “body slamming” the asthmatic Harris. When other Chad staff arrived, Harris was unresponsive, her face was bloody and she had soiled herself. TIMELINE OF UNIVERSAL HEALTH SERVICES’ DEATHS, CRIMES, VIOLATIONS, ETC. October 22, 1991: Larry Ashley, former head administrator at UHS’ BridgeWay hospital in North Little Rock, Arkansas, was sentenced to life in prison without parole for the murder of his wife, whose body was found stuffed into the trunk of her 1988 Acura Legend. She’d been shot twice, once in the mouth. They had been married less than a year. 1 June 17, 1996: Psychiatrist Thomas Cassidy, who was affiliated with UHS’ Lincoln Trail Hospital (in Kentucky), pleaded guilty to three counts of fraud—one each against Medicaid, Medicare and CHAMPUS (now known as TriCare) and was sentenced to 12 months prison and two years probation. He also paid $80,645 in restitution. His guilty plea was in response to charges of using unqualified therapists; billing for sessions not performed and upcoding. 2 August 27, 1996: UHS’ Two Rivers Psychiatric Hospital (in Kansas City, Missouri) pleaded no contest in federal court to paying more than $40,000 in kickbacks to a psychologist for referring patients covered by federal health benefits. The hospital acknowledged receiving more than $63,159.36 in federal reimbursements—which they paid back in restitution. Craig Nuckles, currently UHS’ Regional Vice President for Behavioral Health, was CEO of Two Rivers at that time. He remarked, “This was just the most expeditious way to get this over with.” The hospital reported to federal authorities that the kickbacks had stopped (in other words, they did not deny they were doing it). 3 February 27, 1997: A former managing director of UHS’ Two Rivers Psychiatric Hospital) pleaded guilty to defrauding the federal CHAMPUS (now known as TriCare) health care program (for families of military and reserve personnel). 4 June 10, 1997: 18-year-old Sakena Dorsey died at UHS’ Foundations Behavioral Health Center in Bucks County, Pennsylvania while she was being restrained face down. No criminal charges were filed. Dorsey had a history of asthma and problems with swollen tonsils that hindered her breathing. 5 June 19, 1997: Settlement of Beal, et al v UHS of Delaware and UHS President & CEO Allan B. Miller. This was a federal lawsuit regarding collection of a debt. (Details of complaint not available.) 6 March 4, 1998: 16-year-old Tristan Sovern was restrained face-down on the floor with a towel in his mouth and died of asphyxiation at Charter Hospital in Greensboro, North Carolina. Joe C. Crabtree, UHS’ Divisional Vice President for Behavioral Health, was Vice President of Operations at Charter at that time. 7 July 2002: John Freeman, a mental health technician formerly employed at UHS’ Parkwood Behavioral Health System (in Mississippi), pleaded guilty to felony sexual battery and was sentenced to 20 years in prison. Freeman performed oral sex on a 13-year-old patient. 8 Fall 2002: Massachusetts state regulators forced UHS-owned Pembroke Hospital to stop admitting children for two weeks. A mother of a six-year-old girl had complained that her daughter had been mistreated. According to a local newspaper, a state investigation found that the hospital had kept the 6-year-old in the strictest restrictions for five days without justification. A letter written by the Commissioner of Mental Health in Massachusetts, Marylou Sudders, is quoted as saying, “current conditions present a serious risk to the health and safety of patients.” 9 October 2002: A four-months pregnant Hispanic woman (who spoke little English) was admitted to UHS’ Arbour Hospital after taking herself to Boston Medical Center following the onset of morning sickness. She was locked up at Arbour against her will and forced to take five different psychiatric drugs, despite her protests over the effects of the drugs on her unborn child. One of the drugs she was given caused her to collapse on the floor. All this drugging occurred in the absence of a court order and because of a language barrier. During her time at Arbour, a male patient attempted to rape her. Her baby was born with a heart condition while she was still being held at Arbour. Her husband contacted the Citizens Commission on Human Rights (CCHR) for assistance in investigating the abuses against his wife. He and two CCHR representatives visited his wife at Arbour. The next day, the woman was threatened by Arbour staff with being put in restraint and seclusion if she did not tell her psychiatrist who she had been visited by. They followed through with their threat and released her only after finding out she’d been visited by CCHR. Throughout this time, the husband attempted to have wife released only to be told by the psychiatrist that he would have him put in jail, that he (psychiatrist) “makes the rules” and “has the power.” 10 2002: At UHS-owned Coastal Harbor Treatment Center in Georgia, four adolescent patients were left unsupervised for two hours and inappropriate sexual behavior occurred between the patients. A physical examination of the patients indicated that the sexual behavior was not consensual for at least one of the patients involved. 