After a nearly eight-month investigation stemming from employee complaints and alleged abuses, the state has downgraded Albuquerque's Sequoyah Adolescent Treatment Center, one of the state's key mental health facilities, to a "temporary certification."---
Sequoyah is a state-run facility that provides 24-hour residential care to some of New Mexico's most violent and severely mentally ill teens. According to its website, the facility is "for treatment, not incarceration" and lists as a key bullet point its "culturally sensitive" outlook.
But a lengthy investigation by the state Children, Youth and Families Department show an on-the-ground reality far different from those lofty ideals.
Last month, CYFD sent Sequoyah a report detailing 15 violations the facility made, including injecting patients with drugs as a means to restrain them but failing to “promote the client’s health, safety and welfare.”
The report—which grew out of employee concerns and alleged violations of state regulations—affirms many of the concerns raised last fall in the employee memo, which have since led to two whistleblower lawsuits from two former employees after their terminations. As a result, CYFD's Licensing and Certification Authority downgraded Sequoyah, which is run by the New Mexico Department of Health, to being in only partial compliance with the state's certification requirements. The letter gives the facility a laundry list of tasks to complete to get back into good standing with state regulations.
DOH spokesman David Morgan writes to SFR that the issues at Sequoyah have since been "investigated thoroughly, safety and quality processes implemented and are continuing to be implemented."
"The final report from CYFD was a compilation of requirements for improvements over the last year," Morgan writes. "We have been working closely with our CYFD Monitor, Shauna Hartley to assure we are in and maintain compliance with all requirements from our partners from licensing."
One example of the facility's wrongdoing in the CYFD report includes how its staff restrained a patient who was "not a threat to self/others at the time of physical restraint" with an intramuscular injection, violating regulations.
In another instance, the report also documents how Sequoyah staffers restrained a patient who became “verbally abusive” and stood on top of a picnic table, slammed a door open and kicked a football. Sequoyah injected the patient with 50 milligrams of Thorazine, a powerful antipsychotic drug used to treat patients with schizophrenia. The problem? The patient presented no harm to justify such a restraint.
"Records reviewed did not contain documentation of imminent, serious physical harm to self or others at the time nursing obtained the order for restraint," the report reads.
The facility's practice of drugging patients doesn't stop there. Another violation cited in the report concerns Sequoyah patients who "consistently reported" that "their psychiatric medications had been changed without their consent," which violates a client's right to informed consent for prescription medication.
Sequoyah also failed to properly report how a patient stabbed one of the facility’s nurses. Although the nurse filed an assault complaint to the state police, the CYFD report still found Sequoyah guilty of “non-compliance to regulations related to the lack of Serious Incident Reporting…on this client-to-staff physical assault.”
Violations go all the way up to the administrative level and include "non-compliance to regulations related to staffing schedules, staff to client ratios and staff training."
At the end of the report, CYFD gives Sequoyah four direct action plans to bring the facility back into compliance with state regulations. They include conducting an audit of the facility as well as conducting a comprehensive quality improvement plan.
Morgan says DOH is currently recruiting nurses, therapists and technical staff "for program changes that meets and exceeds national standards for adolescent treatment."
DOH's full statement on Sequoyah:
The final report from CYFD was a compilation of requirements for improvements over the last year. We have been working closely with our CYFD Monitor, Shauna Hartley to assure we are in and maintain compliance with all requirements from our partners from licensing. The issues discussed in the article were investigated thoroughly, safety and quality processes implemented and are continuing to be implemented. We have partnered with Disability Rights New Mexico and SAMSHA to assure our program model continues to meet the needs of our clientele.
We are currently recruiting staff for nursing, therapy services and technical level staff and we are in the planning stages for program changes that meets and exceeds national standards for adolescent treatment.
Our plan for Sequoyah is to be a leading practices facility by integrating our boys into the community early on in their rehabilitation, center our program around community services and improve family involvement with our adolescent care and treatment.
Read the CYFD report below: