TUCSON, AZ (Tucson News Now) - A Tucson hospital is the center of attention, not because of its stellar treatment, but because of its violations.
The KOLD Investigatives team logged and analyzed piles of data from the Arizona Department of Health Services to determine who is to blame and what is being done.
Chayse Vance was a young lady with an eye for art and a heart of gold, according to her family.
Unfortunately, Chayse did not get to see many birthdays.
Three years ago she went to Sonora Behavioral Health Hospital for help and - after discharge - took her own life.
Her family launched a wrongful death lawsuit.
In court documents, the family claims the hospital's "negligent, careless, and reckless acts and omissions, including the failure to diagnose, manage, and treat Chayse Vance proximately caused her premature death."
Chayse was just 17 years old when she died.
A year later, history repeated itself.
Records from the Department of Health Services claim a patient was able to take her own life while in the care of Sonora Behavioral Health Hospital due to numerous facility violations.
In one instance, the hospital allegedly did not have the proper sheets that would break away under a person's weight.
Scrolling down the list, reports say the hospital did not have correct door hinges that a person couldn't hang something from, as well as having a behavioral health technician with "no" medical experience and was in fact hired as a driver.
The nurse was supposed to check on the victim every 5 minutes, but elected to take a 20-minute coffee break instead.
It was during that time that the patient, identified as Tara Moon, hung herself.
The issues stretch far beyond just those citations though.
Of all 17 psychiatric hospitals in the state that the ADHS inspects, Sonora Behavioral Health Hospital has the most citations with 82. To top that off, in the past three years, it is the only facility to have the most severe condition possible - one case of immediate jeopardy.
Colby Bower, the Assistant Director of Public Health Licensing, was asked if there was a certain number of citations that he considered to be a lot.
"I would encourage people to just not look at the raw number of citations," Bower said. "For example, you may have in a child care facility, a lot of citations, but not all of those are particularly concerning."
The records show otherwise.
A close look at those records reveals 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.
Most concerning of them all was the case of immediate jeopardy in which Moon died.
"If something's not corrected a patient could be harmed any moment. That's called an immediate jeopardy," Bower said. "And what that means is our surveyors will not leave. They will stay there overnight, they will stay there two or three days, and we will call additional surveyors in. They will not leave until the facility has corrected that issue."
When asked if the Department of Health Services did everything correctly, Bower said, "I certainly believe so."
Within the citations of this immediate jeopardy case, there were detailed notes that said the chief executive officer "failed" to be accountable for ... the hospital "failed" to ensure patients' rights.
Asked if this means the hospital - or the chief executive officer - is responsible for this death, Bower said that terminology is part of the administrative rules and the wording means those rules were not followed.
"What those terms mean is really in our administrative rules set. We require that the administrator is responsible for a whole host of things," Bower said. "The wording in these reflects the person or facility responsible did not follow those rules and allowed a condition to occur that's in violation of our rules."
Tucson News Now called the hospital multiple times for comment, but the calls were sent to voicemail without response.
CEO Connie Burnett said that the hospital had no comment, but eventually sent the following emailed response to Tucson News Now:
The courts will ultimately determine who is responsible for the deaths of Moon and Vance. As for Vance's family, they hold on tight to her memory through her pictures and artwork.
The data we used for this investigation looks only at the past three years. The Arizona Department of Health Services said inspectors go out to survey once a year, unless there are previous citations they are ensuring are fixed or they receive complaints.
As for the hospital's most recent citation? That was about a year ago, for admitting too many patients.
We should also note any action taken against a provider can be challenged in court, and the citations we've talked about for this story have since been corrected.