4 hospital investigations find ‘no serious wrongdoing,’ despite patient suicide

LOUISVILLE, Colo. (KDVR) — A state investigation into Centennial Peaks Hospital found no serious wrongdoing after cases of suicide, attempted suicide and patients who said they were held against their will at the behavioral health center.

The series of site visits by the Colorado Behavioral Health Administration followed an attempted patient suicide in July, a completed patient suicide in September and two cases of patients insisting they were held against their will when they were ready to be discharged. The mother of one patient, who filed a complaint, found the state investigation underwhelming.

“Something seems amiss,” said Christy Bligh, whose 18-year-old daughter checked herself into Centennial Peaks Hospital in mid-January.

Her daughter and 28-year-old Jonathan Delgado, featured in a previous Problem Solvers investigation, both felt they were held hostage when they asked to be released. Bligh’s daughter checked herself into the hospital for some self-help.

“She thought, ‘I’ll kind of remove myself from outside pressures, check into an inpatient, spend a couple of days there, get some good coping mechanisms, get some good life skills,'” said Bligh, whose daughter would later feel she was being held for no legitimate reason when she asked to be released on her third day at the hospital.

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“At the point that she said she wanted to come home, she was put on a (mental health) hold. She was not informed that she was on a hold,” said Bligh, who added that when she showed up at the Louisville hospital to try to secure her daughter’s release, she was threatened with arrest for trespassing if she didn’t leave.

“It was honestly very scary. I mean, I was definitely extremely frustrated and concerned. I did not have access to any information,” Bligh said.

Investigators visited site, interviewed patients and staff

An investigator with the Colorado Behavioral Health Administration made a site visit on Jan. 18 and interviewed Bligh’s daughter and hospital staff. The investigator said she could not substantiate any findings of wrongdoing besides some minor paperwork issues.

The Behavioral Health Administration confirms that Centennial Peaks Hospital would have needed a court order to keep Bligh’s daughter in treatment past the original three-day hold and not notifying the patient of a court order would be a patient violation, but it “cannot confirm or deny if this patient was notified of a court order, as such information is considered identifiable health information” under state law.

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The Behavioral Health Administration will not confirm, because of patient privacy reasons, that Delgado and Bligh’s daughter are the two cases they investigated for keeping patients longer than necessary. But based on the inspection dates, the Problem Solvers have reason to believe those are the patients involved.

In Delgado’s case, he was never interviewed by state investigators with the Behavioral Health Administration, which admits its investigator only reviewed the patient’s medical chart to determine no wrongdoing by Centennial Peaks Hospital.

“There’s always another side of a story, and every patient should have a voice. These abuses, sometimes nobody does anything about it,” said Delgado, who said he was disappointed that the Behavioral Health Administration investigators did not attempt to contact him.

A spokesperson for the Behavioral Health Administration, while not confirming Delgado was the patient in question, said it did not contact the patient in the November case because the record review “was found to be dispositive, meaning it gave BHA all the information needed to make an informed and accurate decision.”

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Delgado said he was ready to be released after his first two weeks but wasn’t discharged until the day after the Problem Solvers inquired about his status. By then, he had been at Centennial Peaks Hospital for nearly a month.

“I think it was just to get paid. They (Centennial Peaks Hospital) just wanted to get paid,” said Delgado, referring to his Medicaid insurance.

“Insurance fraud is all I can think,” said Bligh when asked why she suspected her 18-year-old daughter, who was also on Medicaid, was kept six days when she was ready to leave after three days.

“She was released only after she secured legal representation,” Bligh said.

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She added that a letter from her attorney and the threat of media exposure finally led to her daughter’s discharge.

In 2020, Universal Health Services, which owns Centennial Peaks Hospital, paid $122 million to settle allegations by the U.S. Justice Department alleging it had engaged in Medicaid fraud “while also failing to properly discharge appropriately admitted beneficiaries when they no longer required inpatient care,” according to a Justice Department press release.

Just last week, Universal Health Services reported revenues of $14.3 billion for 2023.

A spokesman for Centennial Peaks Hospital told the Problem Solvers it entered into the 2020 settlement “in order to avoid the continuing costs and uncertainty of continued litigation. The company vehemently denies the allegations and was able to present significant evidence to effectively rebut the claims.”

In July 2023, a Centennial Peaks patient attempted to hang himself. A state inspection found “staff falsified round records” and failed to check patients every 15 minutes.

Sources told the Problem Solvers a staff member was fired as a result.

‘I did not feel there was any health care happening’

In September 2023, a 41-year-old patient killed himself with a knife found in the hospital cafeteria. According to an autopsy report, his “medical history included depression and post-traumatic stress disorder.”

Multiple sources told FOX31 the man had been on five-minute watches until the day of his death, when he was taken off the very restrictions that kept him monitored on his unit.

According to an investigative report obtained by the Problem Solvers, an inspector for the Behavioral Health Administration “recommended that Centennial Peaks Hospital consider how it may adjust the expectation that one staff is responsible for both utensil return and watching the beverage area in the cafeteria.”

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Centennial Peaks Hospital was not fined or threatened with a license suspension. Instead, the investigative reports from the Behavioral Health Administration essentially told Centennial Peaks to do a better job of following state protocols in the future.

“Based on our experience, I did not feel there was any health care happening,” Bligh said.

In a statement to FOX31, Centennial Peaks shared the following:

Bligh and her attorney have asked for her daughter’s medical records from Centennial Peaks, but they have yet to receive them six weeks later.

“She has a distrust of health care now,” said Bligh, who added her daughter came out of the hospital more traumatized than when she went in. “She’s scared. The experience was scary. And she came out of the hospital with infected wounds that we needed to seek medical treatment for.”

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