The hidden costs of the mental-health industry’s expansion

How a company’s push to expand psychiatric care brought peril

Photo of Torgesen
Marjorie Erickson holds a photograph of her mother, Rosemary Torgesen, in Shoreline. (Erika Schultz / The Seattle Times)
By Daniel Gilbert
Seattle Times staff reporter
Published August 25, 2019

On the first of Rosemary Torgesen’s 99 days as a patient at the Smokey Point Behavioral Hospital, her children felt the placement was especially promising — even providential.

Rosemary, 78 years old, had come to the brand-new psychiatric hospital in Marysville in a state of delusion, believing that a divine voice was instructing her not to eat or take medication. She had been involuntarily committed at least 17 times before and had always stabilized, returning to a routine centered on church and prayer.

Smokey Point was the first newly built psychiatric hospital in Washington state in decades, drawing patients from all over the state. It happened to be a short drive from where Rosemary lived with one of her seven children. Gov. Jay Inslee himself had attended Smokey Point’s ribbon-cutting, praising its executives for expanding access to mental-health care.

“Isn’t it a joy that we know that hundreds of Washingtonians are going to get better because of the Smokey Point Behavioral Hospital?” Inslee said at the July 2017 event.

The Torgesens couldn’t have known that a week before Rosemary was admitted, in March 2018, state inspectors had found problems so grave that they created a “high risk of serious harm, injury and death.” They didn’t know about patient-safety lapses that authorities had documented at other hospitals run by the same company, a for-profit firm called US HealthVest. But as weeks turned to months, they grasped that something was profoundly wrong with their mother’s care.

Rosemary had arrived high-stepping around the hospital. Three months into her stay, she couldn’t walk, had developed a dangerous wound from being bedbound, and appeared alarmingly gaunt. As the Torgesens pressed for more treatment options, the hospital’s staff suggested hospice care to allow her to die at home.

Her family was stunned.

“I got her in there when she was perfectly healthy,” recalled her son Douglas Torgesen, who had been her primary caretaker. Now, he said, “She just looked half dead right there.”

“I got her in there when she was perfectly healthy. She just looked half dead right there.” – Douglas Torgesen, son of Rosemary Torgesen

US HealthVest is at the vanguard of a quiet transformation in how patients receive care for mental health and drug addiction in Washington. Since 2012, the state has approved or expanded 10 private psychiatric hospitals, nine of which are for-profit. This expansion will add more than 850 inpatient beds in a state with one of the highest rates of mental illness and least capacity to treat it, holding the promise of specialized care for patients who often land in jails or hospital emergency rooms.

Primer: Washington's
mental-health care crisis

Link to read the overview of mental healthcare in Washington

Without doubt, the addition of Smokey Point has provided much-needed mental-health care to patients in an underserved area.

Yet the state’s early embrace of US HealthVest, after Washington’s own failures to meet patient needs, has brought a new peril into the system: a model proven to deliver profits that has routinely failed vulnerable patients, an investigation by The Seattle Times has found.

Smokey Point’s first chief executive, with no medical license, would weigh in on which patients to admit. Patients with serious medical conditions worsened while waiting for treatment that the hospital couldn’t provide. Executives failed to boost staffing despite pleas from employees and findings by regulators that conditions were unsafe.

As Smokey Point executives prepared for inspections, they repeatedly instructed nursing staff to fill in records that were incomplete or missing from patient files — even when it would have been impossible to accurately recall details, according to internal records and interviews with staffers. At another US HealthVest facility in Georgia, law enforcement accused the staff of “covering up their own neglect of patients” and “fraudulently documenting care.”

The problems at Smokey Point — and three other of the seven psychiatric hospitals US HealthVest operates across three states — surface in a review of thousands of pages of state health and law-enforcement records, internal documents, hospital records shared by patients and their families with The Times, and interviews with roughly two dozen current and former employees.

Last year, Smokey Point’s own incident log showed 88 assaults, 33 discoveries of contraband and 26 employee injuries. It’s hard to compare this record with other private hospitals, which don’t publicly disclose incident rates, but it stood out to regulators for what was missing: other assaults, suicide attempts and medication errors that weren’t logged into the system or investigated.

Smokey Point’s own incident log showed 88 assaults, 33 discoveries of contraband and 26 employee injuries.

