Disciplinary reports show mistreatment of some mentally ill patients in a state institution, including a patient touched sexually by a nurse, another patient doused with water, two patients unsupervised for nearly an hour, and in one patient's case, left alone long enough to drown himself.
A Channel 4 I-Team investigation found these cases in our ongoing effort to obtain information on 65 disciplinary actions regarding staff who were either fired, suspended or disciplined for abuse, neglect or mistreatment of patients, or failing to manage patients at risk.
So far, the I-Team has confirmed some of the disciplinary actions and has filed open records requests to obtain the rest.
The Channel 4 I-Team began investigating when we were tipped off to the death of a patient inside the institute.
That's how we found what happened to Cody Skelton, a talented musician who had struggled his entire life with mental illness.
On Nov. 27, 2011, Skelton threatened to harm himself and was taken to a nearby hospital, and for reasons unknown to his family, was then sent to the Middle Tennessee Regional Mental Health Institute.
"He (Cody) was in an uncontrollable state. He was just losing it," said Pete Skelton, Cody's father.
Like many of the patients sent to the institute, Cody Skelton didn't have insurance, and the state facility was the last resort for him to get help.
"I thought, 'fantastic, thank goodness, thank goodness he's there at the hospital. People there, are professionals, and they'll be able to take care of him,'"said Milton Skelton, Cody's brother.
On the early morning of Nov. 29, Cody Skelton drowned himself inside the state institution.
"I just want to know what happened," Milton Skelton said.
Cody Skelton's autopsy, which the Channel 4 I-Team obtained through public records requests, explained his terrible suicide.
The autopsy showed Cody Skelton secured his head inside an overflowing toilet and drowned himself, and that he secured the bathroom door shut with a bedsheet.
Cody Skelton's family says those troubling details are important, because it shows Cody was unmonitored long enough to plan and pull off an elaborate death.
"Sometimes I feel angry, sometimes I feel confused. But mostly, I just want to know what happened," Milton Skelton said.
The institution will not release to Cody's family or to the Channel 4 I-Team their internal investigation into his death or explain how often Cody was monitored.
But the institution's own internal policies for handling management of patients at risk stated when a patient is placed on suicide precautions, the patient shall be monitored constantly and the bathroom should be locked at all times.
The institution will not confirm if they deemed Cody Skelton suicidal, but just two days earlier, he threatened to harm himself.
"Cody needed help," Skelton said.
The internal disciplinary records the Channel 4 I-Team has been able to obtain raise serious questions about how other patients were treated.
One report stated a nurse straddled a male patient and took his hands and rubbed them on her chest, thighs and back.
In the report, the nurse denied it, but did admit to kissing him and was suspended.
But just four months later, the report showed that same nurse was fired for failing to check on two patients for nearly an hour - patients who were supposed to be under intense observation.
Another report showed a nurse was suspended for pulling on a patient's arms to get her out of bed, and then dumped a trash can of water onto the patient's head.
The report stated that the nurse's actions had the potential to re-traumatize a patient with a history of physical and sexual abuse.
Another report shows a nurse was suspended when she, and her patient, were found having their hands around each others' shoulders and neck area, and at the end of the encounter, the patient was observed to be lying on the floor.
"If they can't take care of him (Cody) ,they can't take care of others. It scares you," said Pete Skelton.
After the CEO of the institution, Candace Gilligan, refused our repeated requests for an on-camera interview, the Channel 4 I-Team walked up to her in the parking lot of the state institute.
"I wanted to speak to you about the cases of the patients here. Ma'am, please talk to me about what happened," said chief investigative reporter Jeremy Finley.
"I can't talk to you. Sorry," Gilligan said before closing the door to her car.
State department of mental health spokesman Grant Lawrence stated in an email that they could not discuss the specifics of the cases for HIPPA laws, and in general they do not do interviews.
Lawrence went on to write, "The security of patients and staff are of great concern and patient abuse is something we take very seriously."
Cody Skelton's family has now hired an attorney to try to force the institution to reveal answers into Cody's death.
"The family has a lot of questions about the care he received, "said attorney Matt Hardin.
"I miss him. I want my brother back," said Milton Skelton.
The Channel 4 I-Team shared our findings with a state senator who sits on a committee that oversees the institution, and the very next day, he summoned the commissioner of mental health into his office demanding answers.
The Channel 4 I-Team will report on what happened at the meeting, as well as showcase an interview with a former employee, Tuesday on Channel 4 News at 6 p.m.
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