Psychiatric facility in Madera County fined for patient escape, abuse, state says
A recently opened Madera County acute psychiatric hospital was hit with two state penalties for putting patient’s into harm’s way, a state report says.
California Department of Public Health fined River Vista Behavioral Health on April 3 for two “immediate jeopardy” situations that took place in summer and fall 2024. In one incident, a patient escaped from the hospital using a staff member’s unattended identification badge and proceeded to steal a van from a nearby hospital, according to state inspection reports.
River Vista was also cited for failing to ensure staff followed hospital policies and procedures to prevent verbal and physical abuse of three patients. The hospital also failed to a conduct root cause analysis as a result of the abuse cases and failed to report one instance of abuse to CDPH, according to an inspection report.
An immediate jeopardy is a type of serious violation that result from a healthcare facility placing the health and safety of patient’s risk for serious injury, serious harm, serious impairment or death, according to the U.S. Centers for Medicare & Medicaid Services.
Several other central San Joaquin Valley and Fresno-area hospitals received immediate jeopardy citations in 2025 for incidents stretching back several years. The 128-bed River Vista facility provides inpatient and outpatient mental, addiction and behavioral health treatment services, including pediatric psychiatric care, according to its website.
The center, which is a partnership of Valley Children’s Healthcare and Universal Health Services, opened and began admitting patients in 2024, according to the group’s LinkedIn page.
“We are committed to the safety of our patients and staff — and continuous improvement in all aspects of our operations. Every survey is an opportunity for improvement, and we appreciate the input of our regulators,” River Vista said in a statement.
The facility submitted a plan of correction and demonstrated compliance following resurvey, officials said.
“River Vista is in compliance with CMS’ Conditions of Participation and is fully licensed and accredited. We provide comprehensive inpatient and outpatient behavioral health services to children, adolescents, young adults, adults and seniors – supporting thousands of individuals each year in the successful management of the complexities of their mental healthcare,” the statement said.
Mental health staff threatens to hurt patient and his family
In another instance, a mental health technician was witnessed “verbally taunting and threatening” a 24-year-old patient who was admitted with a major depressive episode and was considered at risk for suicide.
The mental health technician threatened to use the patient’s chart, “get the address of where you live and go hurt you and your family,” according to state records and an interview with another mental health technician who witnessed the interaction on Oct. 6, 2024. The threat was not reported to the local police department until after CDPH identified the event, according to the report.
When the interviewed technician approached the offending technician about his behavior and to let him know a complaint had been filed, the latter responded using an offensive slur against gay males, “F--- that f-----.” Even after being assigned to a different unit, the technician followed the patient in the hallway and repeated to call him the slur.
The Chief Nursing Officer said the patient called the technician a “racial slur” which “triggered” the technician’s behavior, according to the report the CNO’s interview with state inspectors. When asked why the incident wasn’t self-reported to CDPH, the CNO stated the incident did not rise to the level of being considered “abuse,” based on internal conversations with the corporate risk department. The CNO also didn’t address the expectation to effectively utilize de-escalating and non-confrontational techniques.
State investigators concluded the incident led to avoidable emotional and mental anxiety as further medication for the patient’s symptoms.
Patient sent to hospital after seclusion in solitary
In another incident, hospital staff witnessed a licensed vocational nurse physically restrain and take down a patient, pushing her face to the floor.
The 30-year-old female patient was admitted on Nov. 6, 2024 on involuntary hold from another hospital with a major depressive disorder with history of suicidal ideation.
After a verbal altercation with a mental health technician, the patient became agitated and took a water bottle from a nearby nurse’s desk and threw it at the mental health tech. The tech then exited nurse station, put their hands on the patient’s arms and pushed the patient backward, and restrained her on the ground. The patient said an unknown staffer punched her in the eye during the takedown, investigators noted the patient bit one of the tech’s fingers while they held her down.
She was then taken to a seclusion room, where she started banging her head against wall. She was given a pillow and directed to place it between her head and the wall to avoid injury.
She did not comply and continued to hit her head against the concrete wall of the seclusion room.
She was later sent to an outside hospital for evaluation after she left the seclusion room with “bruises, lacerations and a bump on the head,” as well as complaints of headaches and dizziness. Doctors said she could have had a mild concussion.
State investigators concluded the patient was inappropriately placed in seclusion without first determining best method to address the patient’s behavior. The hospital personnel failed to follow policies and procedures intended to keep patients safe and free from abuse and that such failures were likely to cause serious injury or death, the report said.
In a third incident, a nurse “pushed” a patient out of a group room and “shoved” her against a window. An internal investigation substantiated the alleged used of excessive force.
The hospital was fine a $57,750 immediate jeopardy penalty for the injuries towards patients.
Patient escapes with staff badge, steals van
The hospital was also fined $41,250 after an 18-year-old patient escaped on Sept. 20, 2024.
The patient’s was admitted to the hospital four days prior as an involuntary “5150” hold, meaning he was risk to himself and others. The patient was described as “very combative” and experienced suicidal ideation.
According to the state inspection report, a “negligent” mental health staff left their security access badge unattended on a table in the group room. The patient then picked up the identification and secure access badge, put it in his pocket, and used it to open a fire escape door, walked down the stairwell and used the badge to exit an unalarmed door on the first floor. The hospital didn’t have security guards, and staff didn’t notice the patient was missing for about 20 minutes, at which time they notified local authorities.
The patient was apprehended by local police after stealing a van from a nearby hospital and driving off the premises. (River Vista is located next to Valley Children’s Hospital).
The patient was returned to facility later that day.
A risk manager told state investigators all staff is expected to use their badges secured on their person at all times and that staff should have identified the patient as a flight risk.
“The elopement should have never happened,” the risk manager said.
