AHCA is investigating a Tampa mental health care facility after a man died in their care. Records show the staff used the prone restraint.
TAMPA, Fla. — A Tampa mental health care facility is under investigation after someone died in their care. Records from Florida’s Agency for Health Care Administration (AHCA) show a man stopped breathing after six staff members restrained him, holding him face down. The state has issued an emergency moratorium blocking Ibis Healthcare from admitting any new patients.
There are still patients inside because the state’s order does not shut the facility down. The order doesn’t allow them to admit or re-admit anyone. Documents 10 Investigates obtained from AHCA also reveal there is video of the restraint. The prone restraint is a controversial technique many law enforcement agencies have stopped using.
Records show a man was admitted to the 30-bed mental health facility back on March 8. Then, 11 days later on March 19, the man who was diagnosed with schizophrenia became agitated while waiting to see his parents. Documents report he was screaming for his mother and threw a plastic hamper. That’s when six behavioral health technicians moved him into a seclusion room and held him face-down as he said, “I can’t breathe. I can’t breathe.”
We reached out to Seth Stoughton at the University of South Carolina School of Law. He teaches criminology and criminal justice, and he’s an expert on prone restraint.
“I have a couple of immediate questions. The first question is, how long was this individual being held in this prone position while restrained? The second question relates to the two people who are described as being on the individual’s back, and particularly the individual on the upper back. I need to know where exactly that individual was on the upper back and how much weight they were putting down on the person.”
Stoughton testified in the Derek Chauvin trial. Stoughton says this same type of restraint used on George Floyd in Minneapolis can be deadly.
“If they’re putting weight down on the diaphragm, it makes respiration, the act of breathing in and out, much more difficult,” Stoughton said.
Documents show an Ibis Health Care tech heard raspy breathing from the man being held down but never reported it to a nurse. Later, the nurse injected the man with medication. After that, he went limp. One tech asked, “What if he is dead?” Another replied,” I don’t give a ****,” although techs would check on the man, who was still in the prone position with no response.
“The idea of putting someone in this prone position and holding them there, and then medicating them and then leaving them there, I just can’t begin to justify that series of events,” Stoughton said.
Documents show it would be 17 minutes before staff started CPR. Less than an hour after the restraint began, he was pronounced dead.
”I cannot begin to justify why anyone would leave someone apparently unconscious, face down and unmonitored for any prolonged period of time. That’s inexplicable,” Stoughton said.
State investigators found the facilities policies do not allow a six-person take down restraint, nor did the facility complete an investigation into the client’s death. When investigators arrived three weeks later, all staff members involved in the incident were still working in the unit. They also failed to report the death to the Department of Children and Families.
We did reach out to Ibis Healthcare about the allegations and the moratorium. They would not speak to us on camera, but they did release this statement:
“We are deeply saddened by the loss of a patient in our care, and our thoughts are with their family and loved ones during this incredibly difficult time.
Out of respect for the individual and their family, and in accordance with HIPAA privacy regulations, we are unable to share any information related to this patient’s care.
As part of our response, one unit within our facility is temporarily not accepting new patients while we conduct a rigorous internal review.
We are cooperating fully with all appropriate parties throughout this process.
The Tampa Bay community has trusted us for over 75 years. That trust is something we do not take lightly, and we hold it dear.
We will continue to communicate as openly as we can, however, we will not be able to comment any further while the review is ongoing, to honor everyone touched by this loss.”
We asked Ibis how long they expect the moratorium to last, and they told us, ”We are working diligently through this process and do not anticipate a long delay in resuming admissions. Our priority is our patients and this community.”
We also asked if the staff involved in the case were still working at Ibis, and they told us, ”As part of our internal review, we are taking appropriate personnel actions.”
As for any training in response to the moratorium, they said, “While our review is ongoing, we have taken the initiative to review all current policies and procedures with our teams. What matters most to us is getting it right for our staff, for our patients, and for this community.”
Our team also learned this is not the only time the facility has been investigated for how someone was restrained. This facility has been investigated a handful of times in the past few years, but no deficiencies were ever found. However, back in 2020, they were cited for the way they restrained a client.