An independent review found staff shortages, budget cuts, inconsistent policies and lack of training were widespread at a Department of Children's Services facility in East Tennessee where two teenagers committed suicide in less than a month.

In both cases, staff at Mountain View Youth Development Center in Dandridge failed to adequately monitor the teenagers, notice signs they were suicidal, and start them on medication shortly after it was prescribed. Since the suicides, DCS fired two officers and security manager Steven Harrison resigned.

The review submitted by Tennessee Commission on Children and Youth (TCCY) showed there was not enough staff with sufficient training at Mountain View to properly oversee about 114 teenage boys housed at the facility. There are currently 30 unfilled positions, according to DCS Commissioner Jim Henry.

  • Only one staff member oversees 12 boys.
  • In segregation units, where the more aggressive teens are housed, there are only two staff members.
  • During sleeping hours, only one staff member monitors 16 students.
  • TCCY said there should be one staff member for every eight teens.
  • To keep up with the staffing demands, employees have to work a minimum of 16 hours of overtime a week.

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Henry vowed his agency is working quickly to address the employment issues.

"We need to improve our ability to fill the vacancies at Mountain View. Our students deserve it, and our staff, which is now working mandatory overtime, deserves it too," said Henry in a release. "Already we have instituted an accelerated interview, background check and training process to get qualified staff into the facility."

Mountain View has cameras in all common areas and units throughout the facility. But the staff doesn't routinely review and monitor these camera feeds, according to the TCCY report.

TCCY said budget cuts have taken a toll on the state's youth facilities. The Juvenile Justice Division receives less federal funding than other programs for children, despite serving kids with extensive mental health and substance abuse issues. The state is left with much of the operating costs.

Extensive mental health needs

About 57 percent of teens living at Mountain View take psychotropic medications. The teens who committed suicide were taking Zoloft, an antidepressant whose side effects include "violent behavior, mania or aggression, which can all lead to suicide," the report said. TCCY also noted that many of the facility's guards didn't know which types of medications were prescribed to the teens in their units or their potential side effects.

The report also found that in some cases, it took as long as one to two weeks for medications to arrive at the facility once they're prescribed. One of the teens who committed suicide never had the opportunity to take a medication recently prescribed to him; the medicine arrived after his death.

A history of suicide attempts

Editor's note: WBIR 10News doesn't typically report suicides, but because Mountain View is a state-run facility, we thought the public needed to know about the staffing, training, budget, and security issues facing the facility.

The two suicides were the first at the Dandridge facility in more than 20 years.

On July 13, Brandon Charles Greene, 16, of Johnson County hanged himself from a shelf in his room while the other teens left to shower.

Over a two month period, officials placed Greene on suicide watch three times. In July, Greene tried to poison himself by drinking ink from two pens. During the same month, Greene was found lying on the floor with a shoe string tied around his neck. But four days after his last attempt to kill himself, he was taken off suicide watch. Two days later, a teen found Greene hanging by a t-shirt, wrapped around a laundry bag cord, attached a metal shelf above his bed.

Three weeks after Greene's death, an 18-year-old hanged himself with a bed sheet anchored to a metal shelf in his room. The Tennessean reported that the teen's name is Frank Cass Jr.

Like Greene, Cass attempted suicide in the past. Before Mountain View, Cass tried to kill himself three times and was a patient at a psychiatric hospital five times.

Officials placed Cass in the segregation unit after he assaulted people in three separate incidents in one week. In the two months before his death, the report said staff restrained and confined Cass in eight incidents.

The day Cass died, the staff was supposed to monitor him every 15 to 30 minutes; instead they waited an hour and 45 minutes to check on him. During that time, the 18-year-old took his own life.

Henry promised DCS is working to strengthen its suicide prevention protocol and security.

A push for more therapeutic facilities

TCCY said it's difficult to monitor and rehabilitate children housed in large correctional facilities like Mountain View. The state agency said DCS should consider creating smaller, more "therapeutic" facilities.

Henry agreed that his agency needs to use a more therapeutic approach.

"We need to move further away from a correctional-style approach and more closely toward a therapeutic approach in order to get our students on the right track," said Henry in a release. "A majority of our juvenile justice youth has mental-health and substance-abuse issues. . . We have been reaching out to other states and experts to learn how they have delivered the services to juvenile-justice youth."

Contributing: Anita Wadhwani, The Tennessean