Hundreds of serious incidents at Meadows Psychiatric Center were not reported to the Patient Safety Authority and Department of Health, as required by law. In just the preceding three months, there had been internal incident reports of 13 escapes, 370 physical confrontations, 77 attacks on staff by patients, 62 attacks on patients by other patients resulting in 26 injuries, 25 sexual allegations, and 12 self-inflicted injuries including 6 suicide attempts. Only 3 reports were submitted to the health reporting system for the entire year. Among the incidents uncovered by inspectors, a 14-year-old female patient reported she had been forced by a male peer to have sexual intercourse.
The Department of Health also found violations of cross-boarding regulations. One staff member reported feeling uncomfortable with cross-boarding, in part, because of a specific incident in which younger children slept in the adolescent unit which the staff member believed had housed two “known pedophiles,” but the staff member felt that the administration was not responsive to employees’ concerns.