11 2002: UHS’ Westwood Lodge in Massachusetts was investigated for allegations that two employees sexually abused a 15-year-old female patient. UHS administrators did not believe the allegations made by the patient and did not report the allegations to officials or limit contact between the patient and the employees. The hospital kept the employees on staff and in contact with the patient for two months, even though the patient had talked about the abuse to multiple people, her family had reported their suspicions to the facility twice and the hospital had confirmed that the patient had the employees’ private cell phone numbers. UHS officials also knew that the patient had written about the abuse in a diary and had said that the employees had promised to help the patient escape the facility in return for sexual favors. The patient did escape the hospital on one occasion, and was returned to the facility by police. UHS eventually transferred the two mental health aides to a male unit in order to “minimize” the contact between the employees and the patient, but the employees were allowed to monitor the patient on two occasions after she had attempted suicide. Westwood Lodge administrators still did not report the allegations to state officials, who were not informed until a doctor from a different hospital reported the allegations after treating the teenager for sexual abuse. 12 2002: UHS-owned Laurel Heights Hospital in Georgia did not document whether it had investigated allegations by an adolescent patient who claimed to have been physically abused and raped; the child’s treatment plan did not explain why the patient was regularly put into the seclusion room; a staff member caused another child resident to break his/her arm by the utilization of an improper behavioral management technique and a different staff member did not follow proper procedures while administering an enema to the child resident. 13 March 10, 2003: Settlement of Andrews v New Perspectives, et al. In this case, a man who had injected himself with heroin went to the hospital due to feeling ill and having redness and swelling at the injection site on his left arm. He was given antibiotics and transferred to New Perspectives, a drug-alcohol rehab facility connected with Roxbury Treatment Center, which is owned by UHS. Despite the patient’s ill condition and repeated complaints about his infected arm, New Perspectives did not care for his medical concerns until three days later, when he was admitted to another medical hospital, where he had to have extensive surgical removal of tissue from his left arm due to gangrene. 14 July 2003: Seventeen year old Julie Woodward of New Wales, Pennsylvania began attending a two-week group therapy program at UHS’ Horsham Clinic due to a break-up with a boyfriend and conflicts with her parents. One condition of the program was that she take antidepressants. Just over a week into the program and while taking Zoloft, Julie hanged herself in her family’s garage. 15 August 10, 2003: 12-year-old Ronald Hamilton committed suicide by wrapping a bedsheet around his neck and attaching it to the door of his room at UHS’ The Pavillion, in Champaign, Illinois. Ronald had become upset upon hearing that he was to be transferred to another foster home the following day. Though Pavillion staff were supposed to check on him every 15 to 30 minutes, they failed to prevent his suicide. Ronald had no history of mental illness but it was noted that his spirits rapidly deteriorated upon being removed from his home (due to domestic violence). 16 December 2003: CCHR International received a report from a 16-year-old girl from Southern California who had been a resident of UHS’ Provo Canyon School in December 2003 which she describes being “kicked, restrained in several take-downs, my back was injured, I was drugged against my refusal by force, I was denied medical care for an overdose of Haldol (which was given by forced injection…)” She described “being held down so hard” by six Provo Canyon staff members while being injected with five milligrams of Haldol “that I nearly died of asphyxiation.” She states that Provo Canyon did not have parental consent for any type of restraint on her—chemical or physical. 17 In 2003, a charge nurse from UHS-owned Pembroke Hospital in Massachusetts wrote a letter to hospital administrator regarding an incident involving teenage patients that occurred one week after state regulators lifted a freeze on the admission of children. The incident is described in the letter as, “(one patient) started punching and kicking herself violently in the face…(another) was curled on the floor rocking, crying and scratching her wrists saying that she needed to see blood to make herself feel better.” The charge nurse reports in her letter that only one worker was available to watch both of these teenagers because another worker was caring for a third out of control patient. The boys’ unit was also out of control, with patients throwing furniture and breaking overhead light fixtures. No therapy groups were held that weekend, there were no outside trips, and the children were not even able to go to the cafeteria. The nurse wrote in the letter to hospital administrators, “Those children did not receive one bit of psychological therapy all weekend…. all because we did not have the appropriate staff and things were too out of control.” The licensing survey that resulted from the investigation done by the Massachusetts Department of Mental Health is reported to say, “Senior staff confirmed the belief that decisions are driven by finances with little consideration given to the impact of systematic quality of patient