Acadia Healthcare: State Surveyors Find Serious Suicide Risks at Sonora Behavioral Health

January 30, 2020

The Sonora Behavioral Health Hospital in Tucson has been the subject of lawsuits and state investigation for years.

A new crisis, brought to the state’s attention by KOLD Investigates, was so bad it required immediate action.

"It's serious," said Colby Bower, Assistant Director with the Arizona Department of Health Services.

Serious enough for surveyors to stay at Sonora Behavioral Health Hospital for six days in October.

That’s when KOLD Investigates submitted some complaints to the state after interviewing workers, former workers, as well as patients and their families.

State officials said while surveyors were investigating the submissions, they found the worst case scenario -- a case of immediate jeopardy.

Bower explained what that means.

“If that condition is not corrected right away, the patients or the residents there are at risk of significant harm,” Bower said.

This time, it was because the surveyor found about 75 percent of the toilets had an area patients could hang themselves.

The hinge of the toilet seat had an opening where a patient could slip a cord or shoe lace through.

“Ligature points in facilities are always a big deal,” he said. "particularly in a psychiatric facility.”

Another citation details the case of a patient who was slamming the toilet seat and it broke in two.

The problem with that is the seat could be used as a weapon.

In all, there were more than a dozen new citations listed for October and some could be linked to our reporting.

For example, we submitted a complaint about an emergency cart that was difficult to access.

According to the citation, the fact it was kept in a locked medication room made it inaccessible to many staff members.

Another citation detailed nearly 30 incidents of patients using contraband to hurt themselves. In some cases, patients were able to remove large furniture staples to cut themselves. One of the staples was found embedded in a patient’s arm.

KOLD Investigates once again tried to get an interview with the hospital.

They refused an on-camera interview but released the following statement:

“Patient safety and well-being remains the top priority at Sonora Behavioral Health. Our team is committed to providing quality of care to our patients. All concerns raised are taken seriously to ensure patients are treated in a safe and therapeutic setting. Sonora Behavioral Health is licensed by State and Federal agencies and our focus remains on continual improvement in the services we provide to deliver high quality, clinical care.”

The new citations have been corrected and the case of immediate jeopardy with the toilet seat hinges was resolved.

Source: Wendi Redman, “KOLD INVESTIGATES: Another crisis at Sonora Behavioral Health uncovered,” KOLD-TV 13 (Tucson, AZ), January 30, 2020, URL:


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