Many mental-health facilities are struggling to recruit and retain qualified staff. Ensuring the safety of patients — who are often at risk of harming themselves or others — can be hard even in ideal circumstances. But no private mental-health care operator in Washington state in recent years has pushed to expand as rapidly as US HealthVest or racked up as many serious violations as quickly, records show.

Government inspectors have found violations at Smokey Point on 12 separate visits over 15 months. After meeting with senior US HealthVest executives and their attorneys, the Department of Health in June agreed not to take action against Smokey Point’s license in exchange for the company hiring a state-approved consultant, analyzing its failures, submitting an improvement plan and undergoing stepped-up monitoring for a year.

Separately, the Department of Health denied US HealthVest’s application to build a new psychiatric hospital in Bellingham.

Nate Weed
Nate Weed is director of Community Health Systems at the state Department of Health. (Steve Ringman / The Seattle Times)

“They’ve demonstrated that they don’t have a good track record of being able to care for patients safely, so we’re not going to allow them to do that,” Nate Weed, director of the Department of Health’s Office of Community Health Systems, said in an interview.

Yet the limits of this statement were on display just a 15-minute drive away from the regulator’s offices near Olympia, where US HealthVest recently opened a second psychiatric hospital. The department approved it before Smokey Point had opened its doors.

Richard Kresch, US HealthVest’s chief executive, did not respond to requests for an interview or provide answers to written questions. In a general response, he wrote in an email: “At Smokey Point, we care for many of the sickest members of our community. Our patients turn to us in crisis and we take our responsibility to provide the highest level of care in the safest of therapeutic environments with the upmost seriousness. We are first and foremost caregivers and the health and safety of our patients is our top priority.”

He added, “all of our hospitals have been fully compliant with all state and federal regulations.”

Many of the Smokey Point employees asked to remain anonymous because they were warned by executives not to speak to a Times reporter, or they worried it could hurt their ability to work in health care. One common complaint, confirmed by state inspections, was that the hospital was too thinly staffed to adequately care for patients.

In March of 2018, a nurse told state inspectors that there had been “many suicide attempts,” including three on a single recent day. “It was only a matter of time until someone dies,” the nurse said, because when patients need more staff to check on them “there is no one available.”

Inspectors asked the chief nursing officer about staffing and recorded this explanation: “corporate leadership asked him to be within budget.”

“They’ve demonstrated that they don’t have a good track record of being able to care for patients safely, so we’re not going to allow them to do that.” – Nate Weed, director of the Department of Health’s Office of Community Health Systems
Smokey Point Behavioral Hospital
Washington’s severe shortage of inpatient beds for psychiatric patients put pressure on state officials to add more capacity. Smokey Point Behavioral Hospital, a for-profit hospital in Marysville operated by US HealthVest, aimed to address the need. (Erika Schultz / The Seattle Times)

“Immediate jeopardy”

Kresch, US HealthVest’s founder, has made a career developing psychiatric hospitals and selling them for a profit. A psychiatrist by training, Kresch ran Ascend Health before selling it to industry giant Universal Health Services in 2012 for $503 million in cash.

US HealthVest was incorporated four months later, drawing well-heeled investors like Polaris Partners, which reportedly earned 10 times its investment by backing Ascend. US HealthVest has raised more than $180 million so far from investors and lenders.

Washington state was one of the first places where US HealthVest looked to establish a presence, and its timing was good. The state was in the midst of a mental-health crisis, with so few inpatient beds that emergency rooms were holding patients who had been involuntarily committed. The state Supreme Court in 2014 found this practice illegal, ratcheting up pressure on state officials to add more beds. Smokey Point directly addressed this need.

“Our patients turn to us in crisis and we take our responsibility to provide the highest level of care in the safest of therapeutic environments with the upmost seriousness.” ­‑ Richard Kresch, CEO of US HealthVest

To open the hospital, US HealthVest’s proposal had to pass muster with the Department of Health. Given that US HealthVest was a new company, the regulator considered the track record of Ascend, which had been run by the same executive team.

The department conducted a limited review of Ascend that turned up no red flags. Had the regulator looked a little further, it would have discovered serious violations that government inspectors found at an Ascend hospital in Houston in 2011 and in Salt Lake City in 2012.

In one case, in Houston, a man admitted for “aggressive homicidal behavior” was accused of sexually assaulting a female patient and briefly transferred to a male-only unit. The next night, a staffer found him assaulting another female patient in her bathroom, covering her mouth as she yelled for help. The male-only unit had been closed that day due to a “cost saving measure,” according to an inspection report.