care.” 18 2003: At UHS-owned Glen Oaks Hospital in Texas, short staffing resulted in the facility’s failure to prevent two adolescent patients from having a sexual encounter in the male adolescent’s room. 19 2003: In 2003 at UHS-owned Laurel Heights Hospital in Georgia, an outbreak of patient illness had occurred in a children’s unit of the hospital. A statement from a nurse stated that the residents on that unit had been sick, but there was no documentation that indicated that Medical Director had been informed of the outbreak of an apparent respiratory illness. One resident had been feverish for several days and on bed rest. On the morning of 4/6/2003 the child was unresponsive with blue lips and labored breathing. The patient’s condition was observed by nursing staff at 8:25am, but the patient was not brought to the emergency room until 10:10am. There was no evidence that the patient’s condition was assessed before being brought to the emergency room or that the patient was assessed and monitored while being transferred. When the child arrived at the emergency room, s/he was in an altered mental status, did not have a gag reflex and his/her skin was cool and pale. The resident was diagnosed with pneumonia upon his/her admission to the emergency room. The investigation conducted by the State of Georgia also found that the facility had not done a clinical review of the incident to ensure that patients would not be placed in that kind of danger again. 20 2003: At UHS-owned Peachford Behavioral Health System in Georgia, a patient was suffering from bedsores and the state inspector found no documented plan of treating them or any documented evidence that treatment had been provided. 21 2003: In 2003 at the UHS-owned McAllen Medical Center in Texas, a patient was kept in soft restraints for 35 hours without a doctor order. A doctor then ordered that s/he be kept in restraints for an additional 24 hours without first assessing the patient face-to-face to determine that restraints were still necessary. 22 2004: Barry Bergmann, a former mental health counselor at UHS’ Spring Mountain Treatment Center in Las Vegas, Nevada, was convicted of statutory sexual seduction involving a teenage girl who was a patient at the center. Bergmann was sentenced to 24-to-60 months prison. During testimony at Bergmann’s sentencing hearing, she blamed four previous suicide attempts on Bergmann’s sexual abuses. The girl hanged herself while on suicide watch in a county juvenile detention center in April 2005. 23 February 21, 2004: 16-year-old Kaitlyn Kennedy hanged herself in the garage of her family’s home in Medway, Massachusetts. She had spent six days at UHS’ Westwood Lodge after cutting herself with a paperclip and drawing blood. Upon entering the facility, she admitted to having suicidal ideations of hanging herself or killing herself with a razor. Her parents later discovered that her Westwood medical records had repeated notations of her plans to hang herself. She had been hospitalized in a different facility in January 2004, where her prescriptions of Zoloft (antidepressant) and Seroquel (antipsychotic) were increased. Her Westwood medical record of February 11 (one week after the increase), that she reported, “increase in emotional lability, irritability and anxiety." 24 May 24, 2004: The Georgia Supreme Court ruled that Universal Health Services was not liable for the rape of a patient under a negligent hiring/retention lawsuit. Christine Munroe sued UHS for the rape she suffered while a patient at UHS’ Anchor Hospital. Nowhere in the ruling does UHS deny that mental health assistant Shawn Love raped Munroe—only that UHS did not breach its duty to exercise ordinary care to avoid hiring an employee who posed a reasonably foreseeable risk of inflicting personal harm on others. 25 June 2004: A 54-year-old patient at UHS’ Pembroke Hospital in Massachusetts died of cardiac arrest. The state’s Department of Mental Health conducted an investigation that revealed that a Pembroke aide delayed performing emergency resuscitation, that vital medical equipment was missing and that the hospital’s paging system was not audible in the physician’s room so the doctor on-call did not respond immediately. 26 July 30, 2004: Mark Houck, a former mental health counselor with UHS’ Hampton Behavioral Health Center, was sentenced to four years in prison for sexually assaulting a 17-year-old female patient. 27 July 2004: An inspection done by state regulators in Georgia found that the conditions at UHS’ Peachford Behavioral Health System placed patients in immediate jeopardy. A patient had been admitted to the hospital with a severe headache and an opiate dependence. An RN reported to state investigators that on the night in question, there was one nurse and one mental health assistant caring for 17 acutely ill people. The patient was found dead the following morning from an overdose of methadone, which the patient had smuggled into the hospital. The state of Georgia found there was not enough staff to carry out the doctor’s orders. 28 July 2004: UHS-owned Glen Oaks Hospital in Texas was issued a 90-day termination notice from the Centers for Medicare and Medicaid when an unstable suicidal person was transferred to a different facility without being evaluated or stabilized, and without notifying the receiving facility or sending the patient’s records. 29 October 27, 2004: The Alaska State Medical Board revoked psychiatrist Michael Bernzott’s license. Bernzott engaged in unprofessional conduct by bringing a concealed handgun to a 1995 treatment meeting with a patient and staff at UHS’ North Star Hospital. He informed the patient that the weapon was loaded and allowed the patient to point the gun at staff members in the meeting before giving it back to Bernzott. 30 October 29, 2004: Parents filed a lawsuit against UHS’ Boulder Creek Academy (in Bonner’s Ferry, Idaho) claiming their child was neglected and abused. Among the allegations in the suit: In the late 1990s, a 16-year-old boy was forced to dig a grave, crawl into a coffin in the grave and have dirt thrown on it by staff members and a 16-year-old girl was called a “whore” and forced by staff members to wear a sign advertising oral sex. 31 November 2004: An Arkansas man, Joseph Rayner, was allowed to wander away from UHS’ BridgeWay in broad daylight and jump into oncoming traffic from a freeway overpass, where he was hit by an 18-wheeler and killed. 32 2004: At the UHS-owned Rockford Center in Delaware, state regulators found that the hospital failed to establish a system that would protect patients from abuse and that hospital staff used a “non-therapeutic unapproved escort method,” after a child complained that he/she had been “thrown to the floor” and forced to the seclusion room by an employee. The child had a fresh blood injury on the right side of his/her face and bruises around his/her eye. During the investigation, the state also found that the Rockford Center’s policy on financial exploitation and mistreatment did not conform to state law and the facility’s definition of abuse and neglect were too broad and lacked specificity. 33 2004: UHS-owned Anchor Hospital in Georgia, a patient died four days after being admitted after not receiving the proper treatment because his/her medical condition was not properly monitored. Doctor orders indicated that the patient was to have his/her blood pressure monitored and be given a potassium supplement medication to treat his/her Parkinson’s disease and hypertension. The patient made one trip to the emergency room because of an altered mental state and low potassium. S/he was sent back to the hospital with instructions that her potassium levels and blood pressure needed to be closely watched. The patient’s blood pressure was very low, but there was no documentation on the patient’s chart that the nurse or physician were notified or that a reassessment of treatment was done. The person became incontinent and was drooling excessively and drowsy in a wheelchair, but no reassessment of the patient’s condition was performed. The investigation done by the State of Georgia found critical patient care information missing from this patient’s medical records, as well as from the medical records of other patients who had been transferred from Anchor Hospital to the emergency room. 34 2004: In the Psychiatric Center at UHS-owned McAllen Heart Hospital in Texas, a patient died three days after falling at the facility. An investigation found that, although the doctor had noted in the patient’s record that the person seemed “confused,” and a nurse noted that a new medication made the person “drowsy,” no assessment for fall precautions had been done for the patient, and no fall precautions were in place to protect the patient. 35 2004: A 14-year-old was admitted to UHS-owned Spring Mountain Treatment Center in Nevada. The child was put in seclusion, during which she defecated on the floor of the seclusion room. The child resident told the state investigators that she had repeatedly requested to be taken to the bathroom, but her requests had been ignored by staff. The investigators found no evidence the child was continuously monitored while she was in seclusion and the facility was cited for failing to provide adequate documentation to establish that treatment interventions were safe, proportionate and appropriate to the severity of the child’s behavior. In a separate incident, a 15-year-old female patient was restrained by five members of staff and forcibly administered Thorazine. There was no documentation that the parent’s of the resident were notified or that the staff or the patient were debriefed. 36 March 24, 2005: Haverhilll, Massachusetts parent Charles Sarao said his son, Joshua, was injured twice at UHS’ Westwood Lodge during restraints. 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 punched in the face during the second restraint. 37 July 27, 2005: Daniel Jeudin and Andre Currie, former counselors with UHS’ Westwood Lodge pleaded guilty to statutory rape, admitting they had sex with a 15-patient at the facility in the summer of 2001. Jeudin was sentenced to 2½ years, with one year to be spent in jail and the other 18 months suspended; Currie was sentenced to ten years probation. Both were required to register as sex offenders. 38 September 18, 2005: 14-year-old Linda Harris died at UHS’ Chad Youth Enhancement Center in rural Tennessee. Chad officials said that Harris, who was being escorted to a “time-out” room, “became limp and fell to the floor,” where Chad staffers then sat down next to her and held her arms behind her back as she lay on her stomach. A few minutes later they noticed that her breathing had slowed so called 911 and began CPR. However, paramedics arriving to resuscitate Harris found her with scraped elbows, blood in her mouth and in physical restraints. Sheriff’s investigator’s files, which contain the statements of other staffers as well as children who witnessed the restraint tell otherwise: In forcing Harris to spend the night in the time-out room, 260-lb. Chad staffer Charles Garner was “body slamming” the morbidly obese and asthmatic Harris on a mattress. She had been in the facility only four days. 39 September 2005: Tennessee’s Department of Children Services ceases placing children at UHS’ Chad Youth Enhancement Center following the death of Linda Harris. 