After patient’s eyes ripped out, a scathing report on security at South Florida hospital

When “Patient 2” was admitted to South Florida State Hospital for mental health treatment in 2023, doctors noted he suffered from two disorders, schizophrenia and psychosis.

Five months later, after a savage attack in which his hospital roommate, known as “Patient 1”, tore his eyes out of their sockets, Patient 2’s record included a new, more worrisome diagnosis: He was suicidal.

He “is permanently blind, and has expressed wishes to die and for someone to kill him because he cannot see,” a biting report from the state Agency for Health Care Administration said of Patient 2. The report documented the agency’s decision to declare South Florida State Hospital’s residents in “immediate jeopardy,” the most serious finding health regulators can make.

The immediate jeopardy citation meant the hospital’s mistakes “placed the health and safety of [patients] in its care at risk for serious injury, serious harm, serious impairment or death.” The designation was lifted on Nov. 2 after health administrators accepted the hospital’s plan to correct its mistakes.

Patient 2, as he is identified in the AHCA report, became yet another victim of the violence and mayhem at Florida’s six psychiatric hospitals that is annually documented by police and health regulators. Though many residents, like the man who attacked Patient 2, have long histories of violence, others have grown old and frail under state supervision, and are incapable of defending themselves from such aggression. It’s repeatedly proven to be a dangerous mix.

Another killing, another cover-up. Patients remain at risk at Florida mental hospitals

The Miami Herald is not identifying the 49-year-old man regulators identified as Patient 2 in order to protect his privacy.

The incident last September at South Florida State Hospital in Pembroke Pines reflects a deadly pattern that repeats year after year: inadequate spending, poor decision-making and woeful supervision of dangerous residents committed to the state’s care for their own safety – and the safety of others.

Cleaning up the crime scene

The attack on Patient 2 hewed to the pattern in another way, as well. Employees waited an hour before summoning police, a report said, and by the time officers arrived, workers already had begun to sanitize the crime scene.

At a psychiatric hospital in Macclenny, about 35 miles west of Jacksonville, two men involuntarily committed to the facility died after being assaulted by other residents who had faced felony charges for violence. The attacks occurred after hospital employees had warned the state to stop mixing violent criminal defendants with sometimes frail psychiatric patients.

Read More: Covering up a deadly attack inside a state-run mental hospital

And in both cases, administrators at Northeast Florida State Hospital delayed calling law enforcement authorities — in one case for about 17 hours — while cleaning up the crime scenes.

DCF oversees three state psychiatric hospitals: Northeast Florida in Macclenny with 630 beds; Florida State Hospital in Chattahoochee with 490 beds and North Florida Evaluation and Treatment Center in Gainesville with 190 beds. Northeast Florida is not considered a “secure facility” for forensic patients; it lacks handcuffs, armed guards, barbed wire and pepper spray.

The agency also contracts with a private provider, Wellpath Recovery Solutions, to operate three others – South Florida State Hospital in Pembroke Pines, with 350 beds; South Florida Evaluation and Treatment Center in Florida City, with 249 beds; and Treasure Coast Treatment Facility in Indiantown, with 224 beds – where psychiatrists seek to “restore” defendants to competence, largely through medication and training in the criminal justice system.

‘Step down’ policy admits criminal patients

South Florida State Hospital is among the civil commitment facilities where DCF “steps down” criminal defendants — they are called forensic patients — in order to make room at the forensic hospitals, which are so chronically underfunded and poorly staffed that about 400 people are awaiting a bed.

In addition to the civilly committed patients who have a history of aggression, the criminal defendants place significant stress on the hospitals that accept them. The AHCA report said South Florida State Hospital staff would be given new training “in response to an increase in the number of forensic patients and patients with a high risk for aggression to increase staff awareness and vigilance.

Records show Patient 2 was involuntarily committed to South Florida State Hospital on April 20, 2023, after his psychiatrist diagnosed him as suffering from symptoms of schizophrenia and psychosis.

Reinaldo Uranga Bermeosolo, who is identified as Patient 1 in AHCA’s report, was admitted to the hospital on Aug. 4, 2023, with diagnoses of schizophrenia and intermittent explosive disorder. His psychiatric record included “violent and aggressive behavior, as well as continued extreme psychosis for several years, as well as delusions and paranoia,” the AHCA report said.