At Smokey Point, staffers have become accustomed to measures designed to save money, according to employees and internal records.

Last January, Smokey Point’s nursing staff received a directive on US HealthVest’s approach to monitoring high-risk patients who needed to be watched at all times. Such monitoring is called “one-to-one” or “line-of-sight” — abbreviated as 1:1 and LOS — and often requires additional staff.

“Our corporate offices do not subscribe to the philosophy that 1:1 and LOS are needed for ongoing days at a time,” John Beall, Smokey Point’s chief nursing officer, wrote to his staff.

A couple of nights later, a nurse asked Beall for an additional staffer because two patients on a unit needed one-to-one observation. He responded that one patient was asleep and that sleeping patients do not require such monitoring.

“That’s not a staffing model US HealthVest uses,” Beall wrote back, according to screenshots of the correspondence that another staffer provided to The Times. “Please keep her well medicated & we will re-evaluate in the morning.” Beall declined to comment.

At Smokey Point, a staffing plan calls for one nursing employee for every four to six patients, depending on the unit. Still, a staff member can be alone on the floor with a dozen or more patients for at least an hour, according to current and former employees. While hospitals in Washington can be fined if they fail to staff appropriately, the law doesn’t apply to psychiatric hospitals like Smokey Point.

Christina Perry, a former Smokey Point nurse, often found herself alone tending to as many as eight patients for hours. “Every day I worked at Smokey Point Behavioral Hospital, I was afraid for my life and the lives of my patients,” she later said.

Christina Perry was a nurse at Smokey Point Behavioral Hospital from September 2017 through May 2018. “I felt helpless working there,” she said. “I felt like I didn’t have enough resources to make sure everybody was safe.” (Erika Schultz, Gabriel Campanario & Lauren Frohne / The Seattle Times)

There is no question that some patients have benefited from care they received at Smokey Point, which has provided Snohomish County residents with a treatment option much closer to home and their support networks.

One man, whose 17-year-old daughter spent three weeks there, said she left in much better health.

“They definitely helped her, and they provided something that I don’t think I could have,” said the father, whom The Times is not identifying to protect his daughter’s privacy. “I feel like it was definitely a positive experience.”

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Mary Hintz, 26, spent about 10 days at Smokey Point in February while her medications were adjusted. She felt safe and well-attended by staff. “It was just a great experience for me,” she said in an interview. “The doctor was amazing.”

Yet other patients complained of the lack of therapy, according to interviews and complaints filed with the Department of Health. Group sessions were often cut short or canceled, in some cases because there weren’t enough staff to run them. Patients passed time between meals playing with cards, puzzles, board games and coloring books.

One of the first hospital staffers to take his concerns public was Chris Lurvey, a mental-health technician, who emailed elected officials and the Department of Health in February 2018 to report numerous suicide attempts and fights between patients.

Cammy Hart-Anderson, a Snohomish County official whose division oversees mental-health services, also filed a complaint with the Department of Health. Patients had testified in involuntary commitment hearings that they didn’t feel safe, she wrote, and neither did county staff.

The next month, in March 2018, the Department of Health dispatched six inspectors to Smokey Point. Among their findings:

  • A suicidal patient was checked on with the same frequency as patients who were not suicidal. Six days into his stay, he was found unresponsive hanging from his bed sheets and taken to a medical hospital. Three days later, back at Smokey Point, the man made a second suicide attempt.

  • Another patient had a plan to kill herself by “banging her head as hard as she can into the wall.” She had been slamming her head into a wall, a nurse had written, but inspectors found no evidence that staff intervened to stop her.

  • A staff member threw away the catheter that a “wheelchair bound” patient used to manage a urinary condition, only for another staffer to remove it from the biohazard trash, wash it off and return it to the patient.

  • One diabetic patient had a foot ulcer and had a referral to a wound-care clinic “as soon as possible.” Instead, the wound worsened for another nine days until the patient was sent to a medical hospital.

  • An aggressive patient was found having sex with a developmentally disabled woman, hours after he was ordered to stay five feet away from all female patients. When a mental-health worker asked if the encounter was consensual, the woman said it was. “He was sent by God to have babies with me,” she said, according to state investigative findings. US HealthVest didn’t respond to whether the matter was referred to law enforcement.
  • The inspectors declared a state of “immediate jeopardy,” the most serious kind of violation that can put patient lives in danger, triggering a process to cut off the hospital’s access to federal funds. For facilities like Smokey Point that rely heavily on reimbursement from taxpayer-funded Medicare and Medicaid, such a penalty could have had a dire financial impact.

