A few days after Benjamin Bannister tested positive for coronavirus in, he told medical staff at the Virginia Center for Behavioral Rehabilitation that he was experiencing shortness of breath and headaches. Nurses said he would receive medical attention, but, like with his prior requests for assistance over the last days, nobody offered care.
When he stood up the next day for a temperature check, he collapsed, and woke up 27 days later in the Centra Lynchburg General Hospital.
“They said I was lucky to come home from ventilating,” said Bannister. In mid-November, hospital staff “told my family to prepare for my funeral.”
Though only one resident and three staff members were currently positive for the virus as of January 27, 64 staff and 186 of the approximately 420 residents at the facility had already recovered from the virus, according to figures from the Virginia Department of Behavioral Health and Development Services (DBHDS), the agency that operates the Virginia Center for Behavioral Rehabilitation (VCBR). Five men who were detained at the facility have died from the coronavirus.
Though DBHDS offers a range of mental health services at 13 facilities across the state, VCBR is unique. Men living in the facility have been deemed incompetent to stand trial or served time in prison. They are branded ‘sexually violent predators’ at risk of reoffending and civilly committed through a process that critics have decried as unscientific. Residents of VCBR experience conditions they compare to an incarceration facility, but they haven’t received time-limited sentences and don’t know when they’ll be released.
As COVID has ripped through the facility, residents said they struggled to obtain basic medical attention. Staff only provided COVID tests after an infection had been identified, by which time many of the men, living in close quarters, had already been exposed to the virus. Even after tests confirmed the spread of coronavirus, the facility placed infected men with those who had not yet contracted the virus.
“They don’t have [any] experience of how to treat people with [coronavirus],” said Howard Morris, who has been in the facility for six years.
Infected men were initially moved out of Morris’ unit into an area set up to quarantine the sick. As more men began testing positive, staff moved those with COVID-19 back into the unit, claiming that everyone had been exposed. Morris said his rapid test came back negative.
Later in December, Morris’ roommate fell ill. The facility didn’t move Morris out of the room, and he contracted coronavirus.
“It was cruel and unusual punishment towards me and towards him,” Morris said. “When I caught it, they waited a couple days to give me some medication and some assistance.”
Barriers to medical treatment existed at VCBR before COVID-19, according to Cynthia Brown, a nurse who stopped working at the facility in 2019.
“We were always short-handed,” Brown said. “There were nurses there that didn’t respect the residents or the people they worked with.”
A report from the Virginia Office of State Inspector General (OSIG), found that between July 1, 2017 and March 31, 2019, VCBR regularly failed to meet required staffing minimums. One-fifth of the logs viewed by OSIG found that VCBR did not meet needed staffing levels.
In other incidents, staff logs were missing, so VCBR could not substantiate whether it had the required number of employees working.
In 2019, Bannister suffered a small bowl eruption. He couldn’t use the bathroom or eat and was vomiting his own feces. When he sought medical attention from staff, nurses said they needed to see him throwing up; but when he requested help, they wouldn’t come quickly enough.
He said he wasn’t sent for external medical care for more than a week and a half.
“You go through so much here just to get medical attention,” Bannister said.
One resident, who was released from the facility in 2020, said he waited three weeks before receiving medical care for a tooth, even though his face was visibly swollen.
“When they finally close that place down, these people are going to be suing left and right. I know I would,” Brown said.
For much of the year, even as coronavirus swept across the country, the facility avoided a surge. Cases flared up sporadically through the year, according to documents sent to Shadowproof by advocacy organization Just Future Project.
On June 9, facility director Jason Wilson sent a memo to staff saying that an employee had tested positive. Fearing that a resident was infected in July, the facility temporarily reduced one unit’s movement.
In October, cases started rising. On October 7, Wilson sent out a memo saying “two full units of VCBR were tested for COVID-19. This testing resulted in some residents testing positive.”
A month later, the virus entered resident Scott Traber’s unit. Shane Wright, another resident and a friend of Traber’s, tested positive for COVID-19 at the beginning of November. The facility had repurposed unit 2B as a quarantine space for sick men. VCBR moved Wright, who was struggling to breathe, out of his regular pod.
But Traber said he and other friends of Wright had to request COVID tests from facility workers.
Traber tested negative. Three days later, after Traber’s roommate woke up feeling ill, both men tested positive for COVID.
Staff moved Traber out of unit 1C. About 24 hours later, he and others were back into their normal living quarters; a nurse said that everyone in his unit had tested positive. Traber said some people hadn’t even been tested.
“At the beginning of the global pandemic, VCBR quickly established isolation units to house individuals that are positive for COVID-19. If an individual is positive or symptomatic of COVID-19, the individual is moved to one of these isolation units,” DBHDS spokeswoman Lauren Cunningham said in an email statement.
“Unfortunately, there have been instances in which the number of positive residents on a living unit exceed the capacity of our isolation units. If this occurs, individuals that are positive for COVID-19 may be kept in their living unit and encouraged to separate themselves from others.”
“Other individuals on the living unit are encouraged to maximize hygiene practices and receive increased monitoring for symptoms of COVID-19 by medical personnel. VCBR implemented this strategy in consultation with their local health department.”
“I would caution the assumption that the individuals on a living unit eventually tested positive because of this strategy,” Cunningham argued, adding “an individual may be exposed to the virus and test negative with no symptoms, but will test positive days after the exposure.”
