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State investigating Willow Springs after suicide


Note: This article mentions suicide, which is preventable. The National Suicide Prevention Lifeline is 988. Nevadans can reach services by calling, texting, or chatting online. 

Willow Springs, a youth residential treatment facility on Edison Way, is again being investigated by the state’s Department of Health and Human Services. 

A 15-year-old girl in late March died by suicide, according to the Washoe County Medical Examiner’s Office.

The girl was from California.

“State health inspectors have been at Willow Springs … to investigate a complaint and a facility-reported incident, but details on those inspections cannot be released until the process is complete,” said DHHS spokesperson Nathan Orme in late March.

He would not say whether the investigation was related to the suicide.

“That information is not released while in progress,” Orme added. “During the investigation [the DHHS’ Bureau of Health Care Quality and Compliance] does not request the facility’s root cause analysis, or any documentation regarding the facility’s reporting of the sentinel event.  

“Likewise, if there are deficiencies HCQC makes no mention of the fact that the circumstances were a sentinel event in the inspection report; rather, HCQC inspectors document the deficient practice as they would any other deficient practice.”

“Based on interview, record review, and document review the facility failed to ensure the minimum level of observation…”

— Dept. of Health inspector

A “sentinel event,” according to the state, is a “serious reportable event.” Such incidences are mandated to be reported to the state.

Willow Springs refused to comment. The facility’s Business Development Director Stephanie Brown hung up on This Is Reno when asked questions. 

“I’m not able to say anything,” she said before hanging up the phone.

She said she would only respond by email, but emails to her remain unanswered.

Suicide follows numerous citations, fines

Willow Springs has been cited for deficiencies by the state numerous times. Fines have amounted to tens of thousands of dollars, but the state allows such healthcare facilities to invest fine amounts into improvements in lieu of paying the fines. 

“State regulations allow for certain discounts or the ability for the facility to use the funds to help prevent the issue from reoccurring, instead of paying the fine,” Orme said.

Willow Springs was able to avoid paying the state nearly $40,000 for two separate citations – one for $17,000 in 2020 and one for $21,000 in 2019.

The facility was fined $17,000 during the pandemic after a riot that broke out, allegedly over a COVID-19 outbreak and short staffing.

“The center was severely short staffed, the inspectors found, with units of 10 or more children assigned a single mental health technician,” the Reno Gazette Journal reported at the time. “A sole housekeeper was tasked with keeping the entire hospital disinfected. She was so exhausted trying to keep up that she was near tears when inspectors interviewed her.”

The $17,000 fine was preceded less than a year before that by a $21,000 fine.

Willow Springs paid in 2021 a $3,000 fine in part because two patients were left unobserved and engaged in sex acts, behind a closed door and during a 20-minute period, “resulting in physical harm to a patient,” according to a state report. Staff also misidentified one of the youth.

The state inspector noted, “Based on interview, record review, and document review the facility failed to ensure the minimum level of observation…”

Willow Springs responded to the citation by saying “non-compliance will be corrected immediately, and addressed with staff re-education and/or corrective action…”

“Children who are hospitalized are frequently discharged without needed community-based services, which then can lead to more hospitalizations. Multiple hospitalizations then frequently lead to placement in residential treatment facilities.”— U.S. Department of Justice

The residential facility was mentioned during a U.S. Department of Justice investigation.

The Nevada Current reported in 2021:

A March 2019 Centers for Medicare and Medicaid inspection report of Willow Springs Center, a 116-bed private facility in Reno that also accepts wards of the state, says a 16-year-old admitted “with Bipolar disorder, Gender dysphoria, Borderline personality traits and anxiety disorder…  was attacked by a peer at the nurses station…  punched (47 times in the video) and kicked (3 times in the video) by a peer. (The patient) was send (sic) to the emergency room for evaluation and treatment.”

The following day, the youth was “discharged back to the facility with a head injury and concussion in stable condition.”

Two weeks later, the report says, the youth “was sleeping and three peers entered the room. Two peers held the door closed which prevented staff from entering. One peer held patient by the hair and punched P#1 in the face, the peer kicked P#1 in the face and threw P#1’s head up against a bookcase. P#1 sustained a broken nose, concussion and multiple bruises.”

The DOJ released its report in October 2022. 

It found facilities in Nevada were violating the American Disabilities Act “by failing to provide adequate community-based services to children with behavioral health disabilities, relying instead on segregated, institutional settings like hospitals and residential treatments facilities.”

The report called Nevada’s response to these issues a failure.

“The State’s failure to provide crisis and ongoing community-based services to children also results in admissions to psychiatric hospitals,” it notes. “Children who are hospitalized are frequently discharged without needed community-based services, which then can lead to more hospitalizations. Multiple hospitalizations then frequently lead to placement in residential treatment facilities.”

At those facilities, inspectors interviewed children “who reported discrimination, bullying, or lack of acceptance on the basis of sexual orientation and/or gender identity in these settings.”

“Children with disabilities should receive the services they need to remain with their families and in their communities,” Assistant Attorney General Kristen Clarke with the DOJ’s Civil Rights Division said in October. “The Civil Rights Division looks forward to working with Nevada to bring the State into compliance with federal law and prevent the unnecessary institutionalization of children.”

Willow Springs is owned by Universal Health Services, a Pennsylvania company with facilities all over the country. UHS recently reported a $168 million profit, according to Fierce Healthcare.

UHS also operates Northern Nevada Medical Center.

Bob Conrad
Bob Conradhttp://thisisreno.com
Bob Conrad is publisher, editor and co-founder of This Is Reno. He has served in communications positions for various state agencies and earned a doctorate in educational leadership from the University of Nevada, Reno in 2011. He is also a part time instructor at UNR.