Insane.
Invisible.
In danger.

For years, the state Legislature, the governor’s office and the agencies that oversee Florida’s mental hospitals ignored the chaos and continued cutting. Then state regulators hid the full extent of violence and neglect from the public.

The Tampa Bay Times and Sarasota Herald-Tribune spent more than a year chronicling life in these institutions, interviewing patients and their families and examining thousands of pages of government records. Using police and hospital reports from across the state, reporters pieced together the first comprehensive list of injuries and violent attacks inside Florida’s mental institutions. The newspapers found:

• Over the past five years, at least 15 people died after they injured themselves or were attacked by other patients. One man with a history of suicide attempts jumped off the eighth floor of a parking garage. Another was stomped to death because no one separated him from rivals even though they had beaten him up the night before.
• Staffing shortages are so acute that violent patients wander the halls unsupervised. Employees are left alone to oversee 15 or more mentally ill men. Sometimes they carry no radio to call for help, and the nearest guard is in another building or on another floor.
• Even when patients are placed under special watch, they have been able to swallow batteries and razor blades or hoard weapons to use on other patients. At a hospital in Florida City, a patient needed nothing more than a wad of paper to break out of his locked room and stab his neighbor 10 times. As the man bled on the floor, a staff member, unaware of what had happened, helped the attacker wash his bloody clothes.
• Florida has no statewide minimum staffing requirements. And there are virtually no repercussions for administrators, even when someone dies. State regulators have fined the hospitals a total of $2,500 in the past five years. One hospital paid $1,000 after a patient escaped and was run over by a truck.
• At least three people died because hospital workers took too long to call 911. Some employees say they felt pressure not to call paramedics because of the expense. Others say they were required to track down a supervisor first, leading to delays.

The state Department of Children and Families operates three of Florida’s primary mental hospitals. Three others are run by a private company, Correct Care Recovery Solutions, with DCF oversight.

During an interview in early September, top DCF officials, including Secretary Mike Carroll, initially disputed that their hospitals were short-staffed and had seen an increase in violence.

After reviewing the newspapers’ findings, Carroll said the issue of staffing needed more study “because I’m committed to making sure that we provide a high quality of care.”

When reporters pointed out that DCF’s own numbers show a 45 percent increase in violent and other dangerous incidents since 2008, John Bryant, assistant secretary for substance abuse and mental health, shook his head, puzzled.

“You know we track those numbers daily, weekly, monthly,” he said. “I’m a little incredulous about it because it’s something we pay attention to pretty closely.”

But state officials have no way to know how much violence occurs at their own facilities.

Since 2005, DCF administrators have steadily relaxed reporting requirements so that hospitals no longer need to disclose most patient injuries. The reports that have been filed are in such disarray that accurately comparing them over time is impossible.

DCF administrators were unable to provide copies of dozens of incident reports for their mental facilities. DCF spokeswoman Michelle Glady first said records from three hospitals prior to 2011 had been lost. She later said the documents may never have been created because DCF did not have a standard reporting form until 2011.

Still, the rising crisis at Florida mental hospitals has not been kept secret from DCF officials.

Fourteen times since 2005, DCF and the Agency for Health Care Administration investigated internal complaints about staff shortages that put lives at risk. Investigators confirmed nine of those cases. Then, DCF’s Inspector General warned that workers’ compensation claims related to violence started rising in 2011.

Instead of hiring more guards, adding nurses or increasing counseling sessions for patients, DCF and state lawmakers kept cutting.

From 2011 to 2013 alone — at the same time violent incidents rose across the state — former DCF Secretary David Wilkins oversaw $61 million in cuts from the hospitals, more than 15 percent of their funding. That came on top of about $35 million already cut in the two years prior.

The hospitals eliminated almost a third of their workforce.

Across the state, counseling sessions, training classes and other activities were shut down, reducing supervision and leaving patients bored.

Northeast Florida State Hospital in Macclenny laid off one-third of its psychology staff, according to Harry Reiff, who was head of psychology services at the time. Before Cook was stabbed in the face, her hospital cut the number of guards on duty from 12 to eight, according to former security supervisor Gerald Simmons.

Staffing shortages are now so acute that employees say they sometimes can’t take bathroom breaks, much less control the patients in their care.

The newspapers spoke to more than two dozen current and former employees who said they were too busy to perform routine medical checks and were often left alone on the ward.

“We did these employee surveys and one of the questions was: ‘Do you feel safe?’ ” said Karen Rackard, a former nurse at Florida State Hospital. “No, I do not. Absolutely not. I was the only nurse. The only other staff sometimes was a female smaller than me. When men start fighting, you can forget it. These men can take the ward over at any time.”

Years of neglect

In 2015, some patients had no air conditioning. Others found roaches in their cake.

Inspectors found similar conditions at other Florida institutions.

At South Florida State Hospital, a state-funded mental institution run by a private company in Broward County, doctors told their bosses in July 2012 that patients didn’t have enough food to eat and were picking through trash cans for their meals.

At Northeast Florida State Hospital in Macclenny, employees could not stop a patient from urinating on the floor. Workers repeatedly asked their bosses to replace the flooring. But repairs were not made, leaving the room reeking so badly that employees gagged when they entered, according to an April 2014 state inspection.

The next year at the same hospital, officials found trash on the floor and spoke to workers who said rats crawled through the walls and into patients’ beds.

In an interview with the Times/Herald-Tribune earlier this year, Wilkins said Florida State Hospital and some of the older institutions should be torn down.

“If the average person saw those facilities, they would be ashamed,” Wilkins said.

But under Wilkins’ leadership from 2011 to 2013, maintenance budgets dropped by 12 percent — about $2 million.