Nurses began conducting daily temperature checks using infrared thermometers. The residents didn’t believe the results; prior scans had yielded temperatures as low as 93 degrees. Wright said that while he was sick, a thermal scan showed Wright’s temperature at 97. An oral thermometer measured 103.3.
Traber was experiencing diarrhea and asked for imodium. He said he waited two days to receive just one dose. Traber’s roommate grew blisters on his throat and asked for a liquid diet. Staff provided nothing but chicken broth for six days. Famished, the roommate resumed eating solid food.
“They do these progress reports on us, and in our reports, it says, like ‘Mr. Traber is aware that he has 24/7 access to medical care.’ Now I have access to it, but I’m not getting it,” Scott Traber said. If residents aren’t “deadly ill, it’s really hard to see the doctor.”
Traber and Bannister said staff had not cleaned their unit since COVID-19 spread through the space.
“We take it apart ourselves and clean it,” Bannister said, alleging the facility has implemented “no change in their protocol whatsoever” and offered only watered down cleaning products.
Residents say their treatment never improved. Days before VCBR resident Joshua McClary experienced a seizure and was rushed to the Virginia Commonwealth University hospital (VCU), men who had previously tested positive for coronavirus were moved back into his unit. McClary lost his sense of taste and smell. Then he had a seizure.
Medical staff at VCU intubated him, medical records show. A doctor called his mother to say McClary had COVID-19 and an infected lung, but they wouldn’t administer Remdesivir until he stopped having seizures.
When McClary, who has a history of seizures, woke up a few days later, the doctor said he would return in a few hours. Instead, VCBR personnel wrapped his body in “seat belt cuffs” and took him out of the hospital.
“Nobody came with discharge papers for me to sign. No doctor came back to see me. Nothing,” McClary said. He was released from the hospital on New Years Eve, just four days after he arrived. “It really disturbed me how I was treated.”
VCU and DBHDS said that VCBR does not influence treatment provided at the hospital.
“Adult residents of VCBR maintain their right to make informed decisions regarding their medical care and may consent for their own treatment, except if determined to be incompetent or incapacitated. If a patient is unable to make an informed decision, the patient’s personal representative is contacted,” Associate vice president for public affairs at VCU Michael Porter said in an email statement.
“If an individual from VCBR is brought to VCU, their medical care is directed by the clinical team at VCU. VCBR does not influence or direct treatment rendered at VCU for that individual,” Cunningham told Shadowproof.
Back at the facility, Joshua said he was placed, alone, in unit 4A, rather than in 2B, the unit set up for medical isolation.
“I was literally crying, telling my mom I was scared.” he said. “I felt like I was being punished,”
He told his mom he had no regular supervision and nothing to do. A staff member later brought McClary movies to watch.
“I could hardly understand him, he was breathing so fast, and that concerned me,” McClary’s mother, Diane Mountain, said. Hearing about his isolation, she called the facility and asked why her son was isolated. “He’s a human being too, and so is everybody else in there.”
“Since the beginning of the global pandemic, VCBR has worked with the DBHDS and the Virginia Department of Health to ensure appropriate services are rendered,” Cunningham said.
Detention in VCBR is a type of purgatory. Though the Supreme Court has ruled that civil commitment is legal, civil rights experts have argued that the sentences “smack of double jeopardy” and deprive defendants of a fair hearing.
In January , Virginia State Senator Joseph Morrissey introduced a bill to abolish the state’s Sexually Violent Predators Act, which established the process to send someone to civil commitment after prison.
“There is no code section that I find more offensive and more inconsistent with due process and fairness than this, civil commitment,” Morrissey said at a Senate hearing on January 27. “It reminds me, quite frankly, of a Tom Cruise movie where you could look into the future and determine whether this person may create a crime in the future, so lock them up in another jail.”
In many ways, the conditions mirror those of a prison or jail. The men pay for phone calls. The VCBR Resident and Family Handbook from 2018 notes that incoming personal mail will be opened and inspected for contraband and may be read. Clothing is regulated.
Treatment in VCBR modulates between three distinct phases, which also influence the activities permitted. The amount of hours residents can work, the frequency with which they can visit the gym and the number of packages they can receive, correlate to a resident’s treatment phase and “Privilege Level.”
Since its inception, 251 individuals have been court-determined to have successfully completed the treatment program at VCBR and have been conditionally released, according to VCBR.
Morris, who said he has been in the facility for six years, expressed frustration at what he felt was an arbitrary measurement of progress in treatment. The pandemic has exacerbated his frustration, as quarantines force treatment stoppages.
“This is supposed to be a medical treatment, mentally helping us for society. It’s not helping us. It’s hindering us,” Morris said.
At the end of January 2021, Traber, Wright and Bannister hadn’t been able to purchase items from the facility store since the beginning of October of the previous year. Wilson sent a memo to all residents on December 1, saying that personal property distribution, commissary delivery and market store access across the facility had been indefinitely stopped, meaning that those in the facility could only receive items provided by the state. Visitations have been suspended since March, while staff freely bring COVID-19 into the facility.
“We can’t go outside, we can’t do nothing. The TVs cut off at 1:00 o’clock at night time,” Morris said. “I’d rather rather be in [Department of Corrections] than civil commitment.”