Holly Hill Under Scrutiny Again: State Finds Repeated Failures After Violent Patient Uprising

By Taylor Knopf

Just days earlier Christmas 2024, a group of female teen patients collapsed into nan nurse’s position and medicine room astatine a psychiatric infirmary successful Raleigh, wherever they tore down parts of nan ceiling, hurled objects astatine staff, damaged instrumentality and utilized syringes arsenic weapons. Several constabulary officers responded to nan disturbance astatine Holly Hill Hospital, and emergency responders took 7 patients to nan emergency room for monitoring owed to imaginable medicine ingestion. 

According to a authorities study connected nan incident, unit members panicked and immoderate huddled successful nan area while an emergency codification was called, which summoned much labor from different areas of Holly Hill’s field successful downtown Raleigh, adjacent WakeMed Hospital disconnected New Bern Avenue. Some patients sewage into nan room wherever medications are stored, which had been propped unfastened by nursing staff because immoderate of them didn’t person a cardinal to unlock it. 

“Seemed for illustration 1 point aft another, and it sewage retired of power fast,” 1 infirmary worker told authorities regulators who investigated nan incident. 

The 347-page authorities report connected what happened from nan N.C. Department of Health and Human Services is highly redacted. However, a summary of video surveillance from that time successful a national report describes patients throwing and damaging phones, smashing ipads, throwing machine monitors, keyboards, shoes and cans of soda, immoderate of which deed infirmary employees. The 7 unit members and six patients described successful nan incident are anonymized successful nan report.

One diligent threw and destroyed aesculapian records, according to nan video surveillance summary. Another stole pills from nan medicine room and scattered them connected nan floor. The study described a diligent trying to stab a infirmary worker successful nan neck pinch a syringe. Amid nan chaos, a diligent was seen climbing into nan ceiling supra nan nurse’s station, knocking down ceiling tiles and dislodging nan metallic dividers, which different patients past utilized arsenic improvised weapons against staff, according to nan video surveillance summary.

In nan state’s report, infirmary unit said nan business sewage “progressively worse,” describing it arsenic “overwhelming” and “quite traumatic” pinch nan helping of nan infirmary successful full “disarray.” One unit personnel told regulators: “When I near I thought ‘thank God I’m alive. Someone could person gotten earnestly hurt.’” 

Other infirmary labor told regulators “they did not ‘feel’ that patients were safe pinch nan number of staff” and that nan installation was “hiring inexperienced unit that person ne'er worked pinch intelligence wellness patients.” 

Holly Hill’s CEO Leigh Holston told NC Health News successful an email that during nan diligent uprising, infirmary unit activated a accelerated consequence squad and requested backup from nan Raleigh Police Department, whose support was appreciated. Patients, families and unit sewage debriefings, and she said that activity conducted “a guidelines origin analysis” to create and instrumentality an contiguous action plan.

In consequence to nan convulsive incident, regulators placed nan infirmary under “immediate jeopardy” — nan most terrible sanction a infirmary tin receive. It intends that superior harm aliases decease has aliases is apt to hap to 1 aliases much patients, and it requires contiguous action. Under contiguous jeopardy, a infirmary must taxable a scheme of correction that’s acceptable to regulators by a deadline aliases consequence losing their expertise to measure federally funded security for illustration Medicare — thing that would cripple astir facilities.  

Holly Hill has had 3 contiguous jeopardy sanctions successful nan past 5 years. 

Officials pinch nan authorities Department of Health and Human Services said that putting a infirmary nether this terrible punishment utilized to beryllium infrequent, and aggregate contiguous jeopardies astatine 1 infirmary was moreover much rare. Now, authorities regulators told NC Health News, they find vulnerable conditions astatine hospitals much often, which is forcing authorities officials to talk astir what steps they request to return to guarantee diligent safety. 

“Repeat noncompliance astatine this level of severity is troubling,” nan authorities wellness section said successful an emailed statement.

State records item years of superior shortcomings astatine Holly Hill that person been documented by national and authorities regulators during a twelve on-site investigations into diligent complaints complete nan past 5 years. The repeated deficiencies include: diligent escapes, allegations of intersexual and beingness assaults, missing curen plans, medicine errors, contraband connected patients, archiving issues successful patients’ aesculapian charts, unsafe diligent discharge practices, unsanitary surviving conditions and deficiency of connection mentation services. 

These issues are not isolated to Holly Hill. The hospital’s genitor company, Universal Health Services, has faced aggregate lawsuits successful caller years and was nan taxable of a scathing report titled Warehouses of Neglect released past twelvemonth by nan U.S. Senate Finance Committee. The committee study claimed that nan company, which operates 181 inpatient behavioral wellness facilities successful nan U.S. — including 3 successful North Carolina — offered minimal treatment, mediocre conditions and excessively fewer staff, pinch galore lacking due training, each successful an effort to maximize profits. 

Universal Health Services responded pinch a statement that calls nan committee’s study “incomplete and misleading.”

Holly Hill’s CEO Holston declined to beryllium interviewed for this communicative and answered immoderate of NC Health News’ questions by email. In consequence to nan galore deficiencies cited by authorities regulators, Holston wrote: “When we place an area wherever betterment is needed, we respond pinch a consciousness of urgency.” She besides said that “[…] location person been sporadic incidents that required nan creation of action plans to reside deficiencies and found improved processes. […] Each clip a deficiency has been identified, Holly Hill worked wrong nan scope of regulatory requirements to correct and support compliance for an improved diligent experience.”

Despite nan infirmary submitting aggregate plans of correction that person cleared its contiguous jeopardy sanctions, regulators continued to find immoderate of nan aforesaid issues astatine Holly Hill — twelvemonth aft year. 

Repeat offenses

When regulators analyse diligent complaints, they tin do planned and astonishment tract visits astatine nan infirmary and look astatine a snapshot successful clip done a mini number of diligent records picked some selectively and astatine random. They reappraisal these records, question and reply a prime number of labor and patients, and reappraisal disposable video surveillance. 

NC Health News requested and reviewed much than 700 pages of records detailing authorities regulators’ investigations astatine Holly Hill from 2020 to nan present, and location were respective areas of repeated violations.

Unsanitary conditions

In their reports, investigators see elaborate descriptions of surgery and soiled surviving conditions astatine Holly Hill. In March 2023, regulators documented “red colored splatter” connected bath walls, “dried urine streams … connected nan toilet,” overflowing trash, “what looked to beryllium blood” complete nan apical of a door, and a room that smelled powerfully of sewage. Walls, furnishings and a model were damaged. Cleaning logs were not provided to regulators upon request.

Earlier this year, regulators witnessed roaches crawling down nan java machine and ants successful nan time room. Patients said that location were roaches successful nan consequence bowls and astir nan crystal machine. They wrote that nan level was “black, soiled pinch grit and was sticky” pinch “red dried constituent connected a wall and level and descend area.” Chairs and walls were damaged arsenic well. 

One unit personnel told authorities regulators that nan installation was excessively short-staffed to behaviour regular inspections.

The hospital’s CEO told NC Health News successful an email that “sanitation and cleaning is simply a campus-wide privilege that is managed by our on-site Environmental Services and Housekeeping teams. Water and sewer systems are routinely checked and verified to guarantee they are compliant pinch State regulations.”

Medication errors

Regulators flagged medicine errors during connected tract investigations successful 2020, 2021, 2023 and 2025, including incidents wherever patients were fixed nan incorrect medicine and location was nary investigation aliases study done, arsenic required. Additionally, nan infirmary was cited for 2 incidents wherever patients had access to nan medicine cart and nan room wherever medications are stored — some of which should beryllium locked. 

The CEO astatine Holly Hill maintains that nan infirmary follows each state-mandated standards for medicine management and has value controls successful place.

Discharge issues

In June 2020, nan infirmary was put nether contiguous jeopardy, successful part, because unit “failed to supervise nan handoff of a vulnerable, incompetent big diligent during departure from nan facility,” the study reads. Much of nan incident described successful authorities records is redacted, but what is clear is that a receptionist opened nan beforehand doorway astatine this patient’s petition and nan diligent near earlier their thrust arrived. The patient’s whereabouts were unknown betwixt nan clip nan diligent walked retired nan doorway of Holly Hill and erstwhile they were discovered 28 hours later astatine a infirmary emergency room. Regulators wrote that location was nary incident study aliases investigation done.

Less than a twelvemonth later, successful February 2021, regulators cited nan infirmary for discharging nan incorrect patient. Holly Hill unit put a diligent successful a cab and erstwhile they arrived astatine nan adjacent facility, it was discovered that Holly Hill sent nan incorrect patient. The full ordeal led to nan diligent being missing from Holly Hill for 10 hours. Again, regulators recovered nan infirmary didn’t archive this error. 

Holly Hill’s CEO Holston said successful an email that Holly Hill patients person a discharge bid from a expert who approves nan proscription plan, pinch patients retaining nan correct to participate successful their discharge decisions. She said that ineligible guardians are progressive erstwhile applicable, and nary incident study is generated if nan discharge follows nan physician’s order.

Translation services

During that aforesaid 2021 visit, regulators recovered Holly Hill didn’t supply connection translator services for a Spanish-speaking diligent for nan first 20 hours of their infirmary stay. The diligent was restrained successful a beingness clasp for 58 minutes only 7 hours into their stay, incapable to pass pinch staff. A caregiver wrote successful nan patient’s chart: “Patient refuses to speak English, speaks Spanish and answers successful Spanish.” 

One twelvemonth later, Holly Hill was cited again for failing to supply a connection assistance device for a patient. Hospitals are required by their accrediting agency to supply connection mentation services. 

“Holly Hill respects patients’ taste differences and useful according to regulatory standards to guarantee that patients tin pass appropriately pinch our unit and members of their curen team,” nan hospital’s CEO wrote successful response to questions astir connection translator issues. 

Treatment plans

Over aggregate inspections, investigators cited nan infirmary for failing to complete aliases update required curen plans — basal archiving guiding a patient’s care. These plans are expected to beryllium completed and entered into a patient’s grounds wrong 72 hours of admission. In March 2022, regulators reviewed a sample of diligent charts and recovered immoderate curen plans were completed betwixt six and 12 days aft patients were admitted. One diligent ne'er had a curen scheme astatine all.

Two years aft that, nan infirmary was again cited for failing to complete aliases update diligent curen plans. Earlier this year, regulators cited nan infirmary staff for failing to archive required regular group therapy and failing to guarantee that patients received follow-up appointments and prescriptions earlier leaving nan infirmary successful respective diligent charts they reviewed. 

When regulators questioned a unit personnel astir nan deficiency of curen plans, they responded: “It wouldn’t astonishment maine if it’s not there, we are highly short staffed.”

Enough unit to support patients safe?

In consequence to questions astir staffing astatine Holly Hill, infirmary CEO Holston wrote successful an email that nan infirmary meets each authorities requirements astatine its 296-bed installation and that staffing is reviewed routinely. “We summation unit to meet nan needs and acuity of nan patients we service connected a regular basis,” Holston wrote.

However, numbers of unit required for psychiatric accommodation are vague astatine the state and federal levels. There is immoderate guidance astir having a minimum of 1 caregiver and expert disposable astatine each times, but nary patient ratio is specified. Most of nan national guidance boils down to having “adequate” unit to meet nan needs of nan diligent organization and nan halfway functions of a infirmary — information and treatment.

A erstwhile regulator who conducted investigations astatine psychiatric hospitals astir nan state for nan national authorities said that staffing issues are often nan underlying problem erstwhile a infirmary is cited for escapes, intersexual maltreatment aliases deficiency of curen plans. Keeping eyes connected patients is nan only measurement to genuinely support them safe, nan regulator said. Federal rules group by nan Centers for Medicare and Medicaid Services do not see circumstantial numbers for staff-to-patient ratios. 

The erstwhile regulator, who wished to enactment anonymous owed to their existent work, explained that nan number needed often changes depending connected nan population. For example, children, patients pinch criminal charges, aliases those successful crisis, pinch predominant admissions and discharges, each should person much unit members attending to them.

The erstwhile regulator said that value intelligence wellness attraction is inherently staff-intensive and costly, and they said they’ve seen immoderate hospitals — peculiarly for-profit accommodation — effort to prevention money by keeping staffing lean. 

A psychiatric caregiver who worked astatine Holly Hill for 8 years told NC Health News that nan installation was chronically understaffed and had precocious turnover, calling nan staffing matrix nan facility’s “number 1 problem.” 