More than two minutes after the men started arguing, the first employee arrived. Darlene Debose, 5-foot-6, stared down an enraged mental patient who once beat up three sheriff’s deputies in Ocala.

“Please get off him,” she begged, standing at arm’s length.

Mosley survived the beating after doctors treated his broken skull, face and jaw. Florida taxpayers were left with more than $60,000 in emergency room bills.

As hundreds of hospital workers lost their jobs in 2011, attacks like this increased across the state.

In 2009, state records and police reports show 23 acts of violence against patients or workers at the four hospitals that house people until they are fit to stand trial. The next year, there were 47. By 2014, the number reached 72.

Thousands of pages of records document stories of the mentally ill being left unsupervised and easily able to hurt each other and their caretakers.

One patient had his scalp split to the bone and wound up in a coma because his rival thought he had “demonic powers.” A female counselor left alone with a patient was beaten so badly she now uses a cane to walk. At the hospital in Macclenny, a man lost two fingers when he was trapped in a room and a patient slammed the door on his hand.

In June 2013 at Treasure Coast Forensic Treatment Center near Lake Okeechobee, Daniel Kellond warned staff members he was angry and planned on putting someone in the emergency room.

One day, he punched an elderly patient over a biscuit. Three days later, he poked Lamarkis Davis in the eye and ruptured a blood vessel. The following morning, he attacked Davis again, this time biting off a chunk of his ear and telling workers that it was “just business.”

“I am a criminal,” he announced to the police.

Earlier this year at the state institution in Chattahoochee, two younger patients beat Miguel Menendez-Carrera, 57, because they thought he was a snitch. No one made sure the men remained separated. The next morning, upset about the attack, Menendez-Carrera threw urine on them.

They stomped him to death.

Under-reporting

At North Florida Evaluation and Treatment Center outside Gainesville, administrators determined there were three incidents serious enough to be reported to DCF in the 2011-12 fiscal year. The Times/Herald-Tribune found 16 injuries and attacks during the same period.

A patient threw an employee down a flight of stairs, slamming his head into a brick wall. Another patient wound up with a swollen head after three people held him down and punched him over and over. A third needed stitches after he was punched repeatedly in the face during a fight over the TV.

The newspapers found similar reporting discrepancies across the state. At Florida State Hospital’s forensic and civil units, administrators reported 16 violent incidents from July 2012 to June 2013. The newspapers found three times as many.

During the 2013-14 fiscal year at Northeast Florida State Hospital, administrators reported seven incidents. The Times/Herald-Tribune found more than 40.

Bryant, the DCF assistant secretary, said his agency relies on hospitals to accurately report on incidents that occur.

“If we have an issue with folks not reporting that to us, that’s a problem,” Bryant said.

As his caretakers later learned, the 46-year-old schizophrenic patient had jumped a 5-foot fence and made his way to State Road 121, where a semitrailer truck ran him down at 9:30 a.m.

As the state cut mental hospital staff and demanded more work from those few who remained, employees found one easy way to save time: They stopped checking on patients.

Treatment teams headed by doctors order dangerous or suicidal patients to be checked regularly, sometimes as frequently as every 15 minutes.

But their orders routinely go ignored. In recent years, dozens of employees have been caught skipping the safety checks, hospital personnel records show.

Vince Druding, a former night nursing supervisor at North Florida Evaluation and Treatment Center, blames understaffing.

His hospital near Gainesville once had as many as four medical technicians on every ward, Druding said. When that number was cut in half, it became “impossible” to check on every patient, he said.

“As soon as you get done, you’ve got to turn around and do it again,” he said.

“The problem is if everything is quiet, people skip rounds. They do it every two hours. But that’s way too long for this kind of patient. If you miss someone who’s suicidal, one hour is bad enough. Two is impossible.”

Since 2009, at least seven people died after staff members missed a safety check or broke other hospital rules. One patient was left alone in a scalding bath for so long his skin came off when workers tried to revive him. A 33-year-old woman on suicide watch wasn’t supposed to have access to bed linens but managed to sneak them into her room and hang herself.

John Kenyon Whitaker III choked to death on a slice of pizza after an employee says his co-worker was called away from a post that is never supposed to be empty. Instead of watching closed-circuit video monitors from the control room, she was passing out lunch trays, leaving no one to trigger a medical alarm, according to Kiren Saucier, the technician who was with Whitaker at the time.

DCF officials disputed Saucier’s account. They said someone came to help “immediately,” but did not provide an exact time.

It’s easy for hospital administrators and DCF officials to ignore the dangerous situations they have created. They face virtually no repercussions.

At least four times in five years, the Agency for Health Care Administration or DCF’s Inspector General found that administrators put patients and employees in harm’s way because their hospitals weren’t properly staffed.

No administrators were fired. AHCA levied a total of $2,500 in fines.

Security guards were stationed outside the wards, in a separate building. There were never enough to ensure she wasn’t alone.

“There was never any security in these buildings at all unless something happened,” she said.

Four days after Cook had her face sewn up with 30 stitches, her boss asked if she could return to work.

She tried. But every time she thought of going behind the locked doors of Building 12, her heart would race, and she froze.

So Cook asked to remain in a medical records desk job that the hospital arranged for her.

A year later, when she still refused to return to her old job, they fired her.

Times computer-assisted reporting specialist Connie Humburg and researchers Caryn Baird and Natalie Watson contributed to this report. Times reporter Leonora LaPeter Anton can be reached at [email protected] or 727-893-8640. Times reporter Anthony Cormier can be reached at [email protected]. Herald-Tribune reporter Michael Braga can be reached at [email protected].