Nevada Agency Substantiated 4 Incidents of Abuse and Mistreatment in 5 Months, despite repeated pledges by facility to improve

In the five months from November 2012 to April 2013, the Nevada State Health Division substantiated four different complaints against Willow Springs Center regarding mistreatment of young residential treatment center (RTC) patients, including abuse, patient rights violations, and use of involuntary seclusion without clinical justification.

On November 16, 2012, the Health Division substantiated two complaints regarding abuse at Willow Springs Center, and found that facility staff “failed to carry out policies and procedures prohibiting and preventing physical abuse.” In the first incident, staff told state investigators that a mental health technician (MHT) had said he was going to “stir some s—” before going into the room of a young developmentally delayed patient who had been placed on assault precautions. The Health Division found that the MHT provoked and then shoved the patient, who fell and hit his head on an empty bed frame. In an interview, the child stated that he was not injured, but “It hurt my feelings.” In the second incident reviewed on November 16, a child suffering from post-traumatic stress disorder was yelled at, scratched numerous times, and struck in the arm and upper back while being restrained by two MHT’s after becoming combative. The RN on duty recalled telling the MHT’s to let the patient go because the restraint was not necessary. To correct its deficiencies, Willow Springs agreed to provide training for staff on abuse and neglect, seclusion and restraints, deescalation and other topics. The facility also agreed to review all instances of restraint and seclusion if captured on video.

Three months later, on February 22, 2013, the Health Division substantiated a complaint regarding patient rights and found that the facility failed to ensure that a patient was treated with care and respect. The Division substantiated an allegation that a mental health technician had thrown a small trash can at a patient, allegedly grazing his arm. The patient had previously thrown the trash can out of his room into the room of another patient. To correct its deficiencies, Willow Springs agreed to provide education about power struggles to staff and strengthened its policy for reacting to allegations of patients’ rights violations by staff.

On April 30, 2013, the Health Division substantiated a complaint regarding involuntary seclusion and found that the facility failed to protect a patient from involuntary seclusion without clinical justification. The Health Division found that a nurse had ordered a teen patient to be placed in involuntary seclusion because he had disobeyed an order to return to his room. The nurse ordered a “code” alerting staff that the patient was escalating and posing a danger, even though he was sitting calmly in the Day Room. Two staff members then used excessive force to take him to the seclusion room. The nurse stated that he took this action as a “preemptive action in the interest of safety” and would handle the situation in the same manner if given the chance. The facility took corrective action with this RN and assigned all RN’s to “philosophy of Restraint and Seclusion,” an E-Learning program.