The Florida Agency for Health Care Administration imposed an immediate moratorium on admissions at Peace River Center for Personal Development’s crisis stabilization unit in Bartow, Fla., after determining conditions at the facility presented a threat to patients, according to a July 17 order.
Here are four things to know:
- Video footage reviewed by investigators showed the patient vomiting repeatedly over several hours on June 28 without staff assessment, then exhibiting labored, irregular breathing in the dayroom overnight. According to the order, the registered nurse on duty was asleep in the nursing station when a security guard alerted staff to the patient’s distress; nearly 19 minutes passed before any staff member provided physical assessment or care, and CPR was never initiated by facility staff — EMS began compressions after arriving. Bartow police documented the patient’s death at approximately 3:52 a.m. June 29.
- AHCA found staff were unprepared to respond: one behavioral health technician couldn’t locate the facility’s automated electronic defibrillator (AED), the device’s batteries had expired, and staff described receiving no formal training in medical emergencies or AED use. The order also cites expired pediatric AED pads and expired EKG tracer paper found on-site.
- The facility’s director of quality told investigators the on-duty nurse falsified the patient’s chart, entering vitals as though they’d been taken at 2:30 a.m., during the window video confirmed he was asleep and no assessment had occurred. AHCA also said the admitting nurse practitioner cleared the patient for admission despite a known seizure history and new chest pain, in violation of the facility’s own medical-clearance policy. AHCA said the facility, licensed for 30 beds, had 13 patients at the time of the order.
- Beyond placing the nurse on a “do not return” list with his staffing agency, the order states Peace River has not conducted facility-wide retraining, in-services or other corrective action since the death. The moratorium immediately barred new admissions while the agency pursues further regulatory action; all other areas of Peace River Center remain operational, according to a statement from the center.
Peace River Center said in a statement shared with Becker’s, “First and foremost, Peace River Center extends its deepest condolences to the patient’s family and loved ones. The health, safety, and well-being of the individuals we serve throughout Polk, Hardee, and Highlands counties remain our highest priority.”
“This event has deeply impacted our organization. We are committed to thoroughly evaluating this incident, implementing the necessary corrective actions, and continually strengthening our practices to ensure the highest standard of quality, safety, and compassionate care for every patient we serve.”
“We have taken immediate action and are complying with requests from governing agencies.”
“In compliance with the moratorium issued by the Florida Agency for Health Care Administration (AHCA) for the Bartow Crisis Stabilization Unit, we are not accepting any new inpatient admissions at that location until AHCA lifts the moratorium.”
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.