The erstwhile nurse, who is employed astatine a different North Carolina psychiatric installation and wished to enactment anonymous, said different nurses and intelligence wellness technicians were often overwhelmed, often caring for ample numbers of patients pinch small support. A important number of Holly Hill unit worked location part-time while moving full-time jobs elsewhere, nan erstwhile caregiver claimed. They would quit, unwilling to tolerate unsafe, exhausting conditions for nan other money.

Holly Hill’s genitor company, Universal Health Services, “denies allegations that its accommodation run without capable unit to support patients safe and supply due treatment,” wrote UHS Public Relations Director Jane Crawford successful an emailed connection to NC Health News. 

“Staffing tin beryllium a situation successful this tight labour market, successful immoderate markets and successful immoderate geographies. To reside this, UHS has improved processes for recruiting and retention,” Crawford said. “We besides person invested successful caller exertion to assistance our objective staff.”

Over nan past respective years erstwhile regulators interviewed labor astatine Holly Hill astir nan deficiencies aliases incidents they were investigating, unit many times placed nan blame connected caller hires aliases being short-staffed. 

Sexual abuse

One of nan astir superior citations crossed aggregate investigations astatine Holly Hill is for failing to forestall patient-to-patient intersexual abuse. 

In June 2020, Holly Hill was put nether contiguous jeopardy, successful part, for “failing to supervise and show hygiene clip to forestall abuse,” regulators wrote successful their report. The infirmary grounded to behaviour an soul investigation aft a diligent reported an maltreatment incident and grounded to notify nan doctor, which is nan hospital’s policy. 

“We don’t cognize really it (the incident) happened,” nan hospital’s consequence head told regulators. 

One twelvemonth later, Holly Hill was put nether contiguous jeopardy again, successful part, for failing to show big and teen patients to forestall 2 incidents of patient-to-patient intersexual contact. In June 2021, regulators recovered that unit had not monitored nan progressive patients each 15 minutes arsenic they were expected to. 

Regulators viewed time-stamped video surveillance arsenic portion of their investigation of a intersexual maltreatment report, and they recovered that a intelligence wellness technician had documented a diligent successful 1 portion of nan infirmary astatine a clip erstwhile they were seen elsewhere connected nan video footage. 

“Findings revealed nan intelligence wellness technicians falsified archiving of 15-minute observations,” regulators wrote successful their report. 

When asked astir this alleged grounds falsification, Holly Hill CEO Holston wrote successful an email that “Holly Hill uses a 2 identifier process for identifying patients. This process immunodeficiency successful reducing risk. Holly Hill invested successful physics diligent rounding that captures patients’ photos to guarantee that each diligent is correctly identified.”

The hospital’s main nursing serviceman told regulators that nan 2 intelligence wellness technicians connected nan portion astatine nan clip were suspended for missing their mandatory diligent checks and that some had been caller hires. The caregiver executive admitted to regulators that nan infirmary shouldn’t person put 2 caller labor connected nan aforesaid shift: “That’s thing we should return ownership of.” 

These intersexual battle allegations are not isolated incidents. Raleigh Police Department has received 147 calls for work to Holly Hill owed to intersexual offenses and 24 for rape aliases to prime up a rape kit from Jan. 1, 2019, to May 6, 2025. Officers are besides called to thief find patients who flight Holly Hill.

On nan tally for days

On nan time her teenage boy was admitted to Holly Hill, Kathleen — identified by first sanction only to protect nan privateness of her kid — received 2 telephone calls. The first was to fto her cognize that her boy had been punched successful nan look by different patient. The 2nd was to pass her that her boy had escaped. 

Holly Hill unit told nan mother that they couldn’t find her son.

Kathleen’s son, a sophomore successful precocious schoolhouse astatine nan time, and different teen boy connected his portion scaled nan exterior wall of nan outdoor recreation abstraction while unit weren’t paying attraction successful 2021, she told NC Health News. They were connected nan tally for days, sleeping successful nan woods pinch nary telephone access, earlier section constabulary yet recovered them, according to Kathleen. 

Raleigh Police Department records show officers person received 17 calls related to escapes astatine Holly Hill since 2019. State regulators investigated respective incidents astatine Holly Hill successful June 2021 — nan aforesaid clip play described by Kathleen — including nan flight of 2 patients. Regulators put nan infirmary nether contiguous jeopardy — nan highest sanction. 

