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Investigators point to shortfalls after Sierra Tucson suicide

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Investigators point to shortfalls after Sierra Tucson suicide

Ex-staffers not surprised by patient death

  • Sierra Tucson, one of the nation's most prominent residential behavioral health clinics, is under investigation following the January suicide of a patient at the facility north of Tucson.
    PK Weis/, for TucsonSentinel.comSierra Tucson, one of the nation's most prominent residential behavioral health clinics, is under investigation following the January suicide of a patient at the facility north of Tucson.
  • A peek beyond the gate at Sierra Tucson.
    PK Weis/, for TucsonSentinel.comA peek beyond the gate at Sierra Tucson.

Sierra Tucson, one of the nation's most prominent residential behavioral health clinics, is under investigation following the January suicide of a patient at the facility north of Tucson. The incident was the third death of a Sierra Tucson patient in the past seven years.

According to an investigative report by the Arizona Department of Health Services, the patient hanged himself from a shower head Jan. 2, six days after being admitted to the facility. Staff tried to resuscitate the patient with CPR and an on-site defibrillator. He was taken to Oro Valley Hospital and placed on life support; he was pronounced dead on Jan. 5.

An attorney for the man's widow, who is preparing a wrongful death suit against Sierra Tucson, said the treatment center is responsible for "gross negligence."

The man's family "still really can't believe that the facility that promised them they could help, and that they would never let something like this happened, failed so miserably," said Bob Boatman, a Phoenix attorney.

Representatives of Sierra Tucson and its parent company refused repeated requests for interviews, and declined to respond to detailed questions emailed about the suicide.

They are "taking this situation extremely seriously and are reviewing what happened to see if we can make improvements that might enhance the quality of patient care," a spokesman for the center's parent company said in an email.

"Out of respect for the privacy of this patient and his family, we are limited in what else we can specifically say," wrote Jonathan Ciampi of CRC Health Group.

CRC, a Bain Capital-owned company based in San Jose, Calif., faced a Friday deadline to file a response to the state report. State officials said Monday that they had granted an extension to that deadline.

Sierra Tucson faces fines of up to $500 per day if found in violation of state regulations, and the possible suspension or revocation of its license.

The ADHS enforcement team has yet to meet to determine what penalties the state will, if any, in the case, department spokeswoman Laura Oxley said Monday.

ADHS did inform Sierra Tucson that it should not file a "plan of correction," as it had in previous incidents, and that the agency was "going straight to enforcement," she said.

Following the death of a patient in 2011, the center was placed on a one-year provisional license and fined $9,250. The center paid a $3,500 fine to ADHS in 2009 related to two patients leaving the facility.

State officials have declined to characterize the severity of the ongoing investigation, or detail any penalties they may be considering. Sierra Tucson will have the right to go to court to appeal any enforcement action that may be taken, Oxley said.

"Our goal is not to remove treatment options," Oxley said. "Our goal is to have people provide good treatment."

Former staffers not surprised by another death

Former Sierra Tucson staff members and administrators, who requested anonymity because they fear retaliation by the company, said they were not surprised at the recent suicide, saying it was just a matter of time before a lack of trained staff led to another death.

The night prior to the hanging death and with Sierra Tucson staff listening in, the patient called his wife and expressed interest in ending his life, the 16-page report by state investigators said.

The patient "asked his wife if she had found the suicide note he had left prior to his admission," a staffer told investigators.

A staffer who listened to the phone call told investigators that the patient "sounded like he was making plans for suicide," the report said.

Despite multiple Sierra Tucson staffers being aware of the call, investigators said it was not properly documented in the patient's medical record, his risk level was not reassessed nor was his treatment plan updated "to reflect this significant change in his condition."

The patient, a Phoenix professional in his late 50s whose name is being withheld at the request of his family, had been admitted to the hospital at Sierra Tucson on Dec. 27. His risk of suicide was scored "very high": 16 on a 20-point scale. The next day, his "Suicide Risk Scale" was scored at 13.

Although Sierra Tucson's policies require patients with SRS scores of 7 and above to remain in the facility for critical patients, the man was moved to the facility's residential treatment program a day after being hospitalized. There, staff check patients ever four hours.

Az investigators find multiple violations

The Arizona Department of Health Services regulates psychiatric and behavioral health clinics for the state. In this recent case, department investigators found multiple policy violations relating to the patient's death, including lack of documentation, the psychiatrist on duty not heeding concerns from staff, and that staff did not follow Sierra Tucson's established policies regarding suicide risk assessment.

CRC's spokesman described the state investigation as "still in a preliminary stage" and said it "requires review and consideration of additional information we are providing."

According to the state report, Sierra Tucson's nursing director told investigators that the "Kardex" medical record of the man who committed suicide could not be located, and that daily nursing reports are shredded by the center.

Sierra Tucson's executive director, Steven Fahey, acknowledged to ADHS officials that the center failed to "fully implement" a number of policies relating to assessing the risk of suicide, that the patient's "treatment plan was not reviewed and updated on an ongoing basis when the resident experienced a significant change in condition that affected treatment," and that "the medical record did not contain all the appropriate progress notes."

The report — which did not include the names of the patient or staffers — also stated:

"Based on observation, documentation reviews and staff interviews, the administrator failed to ensure that resident #1 did not have access to equipment that may present a threat to his health and safety based on the resident's identified treatment needs for safety resulting in death by hanging."


Based on review of the medical record, resident #1 was found at approximately 12:35 PM 01/02/2014 unconscious with head and left shoulder against the shower wall in room #36 with a cord wrapped tightly around his neck. He had no pulse and was not breathing. Cardiopulmonary resuscitation (CPR) was initiated. An automated external defibrillator was applied and order "no shock"times two. CPR continued until the emergency services arrived and took over care. The patient was transported to the hospital where he died 01/05/2014.

Based on the forensic exam dated 01/07/2014, "the cause of death is ascribed to hanging" for resident #1 and the "manner of death is suicide".

Unlike the other findings of the report, there was no acknowledgement by Sierra Tucson staff regarding the finding that the center did not ensure the patient had no access to dangerous equipment.

Sierra Tucson should have used break-away showerheads, doorknobs and shower rods, but did not do so, the report said. In addition to the lack of these expected devices in a residential behavioral health clinic, ADHS also pointed to administrative issues at the center.

Sierra Tucson has two main levels of care. Level I, know as the Medical Assessment and Stabilization Unit (MAS), is for the most critical patients and calls for one-on-one care with constant supervision. Once patients meet certain criteria in Level I care, they are transferred to the Level II residential program, which calls for staff check-ins every four hours.

According to Sierra Tucson policy, patients are scored on a suicide risk scale the determines whether they are to be transferred from Level I to Level II care. Patients scoring higher than six on the scale are considered "high risk" and are to be kept in Level I care, the report said.

After interviewing Sierra Tucson staff and investigating medical documentation in the case, ADHS found that the patient scored a 13 on the suicide risk assessment and there was no documentation found to support the transfer into Level II care. The SRS scale is scored up to 20.

"Patients with an SRS score of 7 or greater are to remain in the MAS. There is no evidence of a progress note or further evaluation of the resident's SRS score indicating the rationale to support the resident was sufficiently stable to transfer to the residential program," the ADHS report said.

A company spokesman declined to respond to over a dozen detailed questions about the incident and Sierra Tucson's operations, but said that "(f)ollowing accepted medical practice, care decisions are made only by physicians and other appropriate licensed clinical professionals based on the individual needs of their patients."

"Policies and procedures are simply guidelines and, like other health care providers, patient care decisions at Sierra Tucson are based primarily upon the exercise of clinical judgment by our highly qualified professionals," wrote Jonathan Ciampi, CRC Health Group's chief marketing officer.

A peek beyond the gate at Sierra Tucson. PK Weis/, for

Three deaths at ritzy rehab center

Sierra Tucson, located between Oro Valley and Catalina, is owned by San Jose-based CRC Health Group, the nation's largest provider of residential behavioral health facilities, with more than 140 centers. CRC was purchased by Bain Capital in February 2006 for $723 million.

Sierra Tucson, considered the "crown jewel" of the company, charges $1,300-2,300 per day and up. It is known as a rehab center for the rich and famous, with clients such as Tiger Woods, Ringo Starr, Michael Douglas, Heather Locklear and motorcyclist Jesse James having used the facility.

The 160-acre facility, 39580 S. Lago del Oro Parkway, just south of Saddlebrooke, is widely known for its naturopathic treatments — using acupuncture, massage, equine therapy and other practices to alleviate withdrawal symptoms — and describes its programs as based on the 12-step philosophy.

The January suicide was the third death of a Sierra Tucson patient in the past seven years, including the highly publicized case of Dr. Kenneth Litwack in August 2011.

The 71-year-old California infectious disease physician died after walking away from the center's residential area.

Litwack, according to reports, scored a 10 on the Suicide Risk Scale, high enough to be kept in Level I care with round-the-clock observation. Despite this, he was ushered into Level II residential care.

He was found dead two weeks after he left the center, approximately one quarter-mile from the facility near Sierra Tucson's horse stables. His body was too decomposed to conduct an autopsy that would have established a cause of death.

In March 2007, Toby Blanck, a 34-year-old Sierra Tucson patient, drowned in the facility pool in front of onlooking staff members. Blanck would often pretend to be drowning in the pool, then resurface when staff would jump in to help, according to a former center employee whose identity has been withheld due to fears of retaliation by Sierra Tucson and CRC.

A suit by the Blanck family was settled out of court. The wrongful death suit filed by Litwack's family will be heard in August, according to Dev Sethi, an attorney with Kinerk, Schmidt & Sethi in Tucson.

Following Litwack's death, ADHS placed Sierra Tucson on a one-year provisional license, after finding the facility in violation of 42 state rules and policies regarding psychiatric and behavioral health facilities. Among them were issues relating to staff communication, documentation and adherence to Sierra Tucson policies.

Despite the provisional license stemming from Litwack's death, and a $9,250 fine, a number of parallels exist with the more recent suicide.

In both cases, the deceased had been observed discussing their potential death with others.

According to reports from ADHS regarding these deaths, there was a breakdown in communication between staff and medical providers and a lack in documentation to support decisions. In both cases, the decision to move the patients from Level I care and into Level II care was questioned.

Days before his suicide in January, according to the ADHS report, the patient telephoned his wife and expressed his desire to end his life, mentioning a suicide note he had left at their house. He also discussed splitting up their shared assets with his wife so she would not be responsible for his debts, the report said.

A Sierra Tucson staffer listened in on the telephone call and suggested to other staff that the patient be moved back into Level I care. That suggestion was not documented in the patients records, the report said.

After the call, the man's wife phoned Sierra Tucson to discuss removing him from the center, but staff at the facility convinced her to keep him there, said Boatman, the family's attorney.

Former staff point to turnover

Sierra Tucson was founded in 1983 by Bill O'Donnell Jr., a recovering cocaine addict, at the Brave Bull Guest Ranch just south of Catalina. The facility merged with Miraval Life in Balance resort under the name NextHealth Inc. in 2002 in a $82.5 million deal. In 2005, California-based CRC purchased Sierra Tucson for $130 million. According to sources close to the deal, CRC agreed to keep Sierra Tucson's staff intact for a year, maintaining operations as usual.

Following the one-year grace period, CRC was purchased by Bain Capital. After that, Sierra Tucson's main administrators — most of whom were Arizona-based behavioral-health professionals — were replaced by out-of-state business people with little behavioral health experience. Since then, the company has seen a turnstile of administrators and staff, former employees said.

Sierra Tucson has been accused of placing profits ahead of patient care. Among the strongest claims has been the ushering of Level I patients into less comprehensive Level II care, while still charging level 1 rates.

According to attorney Boatman, the widow of the man who committed suicide in January claims Sierra Tucson billed the higher rates for residential care.

More than a dozen former Sierra Tucson staff members and administrators interviewed for this story said that the facility lacks enough trained staff for the number and level of patients it takes in. All asked not to be named for fear of lawsuits by CRC.

Many of those former employees said they were not surprised at the recent suicide, saying it was just a matter of time that the lack of trained staff would lead to another death.

Following Litwack's death, Sierra Tucson laid off the majority of its staff over the course of many months, according to former staffers and administrators. In fact, they said there are only a handful of staff from that time still working at the facility, which employs about 250 people.

In mid-February, less than two months after the recent suicide, Sierra Tucson again conducted a round of "reduction in force," reducing staff by more than a dozen, according to those who were laid off. Multiple former staff members said they were offered severance pay if they did not "disparage the name of Sierra Tucson." Others signed non-disclosure agreements and could be sued for speaking to the media.

After Litwack's death, Sierra Tucson conducted a series of crisis intervention training sessions for its entire staff. The hour-long sessions — conducted by Dr. Michael Sucher, a Phoenix emergency medicine specialist — were detailed in a "Plan of Correction" submitted to ADHS in February 2012.