    A week after the inspectors issued their findings, Smokey Point admitted Rosemary Torgesen.

    Rosemary Torgesen
    Rosemary Torgesen is seen on Christmas Eve in 2017. Just three months later, Torgesen, who had schizophrenia, was involuntarily committed and admitted to Smokey Point Behavioral Hospital. (Courtesy of Jeffrey Torgesen)

    A more appropriate place

    Rosemary stood 5 feet tall and weighed barely 100 pounds, a diminutive stature that contrasted with an exceptionally strong will.

    She had lived most of her life with schizophrenia while raising seven children. When her kids were grown, she volunteered for Catholic Community Services, helping seniors and disabled adults do household chores. She knew seemingly everyone’s name at the St. Mary’s Church in Arlington, and rarely let a kindness go unrecognized; one friend who gave her rides to church would later find money left in her car console.

    A county mental-health worker who evaluated Rosemary in March 2018 determined she was “gravely disabled,” meaning her disordered mind presented a serious threat to her physical health. A judge agreed she met the criteria for involuntary commitment. The question was where to send her.

    At Smokey Point, whenever there was a question about whether it was appropriate to admit a patient, the chief nursing officer would consult with the hospital’s chief executive, Matt Crockett, who held no medical license, according to state records. A physician assistant told inspectors last year that some patients were admitted after a doctor had ruled them too medically fragile to accept.

    Rosemary, who also had a heart condition, was the oldest patient Smokey Point had ever admitted. A county mental-health worker later reported to the state that Crockett had ordered her to be admitted over the objections of a medical doctor. A state investigator found “no evidence” of this, but made no attempt to identify or interview the doctor.

    Crockett, now the interim chief executive of Wellfound Behavioral Health, a new psychiatric hospital in Tacoma, didn’t respond to emails and phone messages seeking comment.

    Almost as soon as Rosemary arrived, Smokey Point’s nursing staff recognized that they lacked the ability to care for her. Staffers said she refused to let them check her vitals, which prevented them from giving her an antipsychotic medication. Two weeks into her stay, a nutritionist recommended that she be “sent to a more medical psych unit” due to “not being able to monitor pt appropriately,” using the shorthand “pt” for patient.

    Almost as soon as Rosemary arrived, Smokey Point’s nursing staff recognized that they lacked the ability to care for her.

    The Torgesen family had another facility in mind: Northwest Hospital in Seattle, operated by UW Medicine. Rosemary had been there for electroconvulsive therapy, which sends electric currents through the brain to alter its chemistry, and had responded well. The procedure is performed under general anesthesia and could not be done at Smokey Point. Her children asked the hospital to transfer her to Northwest.

    Smokey Point’s staff made several efforts to contact Northwest, Rosemary’s medical records indicate. But for reasons that are unclear, no appointment was made.

    A month later, on May 8, a Smokey Point psychiatrist finally sent Rosemary to Northwest Hospital’s emergency department to evaluate her for admission there. A mental-health counselor examined her with some confusion. Rosemary’s family wanted her to be treated there, he wrote, but “Smokey Point staff present in ER are unaware of why pt came from Marysville to Seattle to be seen in the ER.” He added, “Pt has not been discharged from their facility.”

    Rosemary herself was frustrated. “This is a waste of money,” she told the counselor, rattling off the lab costs, the ambulance rides and the staff’s time.

    It was, in fact, a wasted effort. Northwest said its geropsychiatric unit was full and couldn’t admit her. She was sent back to Smokey Point.

    “Hundred percent success rate”

    Kresch, US HealthVest’s chief executive, has spoken candidly about the company’s focus on profitability, boasting of a “hundred percent success rate in turning around all of the distressed hospitals we have acquired.”

    • Thank you for reaching out to us regarding Smokey Point Behavioral Hospital and raising these concerns. At Smokey Point, we care for many of the sickest members of our community. Our patients turn to us in crisis and we take our responsibility to provide the highest level of quality care in the safest of therapeutic environments with the upmost seriousness. We are first and foremost caregivers and the health and safety of our patients is our top priority.
    • We opened Smokey Point Behavioral Hospital in 2017 in response to the mental health crisis in Washington. Prior to our opening, many residents were forced to leave the area and travel long distances for care or to forgo care altogether. Smoky Point Behavioral Hospital is the first new psychiatric hospital to open in Western Washington in over 50 years. We have treated nearly 4000 patients and most of the patients who we treat are funded by Medicaid and Medicare programs and are among the neediest members of our community. Smokey Point has been and continues to be, fully compliant with all state and federal regulations. We continue to work proactively with the state on a voluntary basis to achieve the highest levels of quality care.
    • As you likely know, federal and state mental health spending has decreased dramatically over the past few decades which has ultimately led us to the significant crisis we see today. The recent coverage of KOMO TV’s “Seattle is Dying” and the recent stabbing at Nordstrom in downtown Seattle are continuing to bring this critical conversation to the forefront. Our organization was founded to increase access to behavioral health care by providing high-quality, individualized services to all patients in need, regardless of ability to pay. Our team has operated 21 psychiatric hospitals over the years and all of our hospitals have been fully compliant with all state and federal regulations.
    • Sincerely, Richard A. Kresch, MD

    The company’s flagship hospital, Chicago Behavioral, was such an example. The facility had been run by a nonprofit that was losing money and planning to close when US HealthVest acquired it in late 2014. By the end of 2016, it turned a $7.3 million profit, according to its financial statements.

    A different picture, though, emerges from regulatory and court records. Regulators found serious violations at Chicago Behavioral four times in less than two years, including an immediate jeopardy to patient safety in May. Inspectors found the hospital failed to conduct safety checks on patients, provide individualized care and investigate alleged sexual abuse. The company is contesting two wrongful-death lawsuits filed by the families of patients who died of medical emergencies within a four-month span in 2016.

    Similar problems emerged at the company’s two hospitals in Georgia.

    At the Ridgeview Institute in Smyrna, on the outskirts of Atlanta, regulators found the hospital was providing “generic non-individualized treatment.” The shortcomings were more serious at a second hospital US HealthVest opened 60 miles east, the Ridgeview Institute in Monroe.

    Last year, Georgia regulators received a complaint that nursing staff at the Monroe facility “are forced to provide minimal and unsafe care and monitoring to patients.” The tipster expressed particular concern about an unnamed young woman, admitted to Ridgeview in January of 2018.

    Sarah Reum
    Sarah Reum, 22, died by suicide Jan. 20, 2018, while she was a patient at US HealthVest’s Ridgeview Institute in Monroe, Georgia. Later that year, another patient there killed himself. In both cases, security video shows both patients, on suicide watch, were left alone for more than an hour when they were supposed to be checked every 15 minutes. (Courtesy of the Reum family)

    The patient in question was Sarah Reum, a 22-year-old with hazel eyes and a smooth voice that had won singing competitions. She had two young daughters, a tumultuous relationship with their father and a mental illness she had struggled with since she was a teen.

    Reum was admitted to Ridgeview under Georgia’s involuntary treatment law and flagged as a suicide risk. She, like all patients, was to be checked on at least every 15 minutes.

    On her eighth day at Ridgeview, Reum called her mother and asked to speak to her 3-year-old daughter. “‘I love you so much, I love you so much,’ she probably said it nine times,” her mother, Stacey Jenkins, recalled.

    The next day, hospital records show that Reum was checked on as required. But its camera footage, reviewed by The Times, tells a different story.

    At 4:04 p.m., a camera records Reum sitting in a chair in view of the nursing station, hands to her face, shoulders shaking.

    After two minutes, she gets up and walks down the hall to her room.

    Fifteen minutes go by without anyone checking on her. Thirty minutes pass. Forty-five minutes. An hour.

    At 5:12 p.m., a staffer enters her room, turns and runs down the hall to the nursing station, motioning for others to come.

    A nurse and another staffer accompany her, in no apparent hurry, to Reum’s room.

    More staff come running, followed by police and paramedics, but they are too late.

    Shortly after 6 p.m., Sarah Reum was declared dead by suicide.

    Health inspectors reviewed records of all four units at Ridgeview over 16 days, finding that they were inadequately staffed between 31% and 69% of the time.

    Jenkins and Reum’s father, Ricky Reum, didn’t know that no one checked on their daughter for an hour until contacted by a Times reporter. They didn’t know the unit where their daughter stayed was short-staffed the day she died. They didn’t know that regulators faulted the hospital for their daughter’s death, or that the hospital had fired two employees as a result and hired a new head of nursing — all of which it described as “corrective actions.”

    They were also unaware that Gina Holbrooks, a Monroe Police detective who investigated Reum’s death, concluded that the hospital’s observation log “was falsified as if staff was actually providing care to their patients.”

    In May, Reum’s parents and the father of her daughters sued US HealthVest. The company is contesting the lawsuit and denies that it falsified records, according to its legal response.

    Jenkins still chokes up thinking about milestones Reum is missing, like her older daughter’s first day of school this month. “She didn’t get to see it because somebody didn’t do their job,” she said.

    Her older daughter’s first day of school was this month, but Reum “didn’t get to see it because somebody didn’t do their job,” said Reum’s mother, Stacey Jenkins.

    The state inspectors who investigated Reum’s death determined the hospital had fixed the problems by the time they showed up two months after her death. Six months later, law enforcement responded to another emergency at the hospital.

    Joseph Morris, a 46-year-old patient admitted the previous day for suicide risk, was found dead hanging from a bedsheet in his room. While Ridgeview records showed that he had been checked on every 15 minutes, video footage revealed he was alone in his room for 93 minutes, according to a police report.

    When the coroner informed Morris’ family of his death, his father slumped to the floor. “It is a lie,” his mother said repeatedly, according to the police report. How, she cried, could someone on suicide watch die by suicide in a hospital?

    Holbrooks, the detective who also had investigated Sarah Reum’s death, didn’t disguise her anger in concluding her report.

    “Once again Ridgeview Institute has put more effort into covering up their own neglect of patients,” she wrote, “by fraudulently documenting care.”

    “A family’s shock”

    At Smokey Point, some employees hoped US HealthVest would take Washington state’s investigation to heart and improve conditions. Instead, the turmoil only intensified.

    Days after inspectors left the building in March 2018, executives fired three nursing employees — including one who had been promoted four months earlier — for violating a policy called “solicitation.” The company didn’t elaborate on the reason, but employees believe the message was clear: All three had discussed forming a union.

    The three employees filed a complaint with the National Labor Relations Board, and the hospital ultimately agreed to pay each of them back pay, interest and $10,000 instead of reinstating them.

    Other employees left of their own accord. Christina Perry tendered her resignation in mid-May. “I do not feel safe working here since there is not enough staff,” she wrote to the chief nursing officer.

    Christina Perry
    Christina Perry resigned from her position as a nurse at Smokey Point. “I do not feel safe working here since there is not enough staff,” she wrote to the chief nursing officer. (Erika Schultz / The Seattle Times)
    “Every day I worked at Smokey Point Behavioral Hospital, I was afraid for my life and the lives of my patients.” – Christina Perry, former Smokey Point nurse

    Concern wasn’t limited to staff tending to patients. Lejla Marusic, a senior manager whose job was negotiating with insurance companies, also resigned in May. She said of the hospital’s executives, “They were only focused on passing the next audit, not the well-being of patients.”

    One persistent focus has been on supplementing patient files missing required paperwork, a struggle compounded by short-staffing and turnover, according to internal memos and staffers.

    Patient files, tagged with sticky notes to signal missing information, have at times been so numerous that they were deposited in the hospital’s “yoga room,” internal records show. Employees who failed to complete the charts would face disciplinary action, they were told as recently as March.

    A new chief nursing officer, who replaced Beall last fall, also told staff, “Don’t sign for something you didn’t witness.” But several current and former employees said that too much time had passed to accurately fill in certain incomplete records, such as what a patient was doing in 15-minute intervals days or weeks earlier.

    When inspectors have arrived, staff have been told to remove sticky notes to avoid signaling that files are incomplete, former employees say.

    The hospital had more serious problems than record keeping.

    Listen to the June 16th 911 call

    Link to listen to the 911 call from June 16th

    On June 16, 2018, almost three months after she arrived, Rosemary Torgesen fell in the hallway and broke her arm. An emergency physician who examined her at the nearby Cascade Valley Hospital also noted a second possible injury: to her right hip. X-rays showed a deformity in her hip socket, but no fracture, and the doctor attributed it to arthritis.

    Within days, though, Smokey Point’s records indicate an abrupt change in her mobility.

    On June 20, she didn’t attend a therapy group due to being “bedbound” as a result of “fall and injury.”

    On June 24, nursing staff found she had a bedsore, an open wound near the base of her spine from staying in the same position. The woman who never complained said of her pain, “It’s terrible.”

    On June 24, nursing staff found Rosemary had a bedsore. The woman who never complained said of her pain, “It’s terrible.”

