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Girl who died in ‘troubled teen’ facility was dead for up to 10 hours before staff realized

Posted: 10:15 PM, Jun 09, 2024
Updated: 2024-06-10 11:42:37-04

ST. GEORGE, Utah — Maggie Montelongo was desperate. 

Her daughter, Arianna Duenez, had struggled for years in residential treatment facilities in and out of California – becoming addicted to drugs in the process and increasingly expressing suicidal ideation. 

So when Duenez was transferred from a teen treatment center in southern Utah to Vive Adolescent Care in St. George in May of last year, Montelongo was cautiously optimistic. Maybe this was the place that would finally help her daughter, who loved unicorns and painting and dying her hair vibrant colors. Maybe Duenez would finally get better under their care. 

“I took her there in hopes that they could help her," Montelongo said, her eyes welling with tears during an emotional interview at her home in southern California late last month. 

But now, Montelongo said, all she has of her daughter are the memories – and “her ashes. That’s what they gave me back.” 

Duenez, who once dreamed of becoming an advocate for children who struggled with mental health, was found dead in her bed at Vive on the morning of July 2, 2023. She was 16 years old. 

Police quickly ruled out suicide and found no signs of foul play. The Utah Medical Examiner’s Office, unable to pinpoint the exact reason Duenez never woke up, ultimately ruled her cause and manner of death as undetermined.

“This is a perplexing case,” said St. George Police Sgt. Adam Olmstead, who responded to the facility the morning Duenez died. “Just for the fact that any time you go out and there’s a 16-year-old who’s deceased, that’s not normal.” 

But documents obtained by FOX 13 News now provide new answers for Duenez’s family – and spark additional questions – about the events leading up to their daughter’s death. Records show: 

  • Vive employees didn’t follow the facility’s procedures for 15-minute checks on all clients that night, even though Duenez had vomited repeatedly in the hours before she died.
  • Though staff looked in on Duenez throughout the night to make sure she was still in her bed, her breathing “was not assessed as outlined in ‘Routine Client Monitoring’ policy,” Vive said in documents submitted to the state.
  • For an hour and a half that morning, facility footage showed staff didn’t look in on Duenez at all – even though the state found the employees had signed off on those checks as if they’d been performed.
  • There was no registered nurse on duty that morning as required, one of four times that same week where that was the case.

By the time Vive realized something was wrong, Duenez had already been dead for anywhere between 4 ½ to 10 hours, St. George police estimated. Paramedics arrived to find her “stiff,” “cold” and “purple.”

While the state identified several policy violations related to record-keeping and client monitoring at the facility, it ultimately determined the facility's actions hadn't led to Duenez’s death. 

"There was no direct cause – in our investigation – between the noncompliance and the individual’s death,” Shannon Thoman-Black, the director of the licensing division, said in an interview. 

The Department of Health and Human Services (DHHS) is the main oversight body for so-called troubled teen facilities like Vive – an industry that has received increased scrutiny in recent years over allegations of neglect and abuse, including high-profile accounts from celebrity Paris Hilton. The Utah Legislature enacted new policies in 2021 to regulate the industry, which is one of the largest in the nation. 

Other fatalities in these centers have received local and even national attention, including the death of 17-year-old Taylor Goodridge at Diamond Ridge Academy in 2022. But Duenez’s death has never before been reported. 

Vive declined multiple interview requests for this story, instead releasing a statement. In it, the facility said it was “heartbroken” at Duenez’s death and hadn’t issued a public statement previously out of respect for her family and in compliance with privacy laws. The statement also stressed Vive’s current good standing with state officials. 

“Both regulators and local law enforcement completed their investigations and neither found wrongful or criminal activity,” the statement said. “While we routinely self-reported an issue at the time, it was judged to have had no bearing on the patient’s death. We have long been cleared to accept new admissions.” 

But with what they know now, it all makes Duenez’s parents wonder: If the facility had checked to make sure their daughter was breathing throughout the night, would she still be alive? 

"Whether a defibrillator would have worked or whether it wouldn’t have, the point is Arianna never got that choice," said Daniel Bisinger, Duenez’s stepfather. “She never got that chance. We’ll never know. Because of their neglect.” 

Video below explains how FOX 13 News investigated the death of Arianna Duenez:

Behind the investigation

'NOT ON THIS EARTH ANYMORE’

When she thinks about her daughter, Montelongo remembers Duenez as a supportive friend and adoring big sister, who loved animals and had a vibrant personal style. 

She loved to express herself through her art. She cared deeply about people, and could strike up a conversation with almost anyone. She had a particular soft spot for people who also struggled with mental health. 

“She was fearless,” Montelongo remembered. “Sometimes that scared me, because she really was fearless. It was like a double edged sword. It allowed her to do a lot of good things and a lot of dangerous things.” 

By the time she arrived at Vive in May 2023, Duenez had been sober for about seven months. But as she continued to express cravings for illicit drugs, a psychiatric nurse practitioner at Vive suggested a few weeks later that she try Suboxone, an opioid addiction medication rarely prescribed to youth

“Instantly I was like, ‘No. I don’t think that’s a good idea,’” Montelongo recalled. “‘That’s a Class III medication. And from what I’ve heard, that’s a medication you give to somebody that is in the process of withdrawing.’” 

But after spending the weekend deliberating as a family, they agreed to try the medication on a low dose, hopeful it would make a difference for their daughter. 

Duenez took her first dose of Suboxone on Tuesday, June 27. She told her parents she was nauseous over the next few days, but they’d seen similar symptoms with other new medications, so it didn’t necessarily raise a red flag. 

But by Saturday, July 1, Duenez still wasn’t feeling well. She couldn’t keep food down. And for a 16 year old who usually tried to push the limits of her phone privileges, Montelongo said their conversation was unusually short that day. 

“Three minutes into me talking to her, she said, ‘Mom, I’ve got to go; I don’t feel good. I’m going to go lay down,’” Montelongo said. 

As they ended the call, Montelongo told her daughter she would ask the nurse to check on her again. 

“And the last thing I told my daughter was, ‘I love you,’” Montelongo said through tears. “And she said, ‘I love you.’ That was the last thing.”

PHOTOS: Arianna Duenez through the years

DHHS records confirm Duenez had “multiple vomiting episodes” that day and became tired early, asking to go to bed about 8 p.m. A staff member who spoke with her about 9:45 that night later told St. George police that Duenez appeared happy, though tired, in the hours before her death. 

On Sunday morning about 8 a.m., a staff member went to wake Duenez but “received no response,” according to a police report. The employee said she assumed Duenez “was just refusing to get up,” so she went to wake up other clients.

She and another staff member returned and entered the room for the first time shortly afterward. When they still didn’t get a response, they pulled down the comforter that covered Duenez and immediately realized something was wrong. The teenager’s feet were “cold to the touch” and her skin “appeared mottled and pale,” one of them later told police. 

The employees quickly called 911, telling dispatchers that Duenez was “so stiff” they could barely move her. Paramedics arrived shortly afterward to find Duenez “obviously deceased,” according to the police report. 

About this time, Vive called Montelongo to let her know they were doing CPR on her daughter. 

“When he said that to me, I had a feeling that my baby was not on this Earth anymore,” she said, her voice cracking. “I just knew it.” 

Duenez was pronounced dead shortly after paramedics arrived, at 8:31 a.m. 

But based on her condition, St. George police later estimated she had died long before staff realized – anywhere between 10 p.m., shortly after she went to sleep, and 4 a.m. Supporting that timeline was the department’s review of video surveillance, which showed Duenez died in the same position she fell asleep in. 

“Knowing the process that the body goes through when it passes away, the rigor mortis – the condition that we found her in – would leave us to believe that she had been deceased for more than a few hours,” Olmstead said. 

Video below shares how 16-year-old Arianna’s mother and stepfather remember their daughter:

Remembering Arianna

NO ANSWERS FROM AUTOPSY

Along with the St. George Police Department, state regulators and the Utah Medical Examiner’s Office also descended quickly on Vive to find answers. 

The autopsy, for its part, provided very few – ruling both Duenez’s cause and manner of death as “undetermined,” according to a copy of the report her parents shared with FOX 13 News. 

