By Chuck Strouse
By Scott Fishman
By Terrence McCoy
By Ryan Yousefi
By Ciara LaVelle, Kat Bein, Carolina Del Busto, and Liz Tracy
By Pepe Billete
By Ryan Yousefi
By Kyle Swenson
Though the facility was slammed with people in need, a nurse director told the AHCA investigator "the hospital does not have enough staff" and therefore "89 to 99 [of the then-239] patient beds are not occupied."
Says mental health project coordinator Coffey: "Folks would certainly argue those beds were needed."
Adds former hospital assistant director Dipnarine: "There was a point we were trying to cut staff. It's possible we cut it too close."
All in all, the unit was cited five times during the visit. The staff "failed to provide supervision," "failed to prevent abuse," and "failed to properly assess patients." Jackson corrected the violations April 12, 2007, and funding wasn't terminated. But the next year, the mental health unit was again cited — seven times.
On February 14, 2008, an inspector named Mildred Kincaid found nursing staff allowed a 225-pound male patient with special dietary needs to lose a pound a day for more than a week. There was "no documentation" anything had been done to help him even though the patient complained, state records show. By April, inspectors found "the deficiencies... [had] been corrected."
But the next month, inspector Morales returned without warning. She found long phone cords and damaged thermostats, which were suicide risks. She noted the hospital "failed to make needed repairs" and "failed to maintain a clean and sanitary environment."
The same week, after examining an incident log and interviewing three staff members, Morales discovered the following: Just after breakfast on March 28, 2008, an aide had discovered a "confused and vulnerable" woman locked in a bathroom with two male patients. She stood incoherent as the strangers — a 21-year-old and 36-year-old — tried to undress her. One of the men was delusional; he believed she was his wife.
The woman then reported to staff that the men had sexually assaulted her. According to state regulations, police should have been called and she should have been transported to a rape treatment center. But nothing was done.
Morales "substantiated" the abused woman's claim and again cited Jackson, this time for four violations, including failure to "prevent abuse," "honor patient rights," and "ensure policies after an alleged sexual abuse."
Perhaps most striking of all, according to the report: A doctor was aware of the situation but stated, "No, I'm not going to call the police on this."
Shantavia Robinson, a blunt, voluptuous 17-year-old, was an inpatient at Jackson's adolescent psychiatric program in April 2008. She had bipolar disorder but through good behavior earned the privilege of an outing with her case manager to Trinity Church at NW Second Avenue and 177th Street. She was a foster kid who had a nickel-size scar on her left cheek and the word savage tattooed across her chest.
Soon after arriving at the tall, white church building, she turned to size up her supervisor: high heels, good posture, and a tidy hairdo. Ain't no way this lady's gonna chase me, she thought.
So as the elegant case manager filled out paperwork, Shantavia excused herself and headed to the bathroom. Then she slipped out a side door and sprinted across a busy highway. After passing a cluster of long brown houses, she entered a Wal-Mart and hid there until a gang member she calls "my brother" picked her up.
Shantavia says she had good reason for running: During a three-month stay at Jackson's Statewide Inpatient Psychiatric Program (SIPP), she was repeatedly shackled with locked fabric restraints, much like those worn by hardened criminals in jail. The restraints were the consistency of a seat belt, used to bind her wrists and ankles as she was transported to court and doctor's appointments. She also claims to have been strapped to tables, verbally abused, and given shots in the buttocks to make her pass out.
"It made me feel like an animal," she says. "They'd strap those shackles on tight. Didn't matter how calm I was."
Shantavia's story is dramatically intertwined with that of Lisa Burton, who last year was fired as acting director of patient care for mental health services after protesting inappropriate use of restraints. In a lawsuit filed this past May, Burton claims troubled children and adolescents such as Shantavia were frequently shackled without proper assessment because of understaffing. Her complaint, which is filed under the Americans with Disabilities Act, asks that she be rehired.
"I want this to stop," Burton says. "These are the sickest, most vulnerable people in society. A lot of them are foster children who have no one."
Responds Jackson spokesperson Lorraine Nelson: "The mental health hospital at Jackson Memorial Hospital uses walking restraints on less than 1 percent of its patients when they are being transported outside the MH facility. The fabric restraints are only used as a last resort after a board-certified psychiatrist has reviewed the patient's circumstances and when a patient is determined to be a flight risk." She could not comment on Shantavia's case or the details of Burton's lawsuit.
Shantavia Andrea Robinson was born July 2, 1990, to a crack-addicted mother named Janice. Her father, Nick, collected disability checks and had more kids than he could count on both hands. She was raised by her great-aunt in a four-bedroom apartment in Carol City. At age 12, she was sent to live with a foster family. A teacher sexually assaulted her the same year, she says.