“He has a history of being unpredictable and becoming extremely violent at times, losing his temper for no reason; and he has attacked multiple people, including family members multiple times and an employee at [another psychiatric facility] just prior to the admission,” the AHCA report said of Uranga Bermeosolo.

The following month, on Sept. 10, a mental health worker heard noises coming from Uranga Bermeosolo’s room and found him “beating on his roommate,” the AHCA report said. The roommate was identified as Resident 9.

“The patient is dangerous,” the AHCA report quotes from hospital records. “He was pleasant,” the report added, “but can snap at any moment.”

Hospital administrators moved Uranga Bermeosolo’s roommate. Uranga Bermeosolo’s record also reflected that, on Sept. 13, hospital staff initiated “assault precautions” for him, and restricted his ability to roam the hospital campus freely.

But less than a week later, on Sept. 21, Uranga Bermeosolo’s father asked administrators to restore Uranga Bermeosolo’s “grounds privileges so he can visit,” the AHCA report said – a request that Uranga Bermeosolo’s psychiatrist granted.

“Patient #1 seemed to be doing well and not a threat to others, was calm and pleasant and getting along with his peers,” Uranga Bermeosolo’s psychiatrist told AHCA investigators.

“There was no reason for concern that he would do anything to anyone or himself,” Uranga Bermeosolo’s psychiatrist later explained.

The very next day, Uranga Bermeosolo attacked Patient 2.

Management lapses

A management lapse that day contributed to the tragedy: Both Uranga Bermeosolo and Patient 2 were supposed to be out of their living unit at a program that day, but both men stayed behind. Staff on the unit were not told that it was their job to supervise the two men, who would have been outside the unit for three hours while attending the day program, AHCA wrote.

When asked by AHCA investigators to explain the hospital’s system for supervising patients, a risk manager explained at length that administrators had installed an elaborate “color-coded dashboard” that tracks residents at a distance. The risk manager, however, “provided no plans to ensure staff maintains a presence in all areas where there are patients so as to supervise their activities, other than to conduct proximity scans” at intervals of up to an hour.

Camera footage from the hallway of C-wing, where both men lived, shows that from 2:40 p.m. until 3:43 p.m. on Sept. 22, “staff came onto the C-wing for a total of three minutes and 47 seconds,” the AHCA report said. Uranga Bermeosolo, who less than two weeks earlier had beaten his roommate, was not supervised – or even observed – the rest of that time.

Uranga Bermeosolo “attacked Patient #2…while their door was open, repeatedly punched him, traumatically removed and detached both of Patient #2’s eyes with his bare hands, and restrained Patient #2 on the floor for several minutes before the first staff arrived at 3:54 p.m.,” the AHCA report said.

Said a report from the Pembroke Pines Police Department: “This incident lasted approximately seven minutes before hospital staff was notified at” 3:54.

The report added: “There was an approximate time delay in notifying [police] of one hour.” During that hour, the police report said, hospital administrators already had begun to clean up the crime scene.

When police arrived, Uranga Bermeosolo “was sitting on a chair…acting nonchalant.”

Eyes recovered but could not be saved

Nurses at South Florida State Hospital gave rescue workers Patient 2’s eyes, preserved in ice, to take to the hospital, police reported. But it was not possible to restore the man’s sight.

In a short interview with police, Uranga Bermeosolo said that an argument began over a towel that was on the door they shared. “Reinaldo punched [Patient 2] in the face,” police reported, and then pinned him on the floor.

Uranga Bermeosolo was charged with aggravated battery causing great bodily harm or disability. He has pleaded not guilty, and the case remains pending. On Nov. 27, Broward Circuit Judge Ari Porth adjudicated Uranga Bermeosolo incompetent to stand trial. He was committed, once again, to DCF custody for treatment.

A hospital risk manager told AHCA that no staff members heard or saw anything while Patient 2 was being brutalized.

“Since the order for live camera observation in their room had been discontinued by the physician the day before to accommodate [Uranga Bermeosolo’s] family’s request to increase privileges for visitation, no one was observing the room at the time of the assault to request help.”

During an interview with AHCA, a security officer “initially said he was not sure the event was preventable,” the AHCA report said.

He later acknowledged that leaving residents unobserved for an hour “could have contributed to it and that ‘when they know there’s no one around, it’s an opportunity.”