… [T]he chief executive officer (CEO) failed to ensure there were effective means of communication between all levels of staff, and failed to appropriately implement policies procedures for seclusion and restraints.AHCA also found that University Behavioral Center “was not adequately staffed to meet the needs of clients on the ASAP unit.” The Adolescent Sexual Abuse Prevention Program, or ASAP, treats “males 17 and under that are in crisis due to inappropriate sexual behavior.” Staff had difficulty containing a “near riot” one evening in which several clients threw desks and destroyed property for approximately 3 hours. In interviews, one RN said she “had not felt safe due to staffing numbers,” and another stated that, “she felt that while they met the numbers, they did not meet the acuity level of the clients in the facility.” The CEO stated “he was frustrated” that this RN had called him multiple times during the incident and not the weekend supervisor. As part of its plan of correction, the facility agreed to add additional staff.
The Florida Agency for Health Care Administration (AHCA) found that University Behavioral Center failed to report suspected child abuse, that management failed to provide front-line staff with effective communication equipment, and that a “near riot” on the unit for adolescents with sexually inappropriate behaviors was related to inadequate staffing levels. In one instance, video footage showed two mental health technicians (MHT’s) shoving and restraining clients inappropriately in the seclusion room. The facility’s risk manager “revealed he had not reported the incidents to the Abuse Hotline because the investigator that came to the facility would probably find it was not abuse since the incidents occurred during seclusion.” One of the MHT’s involved also did not have his radio with him during the incident, and stated that this was because it was broken. Four other MHT’s confirmed that they also had trouble with the batteries and functionality of their radios. A female MHT said she had reported that her radio was broken several times but was not given a replacement. AHCA therefore found that: