BARTOW, Fla. — One of Polk County's busiest mental health crisis facilities has been ordered to stop admitting new patients after a state investigation found serious failures in patient care following the death of a patient.
The Florida Agency for Health Care Administration (AHCA) issued an emergency order placing a moratorium on new admissions at Peace River Center's Crisis Stabilization Unit in Bartow after investigators concluded the facility failed to provide appropriate emergency medical care to a patient who later died.
WATCH: State halts new admissions at Peace River Center crisis unit after patient's death
According to the AHCA report, the patient was brought to the facility under the Baker Act in late June after expressing suicidal thoughts. During her admission, she reported she had stopped taking medication for a seizure disorder several months earlier.
The following day, investigators say the patient complained of chest pain, headaches and difficulty breathing. The report states she was given medication, but staff failed to take her vital signs before administering nitroglycerin and did not transfer her to a hospital for additional medical evaluation despite symptoms the facility could not treat.
State investigators also reviewed surveillance video and found the patient repeatedly vomited throughout the day without staff assessing or treating her. Hours later, the woman suffered a medical emergency.
According to AHCA, video showed a registered nurse asleep at the nursing station before responding. Investigators determined staff failed to begin CPR immediately and delayed calling 911. The patient was later pronounced dead.
The investigation identified additional concerns, including staff members who were unable to locate the facility's automated external defibrillator (AED), employees who reported they had never received formal training on responding to medical emergencies or using an AED, and failures to follow the facility's own emergency response policies.
AHCA also found evidence that the patient's medical record had been falsified. According to the report, facility leadership confirmed vital signs were documented at a time when surveillance video showed the assigned nurse was asleep and no assessment had occurred.
Investigators concluded the facility failed to implement comprehensive corrective actions following the incident, despite leadership acknowledging deficiencies in emergency response, CPR initiation and medical decision-making.
Because of those findings, AHCA ordered Peace River Center's Bartow Crisis Stabilization Unit to stop accepting new patients until the facility demonstrates it can safely resume operations. The order applies only to new admissions at the crisis stabilization unit.
Existing patients, other Peace River Center locations and additional services at the Bartow campus remain open.
In a statement, Peace River Center said it is conducting its own review and cooperating fully with state regulators.
"First and foremost, Peace River Center extends its deepest condolences to the patient's family and loved ones," the organization said. "This event has deeply impacted our organization. We are committed to thoroughly evaluating this incident, implementing the necessary corrective actions, and continually strengthening our practices to ensure the highest standard of quality, safety, and compassionate care for every patient we serve."
The admission freeze comes as demand for mental health care continues to grow across Polk County.
"People are seeking out care for anxiety, depression, trauma, ADHD and substance abuse, and the increased awareness has helped reduce some of the stigma around mental health," said Silvana Huayamares with OPA Behavioral Health.
Huayamares said OPA Behavioral Health recently expanded into Lakeland because of the growing need for services.
"The need is there, but not enough providers are in the area," she said. "That's one of the reasons we expanded from Orlando into Polk County."
The AHCA findings have also renewed attention on emergency preparedness in healthcare settings. Culpepper's Cardiac Foundation is working to improve access to lifesaving equipment by donating 100 AEDs to businesses across Polk County.
"They need to know how to use an AED, and they also need to know CPR. That's what my foundation is trying to get out there. The knowledge of the AED and the CPR and hopefully save someone's life," said founder Melanie Brown Culpepper.
The state moratorium will remain in effect until AHCA determines Peace River Center has corrected the deficiencies identified during its investigation.
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