The medical examiner found Duenez had a slightly enlarged heart and fluid in her lungs, along with several medications in her system. But the level of those substances was “non-toxic,” the autopsy said, and all had been prescribed.

Given the findings related to the heart, the medical examiner said it couldn’t rule out “a cardiac cause of death.” And because the office also could not complete some desired testing, the autopsy said a “genetic component” of the death “remains a possibility.” 

The Utah Medical Examiner’s Office declined an interview, saying it was unable to provide information about specific cases. But a spokeswoman for the office said in an email that “undetermined” cause and manner of death are typically used when there’s no “clear evidence about the person’s cause of death or manner of death.” 

A redacted copy of the police report obtained by FOX 13 News indicates that officers asked several questions about Duenez’s medications during their investigation. But Olmstead said police relied on the medical examiner’s findings to determine whether those drugs played any role in her death.

"And in this case, everything appeared to be in therapeutic range,” he said. “Where it gets complicated is when we can’t determine the cause of death, it’s hard to know if that was a factor or not." 

While the autopsy didn’t raise red flags about her medication, Duenez’s parents believe the drug Suboxone, which can cause vomiting, combined with the other medications she was taking in a way that contributed to hear death. 

“A totally healthy 16-year-old girl, has a strong heart – there's no other explanation,” Bisinger said. 

Duenez’s family is now pursuing a second autopsy, which they hope will help offer more clarity about what happened to their daughter. 

“If they do that, and they come up with a report that differs from what our medical examiner has in their report, we’re more than happy to look at that,” Olmstead said. “We would probably then run that with our medical examiner, have them take a look and see if there is further investigation that can be done.” 

POLICY PROBLEMS AND PROSECUTORS

In addition to their concerns about the Suboxone, Duenez's family also believe policy issues at the facility played a role in their daughter’s death. 

Documents from the state’s Department of Health and Human Services, released to FOX 13 News through an open records request, revealed multiple problems with client supervision at the facility. 

Records show, for example, that staff were supposed to check clients every 15 minutes to ensure they were breathing – a policy two former employees and one former client told FOX 13 News was put in place to address self-harm concerns. These checks usually required staff to visualize a client’s head, neck and hands. 

That didn’t happen the night of Duenez’s death, Vive said in a correctional plan submitted to the state afterward. 

Instead, when staff looked in on her throughout the night, they stopped in the doorway to confirm Duenez was still there, according to the St. George Police report. That vantage point offered a “fairly clear view,” but the report said it was possible staff could only clearly see her feet and body under the blankets. 

From 5:53 a.m. to 7:30 a.m., no one checked on Duenez at all, records show. But the police department said that because Duenez was likely “already deceased by this point,” the “lack of checking for approximately an hour and a half is not a factor or contributor to her death.” 

Vive’s correctional plan noted that involved staff were “not aware” of Duenez’s “decline in status.” Neither was the nurse. It also stated that client checks didn’t include visualizing “head and neck while in bed,” and that there had been no licensed registered nurse on duty the morning Duenez died. That was one of four times that week where there was no one available to provide patients care “that required the judgement and special skills of a registered nurse.”

As a result of Duenez’s death, Vive said it would re-train staff to observe three breaths for every client every 15 minutes and to “carry flashlights for checks at night” to ensure “head and neck are visualized” during those checks. The facility also added new “routine nursing observations” with “assessment of client physiological status” and promised to always have registered nurses on duty.
 

Vive corrective action plan.png
This screenshot of Vive’s Corrective Action Plan, which was submitted to the state Department of Health and Human Services after Arianna Duenez’s death, outlines problems that occurred that night and possible solutions. Among the issues, Vive said Duenez’s “respiratory status was not assessed as outlined in ‘Routine Client Monitoring’ policy.”

DHHS ultimately fined Vive $1,000 after its investigation into Duenez’s death. It also put the facility’s psychiatric side under a conditional license, which requires additional scrutiny from state regulators, and imposed a temporary ban on admissions there. 

