At the end of August, Charlottesville police indicted five former employees of the Whisper Ridge Behavioral Health facility on abuses ranging from sex with a minor while in a custodial role and contributing to delinquency to failing to report abuse. The indictments came near the end of months of internal investigations by the State Department of Mental Health, Substance Abuse and Mental Retardation.
But Whisper Ridge’s history of violations goes back much further. In November 2004, investigations by the Department of Mental Health’s Office of Licensing (OL) prompted sanctions that threatened to close the hospital unless it cleaned up its act. The hospital was under watch for those violations until September 30, 2005. But, reports from October 1, 2005 onward suggest the abuses at Whisper Ridge never really stopped.
From fall 2005 to spring 2006, it has been alleged, Bryan Antwann Vaughan had sex with two female residents, Michael Prosise sexually abused a 15-year-old male resident, Bianca Nicole Johnson took indecent liberties with a boy under her care, and Jenicia Minter and Melissa Pohl Sargeant failed to report what they knew about some of the abuse. In addition, several serious assaults and suicide attempts were hidden from the State licensing board, and residents weren’t treated properly for injuries.
Charlottesville police provided indictment documents that name the five accused and give brief descriptions of the events behind the charges. State internal documents black out names or replace employees and victims’ names with symbols like “XX.” So C-VILLE has reported most incidents without names; the victims remain anonymous. But, where situations were clearly one and the same, we linked the names from the indictments with events detailed in internal documents.
There is another piece to the Whisper Ridge puzzle. The facility operates as a for-profit business, and has changed hands a number of times. In 2003 it was purchased by publicly held Psychiatric Solutions, Inc. Psychiatric Solutions’ executive members have, cumulatively, decades of experience with Hospital Corporation of America (HCA) and Columbia Healthcare Network, which, merged, was a company that pleaded guilty to defrauding the Medicare system through shady accounting practices in the late 1990s. The scandal reached congressional proportions when Senator Bill Frist of Tennessee (whose family started HCA) was implicated for dumping shares before HCA’s stock crashed.
Now, Psychiatric Solutions’ CEO, Joey A. Jacobs, has also been selling off stock, but more slowly. The company has sold off 14 percent of its internal shares in the last six months. Psychiatric Solutions operates 64 facilities with more than 6,900 beds in 27 states around the country. The company employes 8,800 full-time employees.
On paper, Psychiatric Solutions’ administration seems to stay out of the nitty-gritty of running the hospitals. But, Whisper Ridge’s CEO, Taylor Davis, is documented to have defended an employee who had sex with a male resident in 2004 and was then allowed to resign. He said the pressure of the job got to her, given that she was a single mother.
Whether Psychiatric Solutions’ ties to Columbia/HCA indicate a culture of corruption that trickled down to local patients’ care is unknown. Based on this partial account of one year at Whisper Ridge, what is certain is that the facility is a place where young residents got worse, not better.— Meg McEvoy, with additional reporting by Brendan Fitzgerald
October 2005: Internal reports from the Office of Licensing (OL) say fighting among residents is a continuing problem. Staff are accused of improperly restraining residents and not documenting assaults among patients properly.
November 2005: Staff are reported to be removing patients from their beds by lifting up mattresses and “flipping or rolling” residents out of bed, which is deemed abusive by the Office of Human Rights. Male residents interviewed by staff said later that the practice continued anyway.
November 2005: OL documents note a “failure to report” sexual abuse of a 15-year-old male resident by, allegedly, Michael Prosise (named in internal documents as “ZZ”), an employee at Whisper Ridge. Later, the boy admitted to performing oral sex on Prosise, who asked him not to tell anyone that he was gay.
December 2005: Bianca Nicole Johnson allegedly proposes sex to a 15-year-old resident through a graphic letter, according to City spokesman Ric Barrick. Letters were also used as sexual communication in an incident in 2004, when staff found a letter from a female employee to a male resident referencing a sexual encounter and expressing interest in another. Staff saw the employee leave on an unscheduled outing with the resident. The employee resigned four days later.
January 2, 2006: A female resident attempts suicide by attaching a belt to the handle of her drawer and tries to strangle herself with it. She received no medical attention (reports indicated that staff would simply “monitor her behaviors”). Several other strangulation attempts (one resident used a bedsheet, another a cord from a pair of sweatpants) occurred throughout the month of January. None of the attempted strangulations were reported to the Office of Licensing. The hospital also neglected to restrict access to sharp objects by residents who were known to self-mutilate.
