NEWPORT NEWS, Va. (WAVY) — A 17-year-old girl died while being treated at the Newport News Behavioral Health Center (NNBHC), and a state report concluded the facility failed to provide adequate care for her.

Three years later, a nurse who was disciplined by NNBHC leadership for her involvement in the teenager’s care is being held accountable by the Virginia Board of Nursing.

Raven Keffer was already sick when she was admitted to the NNBHC on June 22, 2018. She had been in and out of doctors’ offices and emergency rooms nine times in the five months leading up to her death, including two days before she was admitted to the NNBHC, according to a lawsuit filed against the facility by Raven’s sister, Haley Keffer.

The original lawsuit has since been withdrawn and will be refiled soon with additional attorney representation.

Raven had a troubled childhood and began abusing drugs and alcohol at a young age. She was seeking help for her addiction at Phoenix House in Arlington before she was transferred to the NNBHC. Her social workers didn’t believe Phoenix House could care for her medical issues, which included an increased heart rate, difficulty breathing, vomiting and dehydration, the lawsuit states.

Social workers believed the NNBHC would be a more appropriate place for Raven. That facility provides mental health and addiction treatment for children and adolescents. The Department of Social Services told NNBHC staff about Raven’s medical issues before the center accepted her as a patient, the lawsuit alleges.

A nurse named Jamie Holmes assessed Raven’s health on the day she arrived at the NNBHC. Holmes noted Raven’s low blood pressure but failed to notify her supervisor, a doctor, or the facility’s nurse practitioner of the teenager’s symptoms. Holmes would later admit that Raven was the first patient she’d ever conducted an admission assessment on by herself, according to a VBN report.

Raven’s symptoms got worse over the eight days she was at the NNBHC. Raven told Holmes she couldn’t keep food or liquids down and that she was vomiting bile on June 25, 2018. Although Holmes documented that Raven looked pale, she again failed to tell anyone about the teenager’s symptoms, the VBN report states.

Raven’s health continued to worsen. The day before she died, she told Holmes she couldn’t walk, felt dizzy, and was seeing black spots. Holmes helped Raven to her room and told her to go to bed early, but again failed to notify anyone of the teenager’s deteriorating condition, according to the VBN report.

Despite several requests to go to the hospital, no one in the facility took the initiative to get Raven medical attention. A former NNBHC staffer, who spoke to 10 On Your Side investigators under the condition of anonymity, said that nurses instructed staff to ignore Raven’s pleas for help because they believed she was trying to get pain medication.

Raven collapsed and became unresponsive on June 29, 2018, but NNBHC staff didn’t immediately call 911. A 15-year-old resident made an emergency call and told the dispatcher she was worried that center staff weren’t doing everything medically necessary to take care of Raven.

“They’re telling her she’s doing this to herself, and she’s faking it,” the resident told the dispatcher.

Eventually NNBHC staff did call emergency services, but by that time Raven was lethargic, gasping for air, had dilated pupils, and was pale and cold to the touch. She went into cardiac arrest on the way to Mary Immaculate Hospital and died later that night, the lawsuit states.

The Medical Examiner determined that Raven died of lymphocytic adrenalitis, an auto-immune disease. The lawsuit claims that the ME’s report noted that Raven’s illness was treatable and that her death was preventable.

A former NNBHC staff member, who witnessed nurses interacting with Raven, filed a formal complaint against Holmes with the VBN, the agency in charge of regulating nurses. 10 On Your Side attempted to obtain comment from Holmes, but did not receive a response from her before publication.

The VBN investigated those claims and found that Holmes was disciplined by the NNBHC for failing to notify her supervisors of Raven’s condition and demonstrating “poor judgement and poor communication skills.” Holmes told the VBN that she “did the best she could with what she had” relating to Raven’s care.

The VBN also found other issues with Holmes’ work at the NNBHC between February and October 2018. Those additional issues were not related to Raven’s care, but included:

• The nurse failed to document a discontinued dosage of medication and inform the pharmacy of a medication change
• The nurse made a transcription error that resulted in a resident being under-medicated for four days
• The nurse failed to transcribe a resident’s immunization orders into their records
• The nurse made another transcription error
• The nurse was formally disciplined for failing to obtain an order and pass down relevant medical information
• The nurse failed to administer psychiatric medication, resulting in a resident missing a dose of it
• The nurse was formally disciplined for failing to recheck and document vital signs at the direction of a resident’s doctor
• The nurse was formally disciplined for failing to have a resident’s condition evaluated in a timely manner after receiving abnormal lab results
• The nurse failed to discontinue a medication as ordered, causing the resident to receive eight extra doses

The VBN formally reprimanded Holmes and put her on a year-long probation. For the first six months of the probation, Holmes can only practice nursing in a VBN-approved setting under an on-site nurse with an unrestricted license. Holmes must also submit quarterly reports including her current address, contact information, and employment status. Her supervisor must also provide reports to the VBN about her performance, documentation keeping and clinical judgement.