JACKSONVILLE, Florida — A police cruiser pulled away from the elementary school this September. Inside was a person so dangerous that the officer was carting him off to a psychiatric hospital, which locked him up for three days.
That person was 6 years old.
His parents said he had merely thrown a tantrum.
The sheriff deposited the boy, Nicholas, at River Point Behavioral Health, a troubled unit of the nation’s largest psychiatric hospital chain, Universal Health Services. UHS was the subject of a recent BuzzFeed News investigation, which found that current and former employees from at least 10 of the company’s hospitals in nine states said they were under pressure to fill beds by almost any method and to hold patients until their insurance payments ran out. Nicholas was covered by Medicaid, the government insurance program.
At River Point, Nicholas would be given a bloody nose by another child, get locked in a “seclusion” room at 3 in the morning, and wait more than 24 hours to see a psychiatrist, according to medical records provided by his parents.
River Point is under criminal investigation for Medicare fraud as part of a wider federal probe into UHS as a corporate entity, the company told investors. Federal regulators have been looking into whether River Point misused Florida’s involuntary commitment laws to hold patients at the hospital who did not need treatment. What happened to Nicholas raises renewed questions about whether River Point has been holding patients improperly.
Nicholas’s records show that his parents asked at least three times to take him home, to no avail.
In fact, the hospital filed a petition to get a court order to hold him for longer. Nicholas was released only after a lawyer intervened on his behalf. (To protect Nicholas’s privacy, his parents requested that their names not be published and their son be identified only by his middle name.)
In response to a detailed outline of this story, the company wrote that it contained “numerous inaccuracies, selectively quotes the medical record, and draws false conclusions.” The company noted that privacy laws prohibit it from fully discussing Nicholas’s case without his parents’ permission but said it had provided quality care. It pointed to a recent letter from the state of Florida saying that River Point was in compliance with legal requirements for holding patients.
UHS also disputed the earlier BuzzFeed News investigation, calling it an “inaccurate portrayal.” It said it “absolutely rejects” any claim that it held patients solely for financial gain. It launched a website to respond to the article.
The company has denied the allegations of civil or criminal fraud and said it is cooperating with the government’s investigation. It has not been charged with any wrongdoing.
More broadly, UHS said it has received high marks from independent regulatory agencies and stressed that all treatment decisions are ultimately made by physicians and clinical staff.
At 6 years old, Nicholas was under 4 feet tall and weighed less than 55 pounds. Diagnosed with attention deficit hyperactivity disorder and disruptive mood dysregulation disorder, he was seeing a therapist as well as a psychiatrist to treat his conditions but had never shown any suicidal or homicidal behavior, according to his parents. Nicholas sometimes refused to listen to teachers or do his work at school, and he would occasionally hit people when he got frustrated or angry. That day, according to Nicholas’s father, a counselor decided to send the boy to a psychiatric hospital after he had been kicking and biting. (The counselor did not return phone calls seeking comment.)
Florida’s commitment law, known as the Baker Act, allows a person to be sent to psychiatric hospital for an examination if that person seems mentally ill and appears at risk of causing severe harm to themselves or others. Once patients are transferred to a psychiatric hospital, it is the facility’s responsibility to determine if they truly need to be hospitalized. The law authorizes the hospital to hold patients for up to 72 hours to examine them, but it must release patients who aren’t likely to inflict “serious bodily harm” on themselves or others.
The law is clear: Locking a patient on a psychiatric ward is the last resort, meant only for the most serious cases. If any less restrictive treatment is appropriate, it must be used.
It was lunchtime when the police cruiser delivered Nicholas to River Point Behavioral. His mother first heard what had happened in voicemails that both the school and counselor had left for her. River Point called, too, wanting her consent for Nicholas’s treatment since he was a minor, his mother recalled. She said she declined.
“I didn’t want him to be there at all,” she told BuzzFeed News, adding that she immediately asked the facility to release her son because he was so young and didn’t need to be there. This initial request is not documented in Nicholas’s medical records. His mother said she was told she would not even be able to see her son until later that evening during visiting hours.
“It felt like my child had been kidnapped,” she said. “I can’t even hug my kid and tell him it’s going to be okay.”
Distraught and not wanting to upset Nicholas, his mother decided only his father should visit him that night.
His dad walked into River Point’s cafeteria that evening, carrying a stuffed puppy that Nicholas often slept with. In the room, Nicholas stuck out. The other patients, crowded around the tables with their families, were mostly teenagers, he recalled. His father remembered overhearing a brash, older teenage girl cursing and threatening to kill herself. He said he worried about what his son was absorbing.
But Nicholas, he said, seemed calm. His son talked about another boy on the unit who was around his age whom he could play with, his father recalled. His dad also said that he signed a form that he thought was just to let the doctors give his son medication but was really a consent to hospitalize Nicholas. Such a consent is not in the medical records Nicholas's mom provided to BuzzFeed News, but the company provided a blank admission form and wrote, “Based on the nature of this document, it is highly unlikely that there would be confusion with regard to contents.”
A couple of hours after his dad left, Nicholas was found in a hallway, screaming and crying. A boy had thrown a book at Nicholas’s face, and his nose had started bleeding, according to medical records. Nicholas was trying to hit the boy back.
When Nicholas’s mother got a call that he was being transported to a nearby emergency room around 10:30 p.m., she hopped in her car to meet him there.
“He was all blown up, exhausted, deliriously tired,” she recalled. Nicholas usually went to bed around 7:30 or 8:00.
Nothing was broken, X-rays showed, and his mother asked again to take her son home, according to his medical records. But the emergency room was advised not to release him since he was on a Baker Act hold.
Nicholas was transported back to River Point just before 2 a.m., but he became hyper when he returned to the facility and didn’t want to go to bed. He tried to climb on top of the nurse’s station, slammed his door, and spat water out of his mouth.
Unable to calm him, staff took him to the seclusion room just after 3 a.m. In response, Nicholas yelled, kicked, and hit the walls. He threw the pillow that was on the bed in the room and pulled the mattress off as well, using it to block the window into the room. It took nearly an hour until he stopped screaming, according to his medical records. Around 4 a.m. he seemed calmer after he sat down and accepted a snack. Shortly after that, he was let out of the room.
In debriefing notes about the seclusion, a form asked whether Nicholas’s well-being, psychological comfort, and right to privacy had been maintained. A nurse checked “No.”
“I didn’t want to go to that room,” Nicholas told the nurse.
Nicholas got just an hour or two of sleep that night.
That morning, his mother again requested that the hospital release her son. River Point told her it had 24 hours to evaluate Nicholas, get a second opinion from another doctor, and make sure he was not a danger to himself or others.
Nicholas finally saw a psychiatrist that afternoon for an evaluation, more than 24 hours after he was admitted, his medical records show. (UHS told BuzzFeed News that Nicholas had been evaluated “in a timely way.”) The doctor jotted down that Nicholas stated he was feeling “eh” and didn’t know why he sometimes hit others.
The doctor also wrote that Nicholas had no suicidal or homicidal thoughts. Still, the psychiatrist estimated his stay would be three to four days, citing his “poor impulse control” and “aggressive behavior.”
At the same time, the psychiatrist started the process to petition the court to hold Nicholas against his parents’ will. On the petition form, the doctor wrote down a brief clinical evaluation — but even though it was written within minutes of his medical notes, the legal document lists a behavior not found in the records provided by Nicholas's parents: banging his head against walls.
At River Point, it was standard practice to file a petition against insured patients brought in under the Baker Act, unless they decided to sign themselves in voluntarily, said three former therapists who worked at River Point before Nicholas was a patient at the facility. The expectation was “anytime a patient wants to go — file a petition,” said one therapist who worked at River Point until the middle of this year. UHS has denied holding people improperly.
That night, a nurse wrote that Nicholas was on suicide precautions “but is interacting with peers and staff, is not withdrawn, and is not voicing anything suicidal.”
The second time Nicholas met with the psychiatrist, the doctor wrote that Nicholas said “he feels happy today, later states he was mad because he woke up early.” The doctor checked the "yes" box, indicating Nicholas needed continued inpatient care, but this time he left blank the space provided to describe the rationale of a continued stay.
On the afternoon of Nicholas’s third day at the facility, a petition to commit the 6-year old landed on the desk of Stephanie Jaffe, a public defender for the county who represents Baker Act patients. Nicholas was in need of further treatment, the facility alleged, because there was a “substantial likelihood” of “serious bodily harm” to himself or others in the near future.
If the court granted the hospital’s petition, then Nicholas, who had been subject to a 72-hour hold for a psychiatric examination, could be hospitalized against his parents’ will for up to 90 days.
“The Baker Act is supposed to confine really mentally ill people who are dangerous — and a kid who has a temper tantrum is not a danger to the public,” said Stephen Talmadge, a lawyer and psychologist who specializes in that law and who reviewed documents from Nicholas’s case. Talmadge, who has represented clients against UHS, said the standard in the law is vague, giving hospitals wide discretion. But, he said of Nicholas, ”What is the kid going to do, bite a stranger?”
When Nicholas’s parents arrived for visiting hour that evening, Jaffe was waiting for them in the lobby. She had been in to see Nicholas and, they recalled, she told them that she didn’t think he needed to be locked up in the hospital, away from his parents.
When his mother and father saw Nicholas, the boy seemed more exhausted and delirious than ever, they said. He couldn’t hold a conversation, he wasn’t making eye contact, and he was spitting on the floor, his father recalled.
“He was out of his mind, we didn’t recognize him,” said his father. “It was hard to leave him there — you wanted to just grab him and run out of the facility with him.”
Nicholas had already suffered a bloody nose; now, his mother noticed that the front of his legs had bruises, which his medical records say weren’t there when he entered the facility. Nicholas had also been bitten by another boy after an argument about paper airplanes.
When his mother asked a nurse how her son’s legs had gotten bruised, she recalled being told that kids play with each other.
The next morning, Jaffe asked the court to release Nicholas, arguing that Nicholas was not a threat to himself and did not need inpatient treatment because he had the support of his family as well as a therapist and psychiatrist.
On a recent warm December day at a playground in Jacksonville, Nicholas was dressed in a Teenage Mutant Ninja Turtles T-shirt and blue jeans, his skin bronzed from the Florida sun. He kissed his mother and ran off to play.
At one point, Nicholas bumped into a smaller boy on the swing set and looked startled when the boy fell down and began to cry. Nicholas ran and hid under the slide.
But then he emerged and approached the boy. They began taking turns tossing a ball at a hoop in the corner of the playground. Soon, they were laughing.