Sonora Behavioral Health

Sonora Behavioral Health Hospital is a 72 bed inpatient facility located in Tucson Arizona.  Inspection reports we reviewed highlight a troubling pattern of patient deaths, abuse, staffing problems, and medication errors.

Inspectors declared an Immediate Jeopardy situation at the hospital in 2016 “when deficient staffing practices, deficient nursing practices, and environmental issues contributed to the death by suicide of a patient”.   After multiple young patients died, inspectors found that the only Acadia staff person working in the unit during one of these deaths “was not qualified” and “his/her only documented prior employment was as a ‘driver’” (below).  A local news investigation from May 2018 identified other staffing problems including “a nurse without a valid license to work in Arizona, a behavioral health technician who assaulted a child patient, and a nurse accused of being drunk on the job”. After a vulnerable child was assaulted by an Acadia staffer at Sonora Behavioral in Arizona, federal inspectors found that the facility failed to report the incident to the parents or police in 2016.  Other findings include:

  • Medication errors involving drugs administered to the wrong patients or improper doses.
  • Violations involving the improper use of physical restraints on patients.
  • Repeated staffing problems involving lack of patient supervision, training, and qualifications

Relevant Document Excerpts Include: