Back on March 16 when we first started our investigation into the problems on Unit 3 Lower at the Arkansas State Hospital (ASH), we insisted that ASH provide us with a plan of correction.

They did.

In that plan of correction, registered nurses would monitor care and treatment on the unit from 7 a.m. to 11 p.m. each day, and submit their observations, suggestions and recommendations to ASH. We would receive summaries of those RN monitors' observations and follow-up to see if they were being given due consideration. It was just one more safeguard for the children that we felt was necessary.

Last Friday, we received an email from ASH that it was discontinuing the use of the RN monitors on the unit.

Saturday evening at about 6:30 p.m., there was an incident on the unit in which one of the children was hurt badly enough to have to go to the emergency room. During the entire incident, he seemed intent on injuring himself.

We have only just begun investigating that incident, but have seen enough from video coverage of it to be horrified.

A child dragged across the unit floor by his arms and legs.

A child carried upside down into a seclusion room, his head and face dragging the floor.

A child, alone in the seclusion room, in a corner and back to the wall, bloodying his own face with his own hands.

A physician issuing orders...I want him out of there NOW!...Glove up people!...I need soft restraints.

A physician being told there are no soft restraints, and that's just the way he is, by a nurse in no special hurry.

We can still hear that child's voice in our ears - over and over.

Just let me die.

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The Centers for Medicare and Medicaid Services (CMS) survey team re-entered ASH this morning.

The team issued a new finding of Immediate Jeopardy for the Saturday incident on Unit 3 Lower and ASH is trying to clear it now.