40 September 2005: Investigators recommended that a 90-day termination process begin on UHS-owned McAllen Medical Center and Heart Hospital in Texas because a patient’s rights were violated when s/he did not receive the care s/he required. A patient was under doctor orders to be closely supervised, which means that the person needed to be checked every 15 minutes. These orders were not consistently carried out, and the person hanged him/herself. 41 October 28, 2005: Jose Miguel Yambo III, a former employee of UHS’ Chad Youth Enhancement Center in rural Tennessee, was charged with multiple rapes involving a minor female. He was suspended from his position at Chad on October 17, after the Department of Children’s Services notified the facility of their investigation. Yambo admitted to investigators he “finds young female juveniles attractive” but said the victim in question (who was not a Chad patient) the only one he “acted upon,” according to a document in his court file. 42 December 2005: Texas attorney Skip Simpson, who specializes in psychiatric suicide complaints, filed a suit on behalf of Alysia Ashley against UHS’ BridgeWay psychiatric facility in North Little Rock, Arkansas. Ashley was involuntarily admitted in late 2004 after a suicide attempt. She was given an admittance interview but was allowed to wander off afterward, at which time she took an overdose of her drugs and jumped from a freeway overpass. She survived but was severely injured. 43 2005: At UHS-owned McAllen Medical Center and Heart Hospital in Texas was cited for keeping a patient in restraints for two days without a doctor’s order. 44 March 2006: An 18-year-old patient committed suicide at UHS’ Westwood Lodge. He went to Westwood after slashing his wrists. Westwood personnel screened him and then put him in a room outfitted with a wall-mounted air register which the patient used to hang himself. 45 February 2006: 14-year-old Monique Payne died at UHS’ Westwood Lodge facility in Massachusetts. Payne, who had a brain tumor (which the hospital was aware of) began complaining of pressure in her head. She began vomiting and hyperventilating and begged for help. A Westwood nurse thought she was faking and gave her cold medicine. She was dead the next morning. 46 April 12, 2006: UHS Delaware, a subsidiary of Universal Health Services, agreed to reimburse Medicare almost $1.5 million to settle a civil probe involving overcharges at Turning Point Care Center, a Moultrie, GA substance abuse treatment center. The settlement was for non-reimbursable costs such as patient transportation, self-administered drugs and room and board for patients in a partial-hospitalization program run by Turning Point. 47 June 2006: At the UHS-owned Rockford Center in Delaware, a geriatric patient was unnecessarily placed in a mechanical restraints without a physician order and without documentation that less restrictive interventions were first tried. The patient developed bed sores while s/he was at the Rockford Center. Seven days passed from the date the bed sores were diagnosed before any care was provided for the bedsores and recorded in the nursing plan. There was no record of the patient’s progress or response to treatment of her bedsores. 48 July 13, 2006: The Connecticut Department of Children (DCF) and Families shut off admissions to UHS’ Stonington Institute over concerns about children’s safety and supervision. A spokesman for DCF stated that the agency closed admissions after receiving reports of a high number of children running away from the facility. 49 September 2006: An analysis of Boston Police Department incident reports found that between January 1, 2000 and September 17, 2006, police were dispatched to UHS’ Arbour Hospital 192 times for incidents including 16 missing persons reported; 28 assault and batteries; 5 forcible rapes; 2 suicide attempts and 2 sudden deaths. 50 November 22, 2006: A 15-year-old patient at the UHS’ Meadows Psychiatric Center committed suicide. Police said the teen hanged himself in a bathroom. 51 2006: At UHS-owned Rockford Center in Delaware, a patient was admitted with open wounds, but the care for those wounds was not included on the initial care plan for the patient. The plan was not updated for six days. As a result, the patient did not receive care for his/her wounds, including medication that was prescribed by a doctor during those six days. 52 2006: At UHS-owned Rockford Center in Delaware, a patient was diagnosed with bedsores and 7 days passed from the date of diagnosis without any record of care of the bedsores in the nursing plan. There was no record of the patient’s progress or response to treatment of his/her bedsores. 53 2007: The Service Employees International Union, Local 1107 (Las Vegas, NV) issued an undated report, “Failure to Care: A National Report on Universal Health Services’ Behavioral Health Operations” which calls attention to the various adverse manifestations of UHS’ “profits before patients” business model, including sexual exploitation and abuse, runaways, inappropriate reliance on restraints and seclusion and physical assaults. 