Just days before Christmas 2024, a group of female teen patients broke into the nurse’s station and medication room at a psychiatric hospital in Raleigh, where they tore down parts of the ceiling, hurled objects at staff, damaged equipment and used syringes as weapons. Several police officers responded to the disturbance at Holly Hill Hospital, and emergency responders took seven patients to the emergency room for monitoring due to possible medication ingestion.
According to a state report on the incident, staff members panicked and some huddled in the corner while an emergency code was called, which summoned more employees from other areas of Holly Hill’s campus in downtown Raleigh, near WakeMed Hospital off New Bern Avenue. Some patients got into the room where medications are stored, which had been propped open by nursing staff because some of them didn't have a key to unlock it.
“Seemed like one thing after another, and it got out of control fast,” one hospital employee told state regulators who investigated the incident.
The 347-page state report on what happened from the N.C. Department of Health and Human Services is highly redacted. However, a summary of video surveillance from that day in a federal report describes patients throwing and damaging phones, smashing ipads, throwing computer monitors, keyboards, shoes and cans of soda, some of which hit hospital employees. The seven staff members and six patients described in the incident are anonymized in the report.
One patient threw and destroyed medical records, according to the video surveillance summary. Another stole pills from the medication room and scattered them on the floor. The report described a patient trying to stab a hospital worker in the neck with a syringe. Amid the chaos, a patient was seen climbing into the ceiling above the nurse’s station, knocking down ceiling tiles and dislodging the metal dividers, which other patients then used as improvised weapons against staff, according to the video surveillance summary.
In the state’s report, hospital staff said the situation got “progressively worse,” describing it as “overwhelming” and “quite traumatic” with the wing of the hospital in total “disarray.” One staff member told regulators: “When I left I thought ‘thank God I’m alive. Someone could have gotten seriously hurt.’”
Other hospital employees told regulators “they did not ‘feel’ that patients were safe with the number of staff” and that the facility was “hiring inexperienced staff that have never worked with mental health patients.”
Holly Hill’s CEO Leigh Holston told NC Health News in an email that during the patient uprising, hospital staff activated a rapid response team and requested backup from the Raleigh Police Department, whose support was appreciated. Patients, families and staff got debriefings, and she said that leadership conducted “a root cause analysis” to develop and implement an immediate action plan.
In response to the violent incident, regulators placed the hospital under “immediate jeopardy” — the most severe sanction a hospital can receive. It means that serious harm or death has or is likely to occur to one or more patients, and it requires immediate action. Under immediate jeopardy, a hospital must submit a plan of correction that’s acceptable to regulators by a deadline or risk losing their ability to bill federally funded insurance like Medicare — something that would cripple most facilities.
Holly Hill has had three immediate jeopardy sanctions in the past five years.
Officials with the state Department of Health and Human Services said that putting a hospital under this severe sanction used to be infrequent, and multiple immediate jeopardies at one hospital was even more rare. Now, state regulators told NC Health News, they find dangerous conditions at hospitals more often, which is forcing state officials to talk about what steps they need to take to ensure patient safety.
“Repeat noncompliance at this level of severity is troubling,” the state health department said in an emailed statement.
State records detail years of serious shortcomings at Holly Hill that have been documented by federal and state regulators during a dozen on-site investigations into patient complaints over the past five years. The repeated deficiencies include: patient escapes, allegations of sexual and physical assaults, missing treatment plans, medication errors, contraband on patients, documentation issues in patients’ medical charts, unsafe patient discharge practices, unsanitary living conditions and lack of language interpretation services.
These issues are not isolated to Holly Hill. The hospital’s parent company, Universal Health Services, has faced multiple lawsuits in recent years and was the subject of a scathing report titled Warehouses of Neglect released last year by the U.S. Senate Finance Committee. The committee report claimed that the company, which operates 181 inpatient behavioral health facilities in the U.S. — including three in North Carolina — offered minimal treatment, poor conditions and too few staff, with many lacking proper training, all in an attempt to maximize profits.
Universal Health Services responded with a statement that calls the committee’s report “incomplete and misleading.”
Holly Hill’s CEO Holston declined to be interviewed for this story and answered some of NC Health News’ questions by email. In response to the many deficiencies cited by state regulators, Holston wrote: “When we identify an area where improvement is needed, we respond with a sense of urgency.” She also said that “[...] there have been sporadic incidents that required the creation of action plans to address deficiencies and establish improved processes. [...] Each time a deficiency has been identified, Holly Hill worked within the scope of regulatory requirements to correct and maintain compliance for an improved patient experience.”
Despite the hospital submitting multiple plans of correction that have cleared its immediate jeopardy sanctions, regulators continued to find some of the same issues at Holly Hill — year after year.
Repeat offenses
When regulators investigate patient complaints, they can do planned and surprise site visits at the hospital and look at a snapshot in time through a small number of patient records picked both selectively and at random. They review these records, interview a select number of employees and patients, and review available video surveillance.
NC Health News requested and reviewed more than 700 pages of records detailing state regulators’ investigations at Holly Hill from 2020 to the present, and there were several areas of repeated violations.
Unsanitary conditions
In their reports, investigators include detailed descriptions of broken and dirty living conditions at Holly Hill. In March 2023, regulators documented “red colored splatter” on bathroom walls, “dried urine streams … on the toilet,” overflowing trash, “what looked to be blood” over the top of a door, and a room that smelled strongly of sewage. Walls, furniture and a window were damaged. Cleaning logs were not provided to regulators upon request.
Earlier this year, regulators witnessed roaches crawling behind the coffee machine and ants in the day room. Patients said that there were roaches in the fruit bowls and around the ice machine. They wrote that the floor was “black, dirty with grit and was sticky” with “red dried substance on a wall and floor and sink area.” Chairs and walls were damaged as well.
One staff member told state regulators that the facility was too short-staffed to conduct regular inspections.
The hospital’s CEO told NC Health News in an email that “sanitation and cleaning is a campus-wide priority that is managed by our on-site Environmental Services and Housekeeping teams. Water and sewer systems are routinely checked and verified to ensure they are compliant with State regulations.”
Medication errors
Regulators flagged medication errors during on site investigations in 2020, 2021, 2023 and 2025, including incidents where patients were given the wrong medication and there was no investigation or report done, as required. Additionally, the hospital was cited for two incidents where patients had access to the medication cart and the room where medications are stored — both of which should be locked.
The CEO at Holly Hill maintains that the hospital follows all state-mandated standards for medication administration and has quality controls in place.
Discharge issues
In June 2020, the hospital was put under immediate jeopardy, in part, because staff “failed to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility,” the report reads. Much of the incident described in state records is redacted, but what is clear is that a receptionist opened the front door at this patient’s request and the patient left before their ride arrived. The patient’s whereabouts were unknown between the time the patient walked out the door of Holly Hill and when they were discovered 28 hours later at a hospital emergency room. Regulators wrote that there was no incident report or investigation done.
Less than a year later, in February 2021, regulators cited the hospital for discharging the wrong patient. Holly Hill staff put a patient in a cab and when they arrived at the next facility, it was discovered that Holly Hill sent the wrong patient. The whole ordeal led to the patient being missing from Holly Hill for 10 hours. Again, regulators found the hospital didn’t document this error.
Holly Hill’s CEO Holston said in an email that Holly Hill patients receive a discharge order from a physician who approves the transportation plan, with patients retaining the right to participate in their discharge decisions. She said that legal guardians are involved when applicable, and no incident report is generated if the discharge follows the physician’s order.
Translation services
During that same 2021 visit, regulators found Holly Hill didn’t provide language translation services for a Spanish-speaking patient for the first 20 hours of their hospital stay. The patient was restrained in a physical hold for 58 minutes only seven hours into their stay, unable to communicate with staff. A nurse wrote in the patient’s chart: “Patient refuses to speak English, speaks Spanish and answers in Spanish.”
One year later, Holly Hill was cited again for failing to provide a language assistance device for a patient. Hospitals are required by their accrediting agency to provide language interpretation services.
“Holly Hill respects patients’ cultural differences and works according to regulatory standards to ensure that patients can communicate appropriately with our staff and members of their treatment team,” the hospital’s CEO wrote in response to questions about language translation issues.
Treatment plans
Over multiple inspections, investigators cited the hospital for failing to complete or update required treatment plans — basic documentation guiding a patient’s care. These plans are supposed to be completed and entered into a patient’s record within 72 hours of admission. In March 2022, regulators reviewed a sample of patient charts and found some treatment plans were completed between six and 12 days after patients were admitted. One patient never had a treatment plan at all.
Two years after that, the hospital was again cited for failing to complete or update patient treatment plans. Earlier this year, regulators cited the hospital staff for failing to document required daily group therapy and failing to ensure that patients received follow-up appointments and prescriptions before leaving the hospital in several patient charts they reviewed.
When regulators questioned a staff member about the lack of treatment plans, they responded: “It wouldn’t surprise me if it’s not there, we are extremely short staffed.”
Enough staff to keep patients safe?
In response to questions about staffing at Holly Hill, hospital CEO Holston wrote in an email that the hospital meets all state requirements at its 296-bed facility and that staffing is reviewed routinely. “We increase staff to meet the needs and acuity of the patients we serve on a daily basis,” Holston wrote.
However, numbers of staff required for psychiatric facilities are vague at the state and federal levels. There is some guidance around having a minimum of one nurse and physician available at all times, but no firm ratio is specified. Most of the federal guidance boils down to having “adequate” staff to meet the needs of the patient population and the core functions of a hospital — safety and treatment.
A former regulator who conducted investigations at psychiatric hospitals around the country for the federal government said that staffing issues are often the underlying problem when a hospital is cited for escapes, sexual abuse or lack of treatment plans. Keeping eyes on patients is the only way to truly keep them safe, the regulator said. Federal rules set by the Centers for Medicare and Medicaid Services do not include specific numbers for staff-to-patient ratios.
The former regulator, who wished to stay anonymous due to their current work, explained that the number needed often changes depending on the population. For example, children, patients with criminal charges, or those in crisis, with frequent admissions and discharges, all should have more staff members attending to them.
The former regulator said that quality mental health care is inherently staff-intensive and costly, and they said they’ve seen some hospitals — particularly for-profit facilities — try to save money by keeping staffing lean.
A psychiatric nurse who worked at Holly Hill for eight years told NC Health News that the facility was chronically understaffed and had high turnover, calling the staffing matrix the facility’s “number one problem.”
The former nurse, who is employed at a different North Carolina psychiatric facility and wished to stay anonymous, said other nurses and mental health technicians were frequently overwhelmed, often caring for large numbers of patients with little support. A significant number of Holly Hill staff worked there part-time while working full-time jobs elsewhere, the former nurse claimed. They would quit, unwilling to tolerate unsafe, exhausting conditions for the extra money.
Holly Hill’s parent company, Universal Health Services, “denies allegations that its facilities operate without sufficient staff to keep patients safe and provide appropriate treatment,” wrote UHS Public Relations Director Jane Crawford in an emailed statement to NC Health News.
“Staffing can be a challenge in this tight labor market, in some markets and in some geographies. To address this, UHS has improved processes for recruiting and retention,” Crawford said. “We also have invested in new technology to assist our clinical staff.”
Over the past several years when regulators interviewed employees at Holly Hill about the deficiencies or incidents they were investigating, staff repeatedly placed the blame on new hires or being short-staffed.
Sexual abuse
One of the most serious citations across multiple investigations at Holly Hill is for failing to prevent patient-to-patient sexual abuse.
In June 2020, Holly Hill was put under immediate jeopardy, in part, for “failing to supervise and monitor hygiene time to prevent abuse,” regulators wrote in their report. The hospital failed to conduct an internal investigation after a patient reported an abuse incident and failed to notify the doctor, which is the hospital’s policy.
“We don’t know how it (the incident) happened,” the hospital’s risk manager told regulators.
One year later, Holly Hill was put under immediate jeopardy again, in part, for failing to monitor adult and adolescent patients to prevent two incidents of patient-to-patient sexual contact. In June 2021, regulators found that staff had not monitored the involved patients every 15 minutes as they were supposed to.
Regulators viewed time-stamped video surveillance as part of their investigation of a sexual abuse report, and they found that a mental health technician had documented a patient in one part of the hospital at a time when they were seen elsewhere on the video footage.
“Findings revealed the mental health technicians falsified documentation of 15-minute observations,” regulators wrote in their report.
When asked about this alleged record falsification, Holly Hill CEO Holston wrote in an email that “Holly Hill uses a two identifier process for identifying patients. This process aids in reducing risk. Holly Hill invested in electronic patient rounding that captures patients’ photos to ensure that each patient is correctly identified.”
The hospital’s chief nursing officer told regulators that the two mental health technicians on the unit at the time were suspended for missing their mandatory patient checks and that both had been new hires. The nurse executive admitted to regulators that the hospital shouldn’t have put two new employees on the same shift: “That’s something we should take ownership of.”
These sexual assault allegations are not isolated incidents. Raleigh Police Department has received 147 calls for service to Holly Hill due to sexual offenses and 24 for rape or to pick up a rape kit from Jan. 1, 2019, to May 6, 2025. Officers are also called to help find patients who escape Holly Hill.
On the run for days
On the day her teenage son was admitted to Holly Hill, Kathleen — identified by first name only to protect the privacy of her child — received two phone calls. The first was to let her know that her son had been punched in the face by another patient. The second was to inform her that her son had escaped.
Holly Hill staff told the mother that they couldn’t find her son.
Kathleen’s son, a sophomore in high school at the time, and another teen boy on his unit scaled the exterior wall of the outdoor recreation space while staff weren’t paying attention in 2021, she told NC Health News. They were on the run for days, sleeping in the woods with no phone access, before local police finally found them, according to Kathleen.
Raleigh Police Department records show officers have received 17 calls related to escapes at Holly Hill since 2019. State regulators investigated several incidents at Holly Hill in June 2021 — the same time period described by Kathleen — including the escape of two patients. Regulators put the hospital under immediate jeopardy — the highest sanction.
“In the event that a patient attempts to leave the premises of Holly Hill Hospital, our trained team members take appropriate actions to safely bring the individual back to care,” the hospital CEO wrote in an email to NC Health News. She also said that additional fencing was installed around the outdoor green spaces.
During admission to the hospital, the two patients who escaped should have been identified as “at risk of elopement” — or running away — and were not, according to regulators. They also should have been monitored by two employees while outside. Instead, regulators found that only one employee — who was sitting at a picnic table looking at their phone — was supervising 12 patients when two of them used a chair to jump over the fence.
Kathleen had objected to her son going to Holly Hill initially, when he was under a court-ordered involuntary commitment in a hospital emergency department.
“As a professional in the [mental health] field, I’ve had many experiences with working with and supporting families whose loved ones have been at Holly Hill and had very bad experiences,” she told NC Health News. “It’s not up to parents once they send out a referral. It goes to all the places and the first place with an available bed is where my son would go. It wasn’t up to me, and I didn’t have any say.”
She submitted a complaint against Holly Hill Hospital with the state Department of Health and Human Services and received a letter in the mail dated June 28, 2021, saying the state would investigate.
Kathleen never heard anything more.
Is the state doing anything?
Sen. Jim Burgin (R-Harnett) said he’s been part of three state-level meetings specifically about issues at Holly Hill Hospital.
“We can’t keep having these conversations. Seems like we’ll have the conversation and it will kind of settle down, and a couple of years later, we will have this conversation again,” said Burgin, who is in his fourth term at the state legislature and has taken a special interest in improving mental health care.
“I’m ashamed to say that it’s not new,” the senator said, referring to complaints alleging assaults, sexual abuse and other poor treatment within North Carolina’s inpatient psychiatric settings. “It’s not new news, and it seems like about the time we fix one place or get it to where we either shut a place down or get people out or something, it comes back up.
“And the bigger discussion needs to be: ‘Why?’”
“We need to be having a safe environment where they’re protected and they’re getting services,” Burgin said. “I don’t want people warehoused. And if we’re putting people in a situation where we’re not getting them into a treatment plan, then all we’re doing is holding them.”
There has been a concerning increase in the number and severity of complaints against hospitals in North Carolina lately, according to Karen Burkes, acting deputy secretary of health at the N.C. Department of Health and Human Services. The health department’s enforcement arm, the Division of Health Service Regulation, works with federal regulators at the Centers for Medicare and Medicaid Services to investigate the complaints.
“We recognize we have some hospitals where we're constantly seeing those IJs [Immediate Jeopardies], they’re resolving those deficiencies, and then we’re seeing them again, because they start to slip,” Burkes said.
State health officials have been asking state lawmakers to increase their regulatory budget to hire more staff to investigate these complaints, but their budget has largely remained flat. With limited staff resources, Burkes said, it’s unfair to all the complaints that need to be investigated for the division to keep going back to the same facilities over and over.
“So there are some conversations around ‘what do we do next?’” Burkes said. “What are some other options that we have? Because what has currently been happening isn’t really resolving that issue that we’re facing.”
When asked what further options state and regulators could take beyond issuing immediate jeopardy sanctions to Holly Hill, Burkes said she would have to follow up. When pressed further for specifics, the health department communications office sent an email explaining that the state and federal health agencies are working closely together on additional enforcement measures, which they cannot share until the federal health agency approves them.
Even as health officials debate what to do next, Holly Hill is expanding.
Coming Thursday: Holly Hill opens new units to serve more patients, including veterans and first responders, while partnering with local police.
Reporter's notebook: How I reported this story
After I reported a series of stories about the problems at Brynn Marr Hospital, a psychiatric hospital in Jacksonville, several former patients and employees of Holly Hill Hospital reached out to say they experienced similar issues in Raleigh. They urged me to look into reports from Holly Hill as well.
Both hospitals are owned by Universal Health Services, which has been the subject of investigations by a U.S. Senate committee, the U.S. Department of Justice and national news organizations. They all found a pattern of deficiencies across UHS-owned facilities.
Then, last year Holly Hill announced that it was partnering with the Raleigh Police Department to bring patients directly to the facility. I made a records request to the Raleigh Police Department for its call log of visits to the Holly Hill Hospital campus, which includes the times, dates and reason for which officers responded to a call there. I received several spreadsheets from the Raleigh Police Department with thousands of calls to the multiple addresses owned by Holly Hill. I also requested a copy of the 911 call recording to Raleigh Police Department from the night of the violent patient uprising in December 2024, but the department said the recording was no longer available.
I also tried to talk with the Raleigh Police Department about its partnership with the hospital. I spoke with the head of the police department’s mental health unit who said she didn’t know anything about the partnership. When I pressed the police department’s communications team for more information, they sent an emailed statement that did not answer my questions. The department never responded to emailed follow-up questions.
I made a records request to the N.C. Department of Health and Human Services for all the reports generated from regulatory visits at Holly Hill over the past five years. I received more than 20 document files from the state Department of Health and Human Services totaling more than 700 pages, which were highly redacted. The federal Centers for Medicare and Medicaid Services also releases reports of deficiencies cited at facilities, including psychiatric hospitals. These deficiency reports are released periodically by CMS in large data drops, which the Association of Health Care Journalists has been downloading and then uploading to its site and organizing the reports by state in a searchable way. CMS acknowledges that AHCJ makes these reports more accessible to the public. The federal report was anonymized but not redacted and provided more details, particularly on the violent uprising that happened at Holly Hill in December 2024.
To report this story, I talked to state health officials, state lawmakers, law enforcement officers, a former CMS regulator, a district attorney and former patients and employees of Holly Hill Hospital. I requested an interview with the CEO of Holly Hill, but she declined and only agreed to answer emailed questions. I sent multiple rounds of questions by email to the hospital CEO and to the leadership of Universal Health Services to give the hospital leadership an opportunity to respond to allegations. The CEO and a spokesperson for UHS responded each time, answering many but not all of my questions.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