    Smokey Point’s staff had become so alarmed at her condition that they sent her to Providence Regional Medical Center’s emergency department in Everett, the fifth time they had done so since the beginning of her stay. An emergency-medicine doctor offered a strikingly different assessment.

    “Patient does not appear in imminent danger,” the doctor wrote on June 28. “It appears she needs more mental health treatment.” She was returned to Smokey Point.

    Smokey Point’s staff suggested a new course: discharging Rosemary home to her family and referring her for hospice care.

    Only then did Rosemary’s children suspect their mother had been neglected. “It was them admitting that they’re incapable of caring for her,” Jeff Torgesen, her oldest son, said.

    On June 29, Smokey Point held an emergency meeting with its medical director, chief executive and one of Rosemary’s daughters. Rosemary hadn’t had anything to eat or drink for at least four days. The hospital would send her to Providence and not accept her back.

    Ribbon cutting at Smokey Point Behavioral hospital
    In July 2017, Gov. Jay Inslee and Tulalip Tribes Chairwoman Marie Zackuse cut the ribbon at the Smokey Point Behavioral Hospital grand opening. Since 2012, the state has approved or expanded 10 private psychiatric hospitals, nine of which are for-profit. (Kalvin Valdillez / Tulalip News)

    “A strong supporter”

    Despite Smokey Point’s struggles, US HealthVest benefited from a key source of support: Gov. Inslee and his administration.

    Since Smokey Point opened, the pressure had only mounted for the governor to expand mental-health care options. In June 2018, state-run Western State Hospital lost its Medicare certification after failing to resolve a litany of patient-safety hazards, forcing the state to make up for lost federal funds.

    With Smokey Point and its two other planned hospitals, US HealthVest would add almost 300 inpatient beds, all funded privately.

    The company’s plans were challenged by rivals that were also seeking to build psychiatric hospitals. Providence Health claimed US HealthVest had misled regulators about the scope of services at its proposed hospital near Olympia, and sued to block the project. Inslee’s administration stepped in to broker a settlement in which both companies would open facilities in the area.

    Support from the governor’s office continued despite aides learning of concerns as far back as February 2018. On May 31 of that year, a Department of Health official sent two of Inslee’s health policy advisers the March inspection report that found an immediate jeopardy to patients. A week later, Inslee’s administration dispatched a cabinet-level official to Smokey Point — to celebrate the opening of a new unit for veterans.

    As Alfie Alvarado-Ramos, Inslee’s director of Veterans Affairs, emceed the dedication of the new unit on June 6, 2018, three inspectors from the Department of Health were inside the hospital conducting a follow-up investigation. They completed a report the next day, finding serious violations including the failure “to ensure nursing staff were trained and available to provide safe and effective care.”

    As the state director of Veterans Affairs helped dedicate the new unit at Smokey Point, Department of Health inspectors conducting an investigation inside the hospital found serious violations.

    The next week, Secretary of Health John Wiesman sent a one-page memo alerting the governor’s staff to problems at Smokey Point and offering a series of talking points. He added: “Seattle Times inquired.”

    US HealthVest has continued to leverage the governor’s past support.

    An image of Inslee at Smokey Point’s ribbon-cutting is prominently displayed on US HealthVest’s website. As the company sought approval to open the hospital in Bellingham, US HealthVest reminded state health officials of the governor’s support.

    “Governor Inslee is a strong supporter of our model,” the company wrote in a memo for regulators last August, including a link to a YouTube video of his remarks at Smokey Point’s opening.

    In an interview, Inslee compared Smokey Point to a promising athlete who “fumbles” and needs more coaching. “We can’t just decide we’re not going to open facilities because at one point there was care that was not sufficiently of quality, which we’re now improving,” he said. “We are experiencing what is frequently the situation when you have rapid expansion of any organizational pursuit, that you have bugs in the system.”

    “Governor Inslee is a strong supporter of our model,” the company wrote in a memo for regulators last August, including a link to a YouTube video of his remarks at Smokey Point’s opening.


    The staff at Providence Regional Medical Center seemed to be at a loss for how to treat Rosemary Torgesen. Her problem, some felt, was psychiatric and not medical, but Smokey Point wouldn’t take her back. Doctors at Providence asked Northwest Hospital to accept her but they were losing hope.

    Click to see a timeline of Rosemary Torgesen's last months

    Timeline or Rosemary Torgesen's last months

    Rosemary had refused to eat or drink in life-sustaining quantities for weeks. She was sick and frail, the doctors told her children.