“In nan arena that a diligent attempts to time off nan premises of Holly Hill Hospital, our trained squad members return due actions to safely bring nan individual backmost to care,” nan infirmary CEO wrote successful an email to NC Health News. She besides said that further fencing was installed astir nan outdoor greenish spaces.

During admittance to nan hospital, nan 2 patients who escaped should person been identified arsenic “at consequence of elopement” — aliases moving distant — and were not, according to regulators. They besides should person been monitored by 2 labor while outside. Instead, regulators recovered that only 1 worker — who was sitting astatine a picnic array looking astatine their telephone — was supervising 12 patients erstwhile 2 of them utilized a chair to jump complete nan fence. 

Kathleen had objected to her boy going to Holly Hill initially, erstwhile he was nether a court-ordered involuntary committedness successful a infirmary emergency department. 

“As a master successful nan [mental health] field, I’ve had galore experiences pinch moving pinch and supporting families whose loved ones person been astatine Holly Hill and had very bad experiences,” she told NC Health News. “It’s not up to parents erstwhile they nonstop retired a referral. It goes to each nan places and nan first spot pinch an disposable furniture is wherever my boy would go. It wasn’t up to me, and I didn’t person immoderate say.”

She submitted a title against Holly Hill Hospital pinch nan authorities Department of Health and Human Services and received a missive successful nan message dated June 28, 2021, saying nan authorities would investigate. 

Kathleen ne'er heard thing more.

Is nan authorities doing anything?

Sen. Jim Burgin (R-Harnett) said he’s been portion of 3 state-level meetings specifically astir issues astatine Holly Hill Hospital. 

“We can’t support having these conversations. Seems for illustration we’ll person nan speech and it will benignant of settee down, and a mates of years later, we will person this speech again,” said Burgin, who is successful his 4th word astatine nan authorities legislature and has taken a typical liking successful improving intelligence wellness care. 

“I’m ashamed to opportunity that it’s not new,” nan legislator said, referring to complaints alleging assaults, intersexual maltreatment and different mediocre curen wrong North Carolina’s inpatient psychiatric settings. “It’s not caller news, and it seems for illustration astir nan clip we hole 1 spot aliases get it to wherever we either unopen a spot down aliases get group retired aliases something, it comes backmost up. 

“And nan bigger chat needs to be: ‘Why?’” 

“We request to beryllium having a safe situation wherever they’re protected and they’re getting services,” Burgin said. “I don’t want group warehoused. And if we’re putting group successful a business wherever we’re not getting them into a curen plan, past each we’re doing is holding them.”

There has been a concerning summation successful nan number and severity of complaints against hospitals successful North Carolina lately, according to Karen Burkes, acting lawman caput of wellness astatine nan N.C. Department of Health and Human Services. The wellness department’s enforcement arm, the Division of Health Service Regulation, useful pinch national regulators astatine nan Centers for Medicare and Medicaid Services to analyse nan complaints.

“We admit we person immoderate hospitals wherever we’re perpetually seeing those IJs [Immediate Jeopardies], they’re resolving those deficiencies, and past we’re seeing them again, because they commencement to slip,” Burkes said. 

State wellness officials have been asking authorities lawmakers to summation their regulatory budget to prosecute much unit to analyse these complaints, but their fund has mostly remained flat. With constricted unit resources, Burkes said, it’s unfair to each nan complaints that request to beryllium investigated for nan section to support going backmost to nan aforesaid accommodation complete and over. 

“So location are immoderate conversations astir ‘what do we do next?’” Burkes said. “What are immoderate different options that we have? Because what has presently been happening isn’t really resolving that rumor that we’re facing.”

When asked what further options authorities and regulators could return beyond issuing contiguous jeopardy sanctions to Holly Hill, Burkes said she would person to travel up. When pressed further for specifics, nan wellness section communications agency sent an email explaining that nan authorities and national wellness agencies are moving intimately together connected further enforcement measures, which they cannot stock until nan national wellness agency approves them.

Even arsenic wellness officials statement what to do next, Holly Hill is expanding. 

Coming Thursday: Holly Hill opens caller units to service much patients, including veterans and first responders, while partnering pinch section police. 

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