MIDVALE, Utah — The Utah Attorney General’s Office confirmed it is “aggressively” investigating a psychiatric hospital in Midvale that has been cited 44 times for more than 100 problems since 2019 but has never been shut down.
Highland Ridge Hospital is a for-profit psychiatric facility owned by Acadia Healthcare. The hospital currently treats both adults and minors.
For months, the FOX 13 Investigates team has been interviewing patients and employees. Many of them describe problems involving abuse and neglect, sometimes leading to fights or sexual assaults between patients.
Whitney Godfrey was 14 years old when she stayed at the facility in 2018.
“From the second I got there, I knew I was being exploited,” Godfrey described. “I was convinced that there was no hope, and I was helpless.”
Godfrey spent years checking in and out of seven in-patient psychiatric facilities while battling depression. She said she rarely had a choice of which hospital to go to, due to lack of beds.
“Highland Ridge was the worst in-patient I’ve ever been to,” Godfrey said. “I think I met with a therapist once [at Highland Ridge], and it was like maybe a 15-minute session.”
Godfrey described issues with lack of supervision, her medication being administered incorrectly, and lack of therapy before discharge.
“The nurse wasn’t even in the same room. People were in the hall, and I don’t even know how she would have seen the people that were in the hall,” Godfrey said. “We just sat around late at night watching TV, like Dexter [a show about a serial killer]… It was really really triggering to watch somebody else die.”
When Godfrey and her mother reported the facility to the Utah Department of Health, state employees responded in January 2019 and found the complaints were substantiated.
The inspection found patients were assaulting and sexually assaulting each other inside the facility due to a lack of supervision. For at least two patients, their medication was switched.
Inspectors also found incomplete patient medical records, patients being discharged before receiving the prescribed number of therapy sessions, failure to ensure proper licensing and training for nurses, inadequate cleaning and repair of the facility, and failure to ensure food products were stored properly.
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FOX 13 News has spoken with 12 past and present employees of Highland Ridge Hospital.
A therapist who worked at the facility from June 2018 to July 2019 confirmed that staffing issues led to patients not receiving the correct amount of therapy before their insurance ran out. He spoke with FOX 13 News on condition of anonymity.
“I feel like it’s my job as a therapist to be an advocate for these patients,” he said. “I don’t think it should continue to run, and I’m not the only one who feels that way... Money is the primary driving factor for them. They treated every single patient there — staff and patients included — like a number.”
Godfrey is now 18 years old, and her mental health has improved. She was frustrated to learn that Highland Ridge Hospital continued to be cited for many of the same deficiencies years after she left the facility.
Since January 2019, the Utah Department of Health has found more than 100 issues at Highland Ridge Hospital, citing the facility with deficiencies in 44 areas.
Staff have inspected the property four times in response to eight “substantiated” complaints.
From January 2020 to July 2020, inspectors found the facility had “114 physical confrontations” and “80 boundary violations or sexual allegations.”
In one case, a patient put a pillowcase over their head for “45 minutes” trying to suffocate themself, but “nobody intervened.”
Inspectors found the hospital failed to “complete a thorough investigation” when one of the employees was accused of giving “cannabis gummy bears” to multiple patients and entering an inappropriate relationship with a patient.
The incident was not reported to police.
In November 2021, Courtney Holder-White checked herself into Highland Ridge Hospital. Immediately, she said she noticed differences between the facility and others she had been to.
“It was night and day,” she described. “I went there for treatment of post-traumatic stress disorder, and I was traumatized the whole time I was there... It was so unfair, and I felt so powerless because I know better.”
Holder-White is also a nurse. She does not work at Highland Ridge Hospital, but once she checked in as a patient, she described feeling like she had no choice but to start acting as if she were an employee.
Instead of worrying about her own care, she said she took care of other patients.
She also called the Unified Police Department (UPD) to report the conditions inside.
Holder-White told investigators she suspected one patient in particular was being overmedicated and neglected by employees who did not wash or change her.
“She didn’t know where she was. She didn’t know what she was doing,” Holder-White said. “Glazed over, dazed and confused, didn’t know what was going on.”
Each day, Holder-White said she was the one who came into the patient’s room to help the patient shower and get dressed.
“Patients have free access to each other’s rooms,” Holder-White said. “There’s so much that went wrong there.”
Officers with UPD have investigated 33 calls to the facility from January 2019 to December 2021.
Five calls were to report sexual assault. Some involved children.
In 2021, both police and the Utah Department of Health found sometimes staff were not following legal requirements to report cases to police or protective services; “The hospital did not report allegations of physical or sexual abuse to the appropriate outside agencies as per state law.”
According to one police report, an employee told officers that “providers within the hospital are threatened with being ‘fired’ if they report such incidents, due to it affecting the hospital reputation... [He] did not want to provide more information [because] he was scared of retaliation by administration.”
Another employee, who worked as a behavioral health technician from October 2018 to July 2019, said she witnessed the same issues during her employment that the facility would later be cited for in 2020 and 2021.
She asked not to be identified for personal reasons.
“It’s awful that sexual abuse happens, and it’s still happening,” the technician said. “Really, I think they need to shut down the hospital and start over... Highland Ridge is basically a holding pen. You put them there, you put them on medication, and you leave them [until the insurance runs out].”
The employee said she felt the hospital was unsafe for both patients and staff due to the lack of proper training involving restraints.
"It’s super dangerous for the patient,” she said. “You can hurt them. You can get hurt in the process. There was a time where we did a sitting chair restraint, and the patient actually slammed their head to the side, and it gave me a concussion. I ended up having to go to the [emergency room] after my shift because they wouldn’t let me go during my shift. I had to finish it out while I was throwing up throughout the night, super dizzy. It was not great.”
According to the Utah Department of Health, technicians are supposed to check on patients at least every 15 minutes. In some cases, patients require checks every five minutes.
In July 2021, police found one of the technicians did not realize a patient was dead until he was “cold and stiff to the touch.”
The employee left in July and declined to speak to FOX 13 News, other than to say she “just wanted to move on” and “was just overwhelmed with the working conditions.”
UPD is investigating the case.
“Honestly, I can’t believe [Highland Ridge Hospital] hasn’t been shut down by the state already,” Holder-White said. “It’s a perpetual problem. And who’s responsible for it? … How has this happened for so long? How has the system failed citizens of Utah for so long?”
Enforcement
Despite the facility’s repeated promises to retrain staff and correct issues, employees with the Utah Department of Health told FOX 13 News they are “concerned” with the “pattern of noncompliance” at Highland Ridge Hospital.
“It doesn’t appear that this is something that is sticking for a long period of time,” said Joel Hoffman, the director of licensing and certification for the Utah Department of Health.
However, because Highland Ridge Hospital receives Medicare and Medicaid funding, Hoffman said only the federal government can start the process of revoking the facility’s certification.
Letters obtained by FOX 13 News show the Centers for Medicare and Medicaid Services (CMS) have threatened to revoke the facility’s certification six times since 2019.
Also since 2019, Highland Ridge Hospital has had its state license revoked twice.
In both cases, the Utah Department of Health gave the facility a “conditional license” and re-issued a standard license once administrators corrected the deficiencies.
“Once they show correction, then we allow them to operate unless something else comes up,” Hoffman said. “If they don’t correct those deficiencies, then they would lose their Medicare and Medicaid certification.”
“I think one thing we could look at [in the future] is contacting our CMS Denver office and talking to them about oversight of this facility and what else could be done,” Hoffman added.
Just one of the 12 employees interviewed by FOX 13 News had positive things to say about the facility, blaming most of the problems on difficult psychiatric patients.
“There are inherent challenges that they do face. It is not easy, but again, that is not an excuse,” Hoffman said. “These patients are especially vulnerable.”
CEO Jim Hess sent the following statement to FOX 13 News:
Hospitals, and psychiatric hospitals in particular, are among the most highly regulated and government surveyed business in the U.S. Highland Ridge, like all other hospitals, has had regular surveys where either no deficiencies were identified or deficiencies were identified and corrected. In each of the instances sited (sic) in your report, deficiencies were addressed and systems put into place to ensure ongoing compliance with all regulatory standards. Highland Ridge is fully licensed by the Utah Hospital Association and CMS and currently operates with no pending regulatory restrictions or outstanding deficiencies. We also are accredited by the Joint Commission.
We are aware of a small number of former employees who have sought to damage the reputation of the hospital. Over the last 18-24 months, complaints arising from these disgruntled individuals have given rise to regulatory surveys that in each instance determined that the hospital is in compliance with regulatory standards.
As a hospital we continue to be fully committed to continuous quality improvement and ensuring that every patient we treat receives quality care. When complaints are received we do our best to address those complaints as quickly and as thoroughly as possible. Given the nature of what we do, not every patient who receives services at Highland Ridge, or at any hospital, is going to be satisfied with their experience. Regardless, we will continue to strive for excellence in all that we do with an eye towards continuous quality improvement and positive patient outcomes.
Individuals can file a complaint with the Utah Department of Health by filling out this form. You can remain anonymous.