January 14, 2006: A resident is assaulted by several other residents on the hospital’s 500 Hall, causing a concussion, possible strangulation, bruising and contusions. He is later attacked in his sleep. Administrative staff instructed nurses not to call 911 “because of concerns that the State might find out,” according to OL documents. The boy was told to keep himself safe by staying close to staff. Later, a female resident stated in interviews that at Whisper Ridge she had to learn to “fight back” against other residents. She now has “aggression” listed as one of her problems in her chart.
January 14, 2006: Administrators on call instruct nursing staff not to call 911 for a male resident who had stopped breathing on two occasions, had cyanosis (turning blue) of his lips and nail beds, elevated vital signs and had apparently experienced two seizures.
January 2006: The Office of Licensing receives a call about abuses at Whisper Ridge and begins investigating the assault and other reported incidents at the hospital.
January 24, 2006: A psychiatrist at Whisper Ridge, (referred to as “Dr. M” in internal documents) interviews a female resident who was upset about something but said she “wasn’t supposed to tell.” The female resident eventually told “Dr. M” that Bryan Antwann Vaughan, a former Mental Health Specialist (“XX”) had sex with her. In later interviews, residents said it was common knowledge that he had sex with two female residents. Staff reported hearing him make inappropriate comments about female’s bodies and that he touched them while pretending to horseplay.
January 2006: A resident is able to “cheek” his Seroquel, a treatment for schizophrenia and bipolar disorder, over a number of days and attempts to kill himself by overdosing. Staff delayed taking him to
the hospital for 25 minutes, during which time his blood pressure dropped, his affect became “flat” and his movements slowed. He stayed overnight at UVA hospital and was returned to Whisper Ridge the next day.
February 3, 2006: A male resident turns in a sick call slip to his therapist complaining of rectal bleeding. The same resident was said to have had a close relationship with a male staff member whose name is unknown. The resident later denied any sexual abuse.
February 4, 2006: Following reports of abuse and investigations, the OL sends an e-mail to Whisper Ridge, telling them to develop a “crisis stabilization plan” by February 6.
February 14, 2006: A resident under 1:1 observation attempts suicide by requesting to use the bathroom, where he tries to strangle himself with a shoestring. Within the next several days, one resident goes AWOL and at least two residents attack staff.
February 23, 2006: Charlottesville police seize personnel and patient records from Whisper Ridge hospital and begin a criminal investigation.
March 2006: Interviews between a coordinator at the hospital and the OL reveal several situations in which staff were accused of having sex with residents or writing sexual letters to them.
March 6, 2006: A report shows how the hospital is correcting staff response to assault incidents. One staff member was fired and two others were “reeducated” and counseled.
April 11, 2006: The OL releases their investigation report and makes recommendations in a Corrective Action Plan. In response to “Humiliating, degrading or abusive behavior,” the Department of Mental Health, Mental Retardation and Substance Abuse Services advised, “Continue to focus on education, supervision of staff and therapeutic programs to deliver safe and effective treatment to residents…Performance improvement must be the culture of the organization and not just compliance.” The Corrective Action plan provided provisions for reporting all incidents to the Office of Licensing and the Charlottesville Police. A new management staff, documents say, will guarantee human rights for the residents. Documents also indicate that “employee disciplinary actions” had been completed at the time of the report.
June 2006: Whisper Ridge is allowed to stay open by reaching an agreement with the licensing agency. They agree to pay $30,000 in fines and promised to reform their policies. By that time, the number of residents at the facility had fallen from 60 to six patients.
July 2006: The Daily Progress prints an article saying Whisper Ridge is on track towards remedying its violations. (An employee at Whisper Ridge who declined to be named out of concern for his employment told C-VILLE last week that a change in administrative staff earlier in the year had turned things around at the hospital.)
August 21-22, 2006: Charlottesville Police charge Melissa Pohl Sargeant, a former employee at the hospital, with two counts of contributing to the delinquency of a minor and failure to report child abuse. Specifically, she had knowledge about the 15-year-old who Michael Prosise allegedly abused. Jenicia Minter, a former employee, is also charged with contributing to delinquency. Three others: Bryan Antwann Vaughan, Bianca Nicole Johnson and Michael Prosise are charged with abusing residents.
September 12, 2006: State authorities continue to investigate Whisper Ridge. They will determine if incidents over the summer were in violation of the June agreement. Sargeant and Minter have been ordered to appear in court October 16 for the delinquency charges. Court dates for the other defendants are impending.
