Years of violations, but few consequences for Delaware psych hospital MeadowWood

Hospital staff without CPR certifications. Slow-walked investigations into sexual harassment. And patients given a cocktail of sedatives to “control” their behaviors.

These are some situations outlined in inspection reports citing MeadowWood Behavioral Health Hospital, a New Castle psychiatric facility, for patient safety violations in the last three years.

Yet years of citations went effectively unsanctioned.

These cases were detailed in more than 400 pages of inspection reports dating back to 2022 that were obtained in a Freedom of Information Act request by Spotlight Delaware. The reports, conducted by state officials on behalf of the federal government, also claim the hospital failed to properly report multiple patient deaths and keep track of them for what appears to be an internal review board.

When the government did find the hospital out of compliance, it required MeadowWood to write a “plan of correction,” documents that in some cases went unsigned by hospital leadership for more than a year after an inspection.

MeadowWood is one of a handful of inpatient psychiatric facilities in the state, and one of the largest facilities in northern Delaware. In the state’s southern counties, options are more limited with Dover Behavioral Health in Kent County and SUN Behavioral in Sussex County.

MeadowWood is owned by Acadia Healthcare, a behavioral health giant based in Tennessee, which “lured patients” into its psychiatric facilities “and held them against their will,” according to a New York Times investigation.

The state records reviewed by Spotlight Delaware also reveal at least two other deaths that government officials cited MeadowWood for not properly reporting or investigating.

Delaware State Police denied a FOIA request from Spotlight Delaware for completed police reports following a patient death between 2022 and to April 2025.

According to the reports, the hospital passed its most recent inspection by the Delaware Department of Health and Social Services.

Following a detailed inquiry by Spotlight Delaware presenting the findings to Acadia, the company provided a four-sentence response, saying it’s committed to providing care “to the most vulnerable members of our community.”

“MeadowWood is committed to the well-being of all those in our care,” a spokesperson for Acadia said. “Our clinical treatment programs are designed using evidence-based practices and interventions tailored to the specific needs of each individual receiving support in our facility.”

At least three deaths investigated

One death identified in the documents details an incident from 2022 when a nurse noticed a change in a patient’s mood and mental status, but didn’t notify physicians or change the patient’s treatment plan.

Hours later, staff found the patient unresponsive in between a 15-minute check in with vomit in their mouth. Three days after being admitted to the intensive care unit, the patient died, the report said.

A separate patient who was admitted in December 2022 was found in their room unresponsive with coffee-ground throw-up on their face. That patient was also pronounced dead about an hour following their discovery.

But for three days leading up to that patient’s death, the report says multiple complaints of rib pain went unreported to a physician.

“On 12/11/2022, the RN reported in a note that the patient was restless, complained of rib pain all night, was crying, and thrashing around in bed,” the report said. “No physician notification of a change in condition identified.”

For both of these patients, the report said there was “no evidence” MeadowWood collected or reported data about the deaths or “implemented actions” to address them.

Spotlight Delaware previously reported on a lawsuit brought against MeadowWood and Acadia by the mother of David Tymitz, a 33-year-old man who died in 2023 while he was a patient at the hospital.

A similarity between an unnamed patient and Tymitz’s lawsuit, where the unnamed patient experienced a medical emergency in the same window of time as Tymitz and went nine minutes without CPR after their discovery, was also discovered by Spotlight Delaware.

Spotlight Delaware examined 13 lawsuits brought against MeadowWood since 2016 and found that five accused the hospital of negligence leading to a patient death, which is more than lawsuits filed against the state’s other privately-owned psychiatric hospitals.

In one of those lawsuits, the family of 24-year-old Brooke Dean, a patient at MeadowWood in 2021, claims hospital acted negligently after Dean choked to death on a sandwich while heavily medicated.

In August 2024, the family settled the lawsuit for an undisclosed amount.

In expert testimony, one doctor said doctors also gave Dean an “excessive” amount of medications during her admission in 2021. According to the court filings, Dean received 190 doses of medications during her 12-day stay.

Hours before Dean collapsed in a common room, the testimony said she received seven different medications “including antipsychotic and psychotropic medication,” which the doctor said was a proximate cause of her collapse.

The court documents also said the medications prevented her from swallowing, as well as that the “excessive use” of other drugs made it more difficult to resuscitate her.

The expert testimony said the admission of a cocktail of sedation medications, Zyprexa, Ativan and Benadryl, into her muscles hours before her death was a “proximate cause of her injuries and death.”

According to the testimony, there was “no evidence” the hospital obtained “informed consent” for any parts of her treatment, despite a court ruling that she was unable to care for herself without a guardian.

Yet the court filings say a MeadowWood doctor testified Dean was capable of giving consent, which the expert said “was not true” and “inconsistent with the court order” that made her parents her co-guardians.

“Failing to obtain informed consent, especially given the nature of the medications and treatment MeadowWood provided to Brooke, evidenced a conscious disregard for the rights and safety of Brooke,” the court filing said.

Sedation administered without doctor’s order

The records and lawsuits examined by Spotlight Delaware claim that on multiple occasions staff used sedation, also-known as a chemical restraint, as a means of treating “agitation.”

According to the state report, the use of restraints is only acceptable “to prevent immediate physical injury to the patient or others” after other, non-restrictive measures have been attempted.

One incident in the state inspection report said a patient was sedated after an employee dragged them to the floor by their neck, and held their forearm there after the patient was on the floor.

According to the report, hospital surveillance showed the patient shirtless in the hallway, as some employees tried to verbally de-escalate.

An employee then comes in and places the patient “in a hold” with their arm around the patient’s neck, bringing them to the ground, according to the report. Three other employees then come in to hold the patient down on their stomach.

Soon after, another employee gave the patient sedation drugs.

But according to the report, there was no physician order for sedation, no documentation to show the patient complained of rib pain, as well as no documentation that the drugs were ever administered.

The employee who placed the patient in a hold around their neck was later terminated, the documents said.

The records also tell a story of employees using chemical restraint to “control the behaviors” of patients. In one interview conducted by a team of inspection officials, an employee told the government that medications are used to prevent a patient from harming themselves and others, or if they refuse other interventions.

When the officials pressed the unnamed employee on if the medications were considered a form of chemical restraint, the employee reportedly told them “it depends on what you are giving and how close together [timing] and the reason you’re giving it.”

The employee said that, at a recent training, nurses were told not to administer three sedation medications at the same time, but told the officials they couldn’t “remember which three meds they were.”

“I asked the trainer to tell me what a chemical restraint was, and he/she did not clarify. I don’t think the other nurses know either,” the interview in the report said.

Alleged sexual harassment of a minor wasn’t reported

The documents also say an employee sexually harassed a minor patient multiple times in 2022, later leading to their termination. But the documents say the hospital did not report the incident to the Delaware Department of Services for Children, Youth, and Their Families – the state’s version of CPS – despite being required to do so under state law as a mandated reporter.

“After multiple requests by surveyor, facility was unable to provide evidence that they notified DSCYF of the required reportable event of this incident,” the report said.

On one occasion weeks after the patient’s admission, documents said the employee and patient got into an argument, where the employee told them, “If we were on the streets, I would make you my girl and would beat (your) ass.’” 

Days earlier, the documents said the employee took it a step further, showing the patient a picture of themself naked. The employee was terminated about two weeks later. But the reports say that since MeadowWood did not report the incident to the state, it could allow the employee to work in other facilities with minors.

A separate sexual abuse allegation claimed an employee targeted a rape victim, giving the patient their phone number, offering to buy the them a motel room to have sex and pulling them aside to talk about “planned sexual acts.”

Yet MeadowWood didn’t immediately begin an investigation, nor was the employee suspended.

For an investigation to start, hospital employees must first send information to Acadia corporate management to allow them to determine a “severity level,” the report said.

“Investigations into allegations of abuse or neglect are not initiated immediately upon discovery, and instead are initiated after facility Risk Management emails details of the allegations to Corporate Risk Management, and a ‘severity level’ is agreed upon with Corporate Risk Management,” the report said.

The documents said the investigation of sexual abuse started and ended on the same day in July 2023.

In the report, the government blasted the hospital’s inaction on the investigation. State inspectors then created a plan on the spot to make sure investigations into patient abuse begin immediately and not waiting for corporate approval.

According to the documents, the employee responsible for the investigation was directed by their supervisor to finalize the report, but they did not have access to any documented interviews in the incident.

Additionally, the documents said that even their supervisor did not have access to the interviews, which were conducted by the hospital’s human resources director. In the reports, it said the hospital interviewed the alleged victim and accused, but did not conduct any other interviews with staff or patients.

The supervisor, listed in the report as “EMP8,” would later tell the government they had not received any training on investigations into abuse since starting in their position in May 2023.

“EMP8 stated he/she had not received any training on abuse investigations and since EMP1 (the accused employee) was a good employee, denied the allegations, and had no previous allegations made against him/her, the allegations were not substantiated,” the report said.

Accountability has been limited

For years, MeadowWood was on the wrong end of government inspections that said the hospital violated federal regulations surrounding patient safety. Yet in the same breath, the hospital faced few meaningful consequences.

When reached for comment about how the government sanctions hospitals, a spokesperson for the Centers for Medicare and Medicaid Services (CMS) said hospitals are given “every opportunity” to regain compliance.

But they added that hospitals unable to regain compliance could be terminated from the reimbursement programs – a potential death blow due to the publicly subsidized programs covering more than a third of all Americans.

“Termination is generally the last resort after all other attempts to remedy deficiencies at a facility have been exhausted,” the spokesperson said.

It’s unclear how much the hospital relies on Medicaid and Medicare patients, but the hospital does accept the subsidies. According to the statement, the federal government does not have the authority to “to impose fines against hospitals for noncompliance.”

The spokesperson did not respond to a follow-up question asking if MeadowWood had been sanctioned further than a plan of correction.

The reports that Spotlight Delaware based this story on were conducted by state officials on behalf of the federal government.

Corinna Getchell, the director of the Delaware Division of Health Care Quality, said in an interview that the state can place a hospital’s license on a “provisional” watch, though sanctions based on the reports primarily come from CMS.

“We can write another deficiency report, but enforcement for hospitals, it’s based on what CMS recommends,” she explained.

According to Getchell, the state and federal agency have investigated more complaints from the public on health care facilities since COVID, but she didn’t have a theory as to why.

Tim Mastro, a spokesman for the state health department, said MeadowWood had its license placed on a watchlist multiple times between 2023 and the present day. He also added that the hospital is up for its license renewal next month.

“DHCQ’s primary focus is the health, safety, and well-being of patients at MeadowWood and throughout Delaware,” he said in an email statement. “The State is working with CMS and our partners to use all resources at our disposal, including provisional licenses and corrective action plans, to strive for the highest quality of care.”