According to training material submitted to ADHS, staff should "always take it seriously when a person tells you they want to kill themselves."

The training materials said that minimizing inpatient suicidal opportunity includes one-to-one monitoring, suicide observation every 15 minutes, using plastic utensils, not assigning private rooms and not allowing extended time alone in a room.

During the training, according to submitted presentation materials, Sucher suggested the facility use short electrical cords and keep utility rooms, kitchens, stairwells and other rooms locked. He also suggested staff remove patients' belts, shoelaces, cords and other devices which could be used to commit suicide.

The patient who killed himself in January hanged himself with a shoelace, according to an autopsy report prepared by the Pima County Medical Examiner's Office.

Some former Sierra Tucson employees said they couldn't recall that training.

"This isn't to say it's faked; it may have been so lame that it didn't qualify for a certificate of completion," said one. "Regardless, you don't prevent future deaths by giving highly trained staff a lame online training; you make actual changes."

Suggestions by former employees that the psychiatric and behavorial health center isn't properly staffed aren't new.

"The business side started controlling admissions" after CRC bought the facility, a former employee who worked at Sierra Tucson before and after the acquisition told Salon in 2012 for a report that was critical of operations at the entire Bain Capital-owned chain:

"It doesn't take a brain scientist to realize that if you reduce staff [in key programs] and add sicker patients, there's going to be trouble." With the addition of a new 44-bed lodge in 2007, staff at Sierra Tucson was stretched thin, former staffers say; by 2009, a state licensing office fined the facility for having insufficient staff to prevent high-risk patients from wandering off.

Sierra Tucson paid a $3,500 fine to ADHS in 2009 related to two patients leaving the facility. One involved a patient with a history of psychosis leaving Sierra Tucson without permission. In the other, a patient who had expressed suicidal thoughts was discharged without any documentation that it was safe for him to drive away from the center.

Sierra Tucson, CRC decline to answer questions

An interview request emailed two weeks ago to Sierra Tucson Executive Director Stephen Fahey was not directly answered. Instead, it was responded to by Ciampi, CRC's chief marketing officer, who said he would "appreciate the opportunity to fact-check any statements you intend to make regarding Sierra Tucson or its owners."

"We do not intend to participate in an interview, but we are more than willing to respond to your written questions," Ciampi wrote in another email. "We believe that thorough responses placed in proper context are critical to any fair treatment of the issues that you intend to present in the article. We are confident that, armed with our responses to your written questions, you will be able to properly evaluate the merit of any storylines currently being considered for publication."

Ciampi has not yet directly responded to any of the specific questions emailed to him last Monday, including inquiries relating to the recent suicide, Sierra Tucson's staffing and training, the lack of communication between staff and medical professionals, and the facilities use of non-breakaway furnishings.

Instead, Ciampi — whose background is in technology companies rather than health care — claimed Thursday that an unspecified "technology issue" had kept him from receiving the questions, and then sent a general statement on Friday.

"Sierra Tucson meets or exceeds state training standards for those clinical professionals and also meets or exceeds state staffing standards, maintaining one of the highest staffing ratios in the field. Lastly, we fully comply with all patient safety standards," Ciampi said.

"Sierra Tucson and its employees have agreements designed to protect confidential information, including patient information, which is mandatory under federal and state law and is our responsibility to safeguard," he wrote. "To the extent you are reaching out to current and former employees and encouraging them to violate their agreements you are infringing Sierra Tucson's and/or its patients confidentiality. We caution you against drawing unwarranted conclusions from individuals who would divulge confidential information or are not in a position to know the information they are purporting to provide."

More than a dozen former Sierra Tucson employees, from direct health care providers to administrators, were interviewed as part of's six-week investigation. All requested anonymity and expressed concerns about the center's operations.

Attorney Sethi told that he could not discuss the issues relating to the Litwack case, but did say that the Sierra Tucson employee base "appears to be a transient workforce."

In late 2011, Sethi was less guarded in his criticism of the center, telling the (Nashville) Tennessean that "we have become aware of what seems to be a pattern in CRC-owned facilities."

"Well-regarded hospitals with talented and dedicated staff are squeezed by the new CRC ownership, who focus on revenue over care," he said.

The Litwack family were "heartbroken that other families have been devastated by CRC decisions, which needlessly endanger the patients who come to their facilities for help," Sethi said.

Boatman, the attorney for the widow of the recent suicide, called the lack of attention paid to the husband of his client "egregious."

He and his firm, Gallagher & Kennedy, are in the process of filing a wrongful death suit against Sierra Tucson and CRC now that the ADHS report has been filed.

"The ADHS investigation is critical for a number of reasons," Boatman said. "Most importantly, it holds Sierra Tucson responsible for its gross negligence, and it does so much more quickly than any individual can though a lawsuit. Its powers are broader, including the ability to require important changes, or even shut the facility down."

"More plainly, its early investigation and intervention can help prevent another patient from dying. That is the main concern of my clients," he said. "They pray no other family has to ever experience the horror they have experienced in losing a loving husband and father."

Correction: An earlier version of this story mistakenly reported that there have been three deaths at Sierra Tucson in the past six years. With patient deaths in 2007, 2011 and 2014, the correct time frame is seven years.

State law

Arizona law allows regulators to fine health care facilities up to $500 per day for violations, as well as potentially suspend or revoke licenses to operate.

36-431.01. Violations; civil penalties

A. The director may assess a civil penalty against a person who violates this chapter or a rule adopted pursuant to this chapter in an amount of not to exceed five hundred dollars for each violation. Each day that a violation occurs constitutes a separate violation.

B. The director may issue a notice of assessment that shall include the proposed amount of the assessment. A person may appeal the assessment by requesting a hearing pursuant to title 41, chapter 6, article 10. When an assessment is appealed, the director shall take no further action to enforce and collect the assessment until after the hearing.

C. In determining the civil penalty pursuant to subsection A of this section, the department shall consider the following:

1. Repeated violations of statutes or rules.

2. Patterns of noncompliance.

3. Types of violations.

4. Severity of violations.

5. Potential for and occurrences of actual harm.

6. Threats to health and safety.

7. Number of persons affected by the violations.

8. Number of violations.

9. Size of the facility.

10. Length of time that the violations have been occurring.

D. Pursuant to interagency agreement specified in section 36-409, the director may assess a civil penalty, including interest, in accordance with 42 United States Code section 1396r. A person may appeal this assessment by requesting a hearing before the director in accordance with subsection B of this section. Civil penalty amounts may be established by rules adopted by the director that conform to guidelines or regulations adopted by the secretary of the United States department of health and human services pursuant to 42 United States Code section 1396r.

E. Actions to enforce the collection of penalties assessed pursuant to subsections A and D of this section shall be brought by the attorney general or the county attorney in the name of the state in the justice court or the superior court in the county in which the violation occurred.

F. Penalties assessed under subsection D of this section are in addition to and not in limitation of other penalties imposed pursuant to this chapter. All civil penalties and interest assessed pursuant to subsection D of this section shall be deposited in the nursing care institution resident protection revolving fund established by section 36-431.02. The director shall use these monies for the purposes prescribed by 42 United States Code section 1396r, including payment for the costs of relocation of residents to other facilities, maintenance of operation of a facility pending correction of the deficiencies or closure and reimbursement of residents for personal monies lost.

G. The department shall transmit penalties assessed under subsection A of this section to the state general fund.

36-427. Suspension or revocation; intermediate sanctions

A. The director, pursuant to title 41, chapter 6, article 10, may suspend or revoke, in whole or in part, the license of any health care institution if its owners, officers, agents or employees:

1. Violate this chapter or the rules of the department adopted pursuant to this chapter.

2. Knowingly aid, permit or abet the commission of any crime involving medical and health related services.

3. Have been, are or may continue to be in substantial violation of the requirements for licensure of the institution, as a result of which the health or safety of one or more patients or the general public is in immediate danger.

4. Fail to comply with section 36-2901.08.

B. If the licensee, the chief administrative officer or any other person in charge of the institution refuses to permit the department or its employees or agents the right to inspect its premises as provided in section 36-424, such action shall be deemed reasonable cause to believe that a substantial violation under subsection A, paragraph 3 of this section exists.

C. If the director reasonably believes that a violation of subsection A, paragraph 3 of this section has occurred and that life or safety of patients will be immediately affected, the director, on written notice to the licensee, may order the immediate restriction of admissions or readmissions, selected transfer of patients out of the facility, reduction of capacity and termination of specific services, procedures, practices or facilities.

D. The director may rescind, in whole or in part, sanctions imposed pursuant to this section upon correction of the violation or violations for which the sanctions were imposed.

ADHS report on Sierra Tucson

Read the 16-page report.

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