54 January 16, 2007: Filing of Crawford v. Charter Pines Behavioral Health, a personal injury Medical Malpractice suit file for wrongful death. Universal Health Services and three of its subsidiaries are also named as defendants. Case is still active as of May 2008. 55 March-April 2007: Paul Zani, chief executive officer of UHS’ Pembroke Hospital resigned in early April as the hospital agreed to cap its admissions amid several state investigations into the private psychiatric facility. Unannounced visits by the Department of Mental Health on March 27 and 29 prompted concerns about the adequacy of staff supervision, finding that staff training was insufficient and that the hospital has the staffing capacity for only 70 percent of its beds. The Department of Social Services also conducted three investigations based on reports of neglect or abuse filed in late January and early February concerning alleged episodes in the girls' adolescent unit. 56 May 21, 2007: Settlement of Satterthwaite v USA, Universal Health Services, et al, a case brought by the widow of Dennis Satterthwaite, alleging negligence and other failures on the part of a nurse and psychiatrist at Massachusetts’ Westwood Lodge psychiatric facility (owned by UHS) resulting in Dennis Satterthwaite’s death. 57 June 2, 2007: 17-year-old Omega Leach died at UHS’ Chad Youth Enhancement center in rural Tennessee. State medical examiner Bruce P. Levy found Leach died of strangulation after being restrained, citing “multiple hemorrhages” of his neck muscles. His death was ruled a homicide. 58 June 18, 2007: Verdict of $1,075,218.45 for plaintiff in the case of U.S. Department of Labor v. Universal Health Services. This suit was filed against UHS’ Stonington Institute, a Connecticut drug/alcohol treatment facility that the Department of Labor charged with working employees in excess of 40 hours per week but failing to pay them minimum wage or time-and-a-half for their overtime, in violation of the Fair Labor Standards Act. 59 June 19, 2007: The Tennessee Department of Mental Health placed UHS’ Chad Youth Enhancement Center on a 120-day admissions freeze, following June 2 death of Omega Leach. 60 July 17, 2007: Just prior to jury selection, UHS’ BridgeWay Hospital paid a last-minute settlement to avoid trial on Alysia Ashley’s claims that the facility failed to prevent her from leaving the facility and attempting suicide by jumping off a nearby bridge. While the amount of the settlement is confidential and the hospital made no admission of negligence, plaintiff’s attorney Skip Simpson stated, “They might not be admitting liability, but they all admitted this should not have happened. Rogers (Paul Rogers, defendant hospital employee) said he was wrong and he didn’t blame Ms. Ashley.” 61 July 22, 2007: Amerigroup, a Tennessee state HMO plan, removed all five of the children it was covering for treatment at UHS’ Chad Youth Enhancement Center in rural Tennessee, following the strangulation homicide of 17-year-old Omega Leach at the hands of Chad employees. 62 August 5, 2007: A Philadelphia, Pennsylvania family court judge ordered six Philadelphia children discharged from UHS’ Chad Youth Enhancement Center in rural Tennessee (the teens were sent there as no Philadelphia facility would admit them) following the June 2007 strangulation homicide of 17-year-old Philadelphian Omega Leach by Chad employees. 63 October 2007: Texas attorney Skip Simpson, who specializes in psychiatric suicide complaints, filed a suit on behalf of Anne Millar against UHS’ BridgeWay psychiatric facility in North Littlerock, Arkansas. Millar’s husband John was admitted to the facility after admitting to his wife of being suicidal, stating that he was going to “blow his head off.” BridgeWay released him 24 hours later and, while under home suicide watch, he managed to get out of the house and shoot himself in the head. 64 October 25, 2007: A Massachusetts jury awarded $1,848,000 to the estate of Rose Okoro on the determination that UHS’ Arbour Hospital and Arbour psychiatrist Donna Orvin were responsible for failing to prevent her suicide. 40-year-old Okoro, who was admitted September 16, 1998 to Arbour with psychosis and suicidal tendencies, hanged herself from an exposed shower sprinkler the following day. The plaintiff’s claimed that by not ordering 15-minute suicide checks on Okoro, Arbour & Orvin thus failed to prevent her suicide. 65 January 17, 2008: Attorney Skip Simpson filed the civil complaint McCoy v. Universal Health Service, The Bridgeway Inc., et al. for professional negligence, negligent hiring and retention and other causes. The suit, filed in Pulaski County, Arkansas states that UHS, Bridgeway (a UHS-owned psychiatric facility) and/or the physician that referred the plaintiff to Bridgeway for outpatient substance abuse treatment, should have been aware that the drug counselor assigned to the plaintiff had a violent criminal background, including prison time; that he gained his counseling “skills” while imprisoned for aggravated robbery and that his past criminal conduct would subject the plaintiff to unreasonable risk of harm. It further alleges that the counselor, exploiting the plaintiff’s expressed vulnerabilities, engaged the plaintiff in