DCF reviews deaths at GEO-run state hospital

MIAMI (AP) — Three gruesome deaths at the privately run South Florida State Hospital triggered an investigation that revealed concerns that employees were overmedicating patients and failed to call the state abuse hotline after a patient died in a scalding bathtub, according to documents obtained by The Associated Press.

State officials requested a review of the facility "in response to significant events in past several months," including the deaths. The state also reviewed cases of individuals who had been placed into solitary confinement and restraints multiple times and other incidents at the facility, but the report offered few details of those incidents.

The 335-bed facility, located in Broward County, is operated by The GEO Group Inc., a Boca Raton-based firm that is one of the world's largest private operators of prisons and detention centers. Many of the patients are mentally ill and admitted against their will because they are considered a threat to themselves or others. Some are admitted because they are not competent to stand trial, but don't need to be in a high-security facility.

GEO said in a statement Wednesday that the deaths are not a reflection of its "high quality operation" and noted that patients' health outcomes and the average length of stay have improved since it took over the facility. The state has paid the company more than $500 million to run the hospital since 1998. It was one of the first state civil psychiatric hospitals in the U.S. to be fully operated by a private company.

GEO runs three other facilities in Florida: the Florida Civil Commitment Center in Arcadia, which treats sex offenders; and mental health facilities in Indiantown and Florida City for patients who aren't competent to stand trial or have been found not guilty by reason of insanity.

Department of Children and Families Secretary David Wilkins said his agency is renegotiating GEO's contract. Its facilities will be required to have a DCF investigator on site — a practice already used in the state-run facilities.

Wilkins said GEO has complied with a corrective action plan and praised the facility, which has a more therapeutic environment compared to other state-run facilities, which he said are cold and institutional.

The deaths happened within a two-month period.

— In August 2011, Loida Espina died after her head was perhaps slammed through a wall.

A staffer found her and laid her down. The staffer later returned and found her unresponsive. The report is unclear whether someone actually put Espina's head through a wall and it doesn't say whether the allegation was about a staffer or another patient. GEO declined to give details.

The report offered no other details on her death.

State officials said Espina's death demonstrated the hospital staff's lack of empathy and understanding of their patents' vulnerable mental state.

Espina had a history of falling, believing her spills were an attempt to get attention.

"Staff were used to her falling, and state, 'Oh, she's fallen again,'" according to the review. The employees didn't try to determine what happened before she fell, according to the report.

— In June 2011, Luis Santana, who was highly medicated, was found dead in a scalding bath with skin "sloughing" off his face after staff failed to check on him every 15 minutes as required, according to a November review by DCF. The hospital did not report his death to the state hotline and state officials worried in a report they were trying to cover up staff's poor oversight.

The medical examiner expressed concern that Santana was over medicated, noting he was on six powerful psychiatric medications and about five other medications for cardiac problems when he died. Santana, who had a long history of mental illness, was "pacing, restless, repeatedly flushing the toilet" and staff believed he was having a psychotic episode, according to the state's review. It's unclear how many hours later Santana was given a bath.

Officials randomly checked the water temperature several times last October and found temperatures all exceeded the 120-degree limit, with temperatures jumping as high as 126 degrees, according to the review. Exposure to temperatures of more than 120 degrees for more than five minutes can cause third-degree burns, the report noted. Officials said the hospitals policy for monitoring temperatures "is problematic" and suggested installing a control that will regulate temperatures.

State officials also toured the facility and met with hospital staff to express grave concern that the hospital was not reporting deaths and may have covered up Santana's death.

After Santana's death, hospital employees did not acknowledge "the possibility that a thirty minute gap in observation of the person served in the bathtub might have contributed to his death," according to the report.

An analysis of Santana's death lacked detail and "further drill downs might have helped facility identify and address any concerns about neglect."

Hospital leaders didn't seem to understand the requirements for reporting deaths that were unexpected but that the hospital staff believed were natural. State officials also noted "there seems to be some confusion as to who can report and under what circumstances," according to the review.

— Also in June 2011, a patient with a history of suicide attempts by jumping died after leaping from an off-site building.

James Bragman, a 50-year-old schizophrenic who grew up in South Florida, had been admitted to the hospital in February 2011 with detailed notes in his file about his history and a requirement that at least two trained staffers accompany him whenever he left the facility.

Four months after arriving at the hospital, a nurse and security staffer took Bragman to an off-site appointment. One staffer went to get the vehicle and the other waited alone with Bragman, which is against protocol.

Bragman sprinted away and jumped from the eighth story of the parking garage. The security officer grabbed his jacket, but couldn't keep his grip and Bragman fell to his death. State officials classified the death as neglect.

"They're hiring the cheapest people off the street who aren't qualified for what they're doing," said Larry Bragman, the victim's brother He said it finds comfort knowing his brother is finally at peace.

The hospital has since changed its policy and staffers are now given a fact sheet from a charge nurse about the patient's risks and what precautions should be taken.

None of the three deaths were reported to the state abuse hotline, which triggers a formal investigation. The new contract will include a fine if the facility doesn't report all deaths to the hotline, Wilkins said.