    The Torgesen family refused to give up on Rosemary’s life. They authorized doctors to run a tube through her nose, down her throat and into her stomach to nourish her.

    They “would like to proceed if she has ‘any chance’ of recovery,” a doctor wrote.

    Then Providence staff made an unexpected discovery while performing an X-ray of her abdomen: Rosemary’s right hip was broken, apparently in a fall four weeks earlier while she was at Smokey Point, they wrote. Rosemary had told family members she had fallen several times at Smokey Point, but they weren’t sure how reliable she was in her state. Her records showed only a single fall.

    Providence staff felt she would not survive the artificial feeding.

    The feeding tube was removed. On July 20, two days after the discovery of the broken hip, Rosemary Frances Torgesen died.

    The primary cause listed on her death certificate was malnutrition.

    The secondary cause: “decompensated schizoaffective disorder” — the deterioration of her mental health.

    Contributing factors: “right hip fracture, right humerus fracture.”

    In just over three months at Smokey Point, her mental and physical health had deteriorated beyond survival.

    The Torgesens were bereft — and angry. Angry at Northwest Hospital, which had declined to admit her despite their wishes. Angry at Providence, which recognized only at the eleventh hour that their mother had a badly broken hip. Mostly they were angry at Smokey Point. Barely a week after she died, Jeff Torgesen began filing complaints with the Department of Health.

    Northwest Hospital had told Smokey Point that, as a King County facility, it was required to give priority to local patients, according to an email in Rosemary’s medical records. A spokeswoman for UW Medicine, which operates the hospital, declined to comment about her case but said that family members and psychiatric hospitals “may not have the legal right to determine if a patient is transferred to another facility for mental health care.”

    Providence also declined to comment on Rosemary’s care. The Department of Health faulted Providence for sending Rosemary back to Smokey Point without documenting that the psychiatric hospital could provide the necessary care. A spokesman said Providence submitted an action plan to the regulator, which accepted it.

    Last August, a Department of Health investigator arrived at Smokey Point to review Rosemary Torgesen’s file. The investigator found no record that a medical doctor was involved in reassessing her condition during her stay. The hospital was cited for failing to transfer her “to a higher level of care in a timely manner when the hospital was not able to address the patient’s health care needs.”

    Less than a month later, on Sept. 13, the Department of Health determined that Smokey Point was back in compliance with state and federal standards, meaning its Medicaid and Medicare funding was safe.

    The reprieve, however, was fleeting. In January, inspectors returned to Smokey Point and found many of the same violations they’d identified last year. They cited serious failures again in February, April and June before reaching the corrective action plan with US HealthVest.

    Torgesen family
    Four of Rosemary Torgesen’s seven children visit her grave in Shoreline. From left: Marjorie Erickson, Jeff Torgesen, Maurya Smith and Douglas Torgesen. (Erika Schultz / The Seattle Times)

    Jeff Torgesen, however, remains dissatisfied with the stepped-up scrutiny and has pushed law enforcement to open a homicide investigation. The Marysville Police Department is investigating Rosemary’s death but not, at this stage, as a homicide, a spokesman said.

    “I’ve been consumed,” Jeff Torgesen said. “I feel responsible, not just to avenge my mom, but to show her treatment isn’t being cast aside, being swept under the rug.”

    His last correspondence with Smokey Point came in October, after the hospital mailed a bill to Rosemary. Smokey Point had charged a total of $297,000 for her 99 days of care. She owed $27,965.78.

    “Given the history of the above-referenced account, please see what can be done about an immediate forgiveness in full of account balance,” Jeff Torgesen emailed hospital staff. “The patient is deceased.”

    Smokey Point’s chief financial officer responded within the hour, reducing the balance to $3,015.

    Two minutes later the finance chief emailed again. Rosemary had secondary coverage through Medicaid. There was no longer an account balance. The government would pay.

    Rosemary Torgesen's memorial plaque is prepared at a Shoreline cemetery. (Erika Schultz / The Seattle Times)

    Read the three-part investigation by The Seattle Times


    • Reporter: Daniel Gilbert
    • Project editor: Ray Rivera
    • Photographer: Erika Schultz
    • Photo editor: Fred Nelson
    • Video editor: Lauren Frohne
    • Developer and graphic artist: Emily M. Eng
    • Illustrator: Gabriel Campanario
    • Engagement: Taylor Blatchford
    • Project coordinator: Laura Gordon
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