sexual relations in the course of his employment at Bridgeway.66 October 25, 2010: UHS' 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 Keys resident who was stabbed in the eye with a nail by another resident. The attacked 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 additional (but unfortunately, not uncommon in the psychiatric hospital world) problems including training deficiencies, use of improper restraint techniques and other incidents of violence.67 On April 25, 2011, the Virginia Department of Behavioral Health and Developmental Services (DBHDS) placed all three of UHS’ The Pines Children’s Residential Facilities on provisional licenses for six months. Provisional licenses are issued to health care facilities when corrective measures have been ordered. Failure to make the necessary corrections could result in the state revoking The Pines’ licenses. The state also froze all admissions to the facilities until such time as the facilities can provide evidence of sufficient improvement of a number of safety and treatment issues. This action occurred after state investigators determined that The Pines filed to report and document an allegation of sexual abuse at one of its facilities.68 On May 11, 2011, the North Carolina Department of Health and Human Services Division of Health Service Regulation issued a Statement of Deficiencies and Plan of Correction to UHS’ Old Vineyard Youth Services after state investigators found evidence of approximately 15 instances of improper sexual contact between two male residents (ages 14 and 17) of the facility and accompanying staff failure to properly monitor and detect the abuse.68 Police were called to UHS’ Palmetto Behavioral Health facility in Summerville, South Carolina 128 times since February 2006, including 19 calls for missing persons and runaways, 42 reports of assaults and three reports of sexual assaults. In one incident, a 15-year-old resident was accused of attacking and beating a 64-year-old woman after he slipped away from the facility. She has filed a lawsuit against the facility, accusing it of gross negligence and recklessness.69 Police were called to UHS’ Palmetto Behavioral Health facility in North Charleston, South Carolina 98 times in the last five years, including 13 runaways and missing persons calls, 22 assault calls and six reports of sexual assault.70 - - - - - CALLS FOR SERVICE “Calls for service” is a term for when the police/sheriff are called to a particular address or location to respond to a complaint. The following is a random sample of calls to UHS facilities in recent years. Between January 1, 2003 and January 12, 2008, the San Diego County Sheriff’s Department received 424 calls for service from UHS’ Broad Horizons facility in Ramona, California. Among the reasons for the calls was 27 batteries, 7 assaults, 10 suicides (actual or attempted) and 181 runaway juveniles. From January 1, 2003 to January 18, 2008, the Anchorage Police Department received 230 calls for service from UHS’ North Star Residential Treatment Center. Among the reasons for the calls was 29 assaults, 12 sexual assaults (include two involving minors), 25 runaway juveniles and 4 suicide attempt/threats. Between Mary 26, 2005 and January 14, 2008 the Sherman Police Department (Texas) received 272 calls for service from UHS’ Texoma Behavioral Health Center. Among them is one death. From January 3, 2000 to December 28, 2006 the Casper Police Department received 622 calls for service from UHS’ Wyoming Behavioral Institute, including 115 assaults, 6 suicide-related calls, 8 sex offenses and 17 runaway juveniles. From January 2001 to January 2008, the Provo Police Department (Utah) received 143 calls for service from the UHS’ Provo Canyon School, including 4 child abuses, 35 runaway juveniles, 15 assaults, 2 forcible sexual abuses, 1 forcible sodomy and 1 sexual abuse of a child. From October 2000 to December 18, 2007, the South Salt Lake Police Department received 77 calls for service from UHS’ Cottonwood Treatment Center, including 19 assaults and 6 sex offenses. Between 2003 and 2007, the Aiken (South Carolina) Police received 174 calls for service from UHS’ Aurora Pavillion Behavioral Health Services, including 11 missing persons/runaway juveniles, 5 suicide attempts and 28 “disturbances.” From October 29, 2005 to December 6, 2007 the North Little Rock (Arkansas) Police received 138 calls for service, including 4 rapes/sexual assaults, 4 assault/batteries, 8 runaway/missing persons and 15 “disturbance/altercations.” 1 “A bad business,” Arkansas Business, 6 May 1991and “A 30-second glance at state and local news,” The Atlanta Journal & Constitution, 23 Oct. 1991. 2 NAAG Medicaid Fraud Report, July/August 1996 3 “Hospital pleads no contest in kickback case,” Kansas City Star, 28 Aug. 1996. 4 “Health Care Fraud Report,” U.S. Department of Justice, Fiscal Year 1997. 5 “Deadly Restraint,” The Hartford Courant, 11 Oct. 1998. 6 Beal, et al v UHS of Delaware Inc., et al, case #2:97-cv-00798-MLS, U.S. District Court for the Eastern District of Louisiana. 7 “State demands shake-up at center,” News & Record, 6 June 1998. 8 “Patient abuse: Mississippi,” NAAG Medicaid Fraud Report, July 2002 9 Reinert, Sue, “Hospital ordered to stop taking in children; Suspension ended last year, but state again investigating,” The Patriot Ledger, 15, Apr. 2003. 10 Affidavit and accompanying documentation of Francisco Lopez, 13 Feb. 2003, on file with CCHR New England. 