Thoman-Black, the new director of the state licensing division within DHHS, said financial penalties are determined based on the severity and risk posed by noncompliance issues. And while the department had the ability to issue a maximum $5,000 fine at the time, it ultimately found the problems at Vive hadn’t contributed to Duenez’s death. 

"The facility itself had all the correct policies and regulations in place and as soon as they found staff had not followed policy, they let us know,” she said in an interview. “They completely cooperated with the investigation.”

After completing a plan of correction and undergoing additional scrutiny as part of the conditional license process, Thoman-Black said Vive is currently in compliance with state regulators, adding that there are “no sanctions against their license and no ban on admissions.” 

But for Duenez’s parents, it all feels insufficient – and the $1,000 fine just feels like an insult. 

“So your child’s life means what to them?” Montelongo asked. 

“A thousand dollars?” Bisinger added. “That’s pretty sickening.” 

After completing its own investigation, the police department took its findings – including “the hourly checks, the possible time of death, the medications prescribed and so forth” – to the Washington County Attorney’s Office to screen the case for potential charges. 

The attorney’s office declined an interview request due to its “minimal involvement with this matter.” But prosecutors told the St. George Police Department that while there “may be questions regarding prescriptions or actions taken by medical personnel or staff within the facility, there was no specific intent to do harm." 

The problems concerns brought forth in the case by Duenez’s family could “constitute a potential medical malpractice issue or policy/procedure issues,” the police department’s summary continued, “but the attorney saw no criminal conduct taken by anyone involved.” 

The office ultimately declined to press charges in the case. 

FOX 13 News requested a copy of the screening documents from the attorney’s office but were told no written records existed related to Duenez’s death. 

Courtney Brinkerhoff Sinagra, a prosecuting attorney in the office, reiterated the office’s findings in an email, adding that it’s not the office’s place to determine whether there was “civil wrongdoing or negligence on the part of the treatment providers.”

"The appropriate avenue for those harmed in this tragic situation is to seek civil remedies through the civil lawsuit process,” she said. 

County attorney declination.png
This screengrab from the St. George Police Department’s report on Arianna Duenez’s death explains why the Washington County Attorney’s Office declined to pursue charges in the case. The office told St. George police that there “may be questions regarding prescriptions or actions taken by medical personnel or staff within the facility.”

MOVING FORWARD

As their first year without their daughter comes to a close, Duenez’s parents say they’re still in some form of denial.

They’ve kept her bedroom exactly as she left it, with her stuffed animals on the bed, her clothes on their hangers, her shoes lined up in the closet and her gecko, Pixie, still in his tank. 

Sometimes, they can pretend Duenez is still in Utah. She’ll come home soon – once she’s better.

“We still talk about Arianna as if she’s here in the present,” Bisinger said. “She’s just away. She’s coming home. We have her room exactly the way it was. All of her things. Holidays, we still buy things. We still feel her here. You know, everywhere we go, everything we do reminds us of Arianna and that’s never going to change." 

They see memories of her everywhere – from the garden they created in her honor, to the mourning doves that appeared the morning of her death. They hear her in the sound of the windchimes she loved, and they can still smell her scent when they come into Duenez’s room to pray over her ashes each day. 

“I always ask the Lord to cover her in his love and for her not to be in any pain anymore,” Montelongo said. “Because I know she’s not. I felt it.”

Their loss still feels so fresh. And while they know nothing they do now will bring her back, they hope that increased public scrutiny of her death could lead to more accountability – and more answers – for their daughter.

“There’s things I want to know,” Montelongo said. “I’ll never get to be in the room of her resting, the last time she took her breath. You can’t have peace with that.” 

Montelongo and Bisinger said they also felt it was important to speak out in the hopes that something like this doesn’t happen to another family desperately seeking to help their child. 

“The pain, the suffering is for a purpose,” Bisinger said, “and our purpose is to use that so this doesn’t happen to someone else ... they don’t lose their daughter for no reason when they should still be here with us. That’s what I want people to know. That’s what has to come from this.” 

Arianna Duenez urn.png
Arianna Duenez’s parents come into her bedroom each day to pray over the purple urn that holds her remains. Her parents are still seeking answers about what happened to the 16 year old, who died at a “troubled teen” facility in St. George, Utah, in 2023.