11 Quattlebaum, Peggy, Complaint Investigation Memorandum, Complaint #205550, State of Georgia, Coastal Harbor Treatment Center, July 7, 2002.* 12 Reinert, Sue, “Sex abuse at hospital suspected,” The Patriot Ledger, 6 Mar. 2002. 13 Statement of Deficiencies and Plan of Correction, State of Georgia, Laurel Heights Hospital, June 20, 2002 and Howell, Scott. Complaint Investigation Memorandum, Complaint #206014, State of Georgia, Laurel Heights Hospital, June 21, 2002.* 14 Andrews v New Perspectives, case 1:01-cv-00640-JAS, U.S. District Court for the Middle District of Pennsylvania. 15 Waters, Rob, “A Suicide Side Effect? What parents aren't being told about their kids' antidepressants, San Francisco Chronicle, 4 Jan. 2004. 16 “Jury: Boy’s death in hospital a suicide,” The Pantagraph, 17 Oct. 2003 and “DCFS investigating 12-yer-old’s suicide,” Associated Press, 22 Aug. 2003. 17 Psychiatric abuse report of Angelyn Taylor (pending approval), received via e-mail 26 Dec. 2004. 18 Op cit., Reinert, Sue, The Patriot Ledger, 15 Apr. 2003. 19 Statement of Deficiencies and Plan of Correction, State of Texas, Glen Oaks Hospital, February 7, 2003.* 20 Quattlebaum, Peggy, Complaint Investigation Memorandum, Complaint #GA00003940, State of Georgia, Laurel Heights Hospital, April 16, 2003 and Statement of Deficiencies and Plan of Correction, State of Georgia, Laurel Heights Hospital, April 10, 2003 2004.* 21 Statement of Deficiencies and Plan of Correction, State of Georgia, Peachford Behavioral Health System, January 8, 2003.* 22 Statement of Deficiencies and Plan of Correction, State of Texas, McAllen Medical Center, March 19, 2003.* 23 “Lawyer calls girl’s suicide in detention inconceivable,” Las Vegas Review-Journal, 16 Apr. 2005 and “Psychiatric worker faces assault charges,” Las Vegas Review-Journal, 4 Nov. 2003. 24 “Behind Kaitlyn’s suicide,” The Boston Globe, 27 June 2004. 25 “Hospital is not liable for rape of patient by employee.: Munroe v. Universal Health Servs. Inc., S04A0470 (GA May 24, 2004) – Dex 85316, 11 pp.,” Hospital Litigation Reporter, Aug. 2004. 26 “Massachusetts DMH investigates Pembroke Hospital death,” nePsy.com (website of New England Psychologist), February 2005. 27 “Ex-mental health worker gets 4 years in sex assault,” Courier-Post, 31 July 2004. 28 Statement of Deficiencies and Plan of Correction, Department of Health and Human Services, Center for Medicare & Medicaid. State of Georgia, Peachford Behavioral Health System, July 12, 2004 and Statement of Deficiencies and Plan of Correction, Georgia Department of Human Resources, Office of Regulatory Services for Peachford Behavioral Health System, July 28,2004.* 29 Statement of Deficiencies and Plan of Correction, State of Texas, Glen Oaks Hospital, August 23,2004* 30 “Psychiatrist's medical license is revoked for unprofessional conduct,” Anchorage Daily News, October 27, 2004. 31 “Academy for troubled teens accused of abuse,” Associated Press, 29 Oct. 2004. 32 “Bridgeway faces another lawsuit involving suicide,” Arkansas Business, 8 Oct. 2007. 33 Statement of Deficiencies and Plan of Correction, State of Delaware, Rockford Center, June 4, 2004.* 34 Op cit., Quattlebaum, Peggy, July 7, 2002. 35 Statement of Deficiencies and Plan of Correction, State of Texas, McAllen Heart Hospital, January 30, 2004 2006.* 36 Statement of Deficiencies and Plan of Correction, State of Nevada, Spring Mountain Treatment Center, September 15, 2004.* 37 “Kinder, gentler Mass. Psych wards,” The Boston Herald, 24 Mar. 2005. 38 “Former counselors guilty in rape of mental patient,” The Boston Globe, 28 July 2005. 39 “A new account of death surfaces…,” Newsday, 24 Sep. 2005 and Elizabeth Ulrich, “More details on Chad Youth death,” Tennessee Scene newspaper’s weblog, “Pith in the Wind,” 12 Nov. 2007. 40 “One TennCare HMO pulls kids from Chad,” The Leaf-Chronicle, 22 July 2007. 41 Statement of Deficiencies and Plan of Correction. State of Texas. McAllen Medical Center and Heart Hospital, September 14, 2005.* 42 “Youth worker charged with rape,” The Leaf-Chronicle, 25 May 2006 43 Op cit., Arkansas Business, 8 Oct. 2007 44 Statement of Deficiencies and Plan of Correction, Department of Health and Human Services and Center for Medicare & Medicaid. State of Texas, McAllen Medical Center Heart Hospital, August 2, 2005.* 45 “Why is this hospital still open?”, special report of WFXT-TV (Boston, MA), 6 Nov. 2007. 46 Ibid. 47 “Drug treatment firm settles probe for $1.5 million,” The Philadelphia Enquirer, 12 Apr. 2006. 48 Statement of Deficiencies and Plan of Correction, State of Delaware, Rockford Center, June 23, 2006.* 49 “State halts treatment center admissions; concerns for safety of children prompts move,” Hartford Courant, 2 Aug. 2006. 50 Boston Police Incident Report for Reporting Area 639, 2 Jan 2000 to 17 Sept. 2006. 51 “Teen kills himself at psychiatric center,” Centre Daily Times, 24 Nov. 2006. 52 Statement of Deficiencies and Plan of Correction, State of Delaware, Rockford Center, January 11, 2006.* 53 Op cit., State of Delaware, June 23, 2006.* 54 “Failure to Care: A National Report on Universal Health Services’ Behavioral Health Operations,” The Service Employees International Union, Local 1107 (Las Vegas, NV) issued in 2007. 55 Crawford v Charter Pines, case #7:07-cv-00140-GRA, U.S. District Court for the District of South Carolina. 56 “Pembroke

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