ST. GEORGE, Utah — In the months since 16-year-old Arianna Duenez died at Vive Adolescent Care in St. George last summer, her family could sometimes tell themselves that she was still in Utah receiving care. She’d come home soon, they’d pretend.
But reality was inescapable Saturday, as her family held a vigil in her honor outside the facility where Duenez drew her last breath.
“I just couldn’t bring myself to come here,” her mother, Maggie Montelongo, said through tears. “Because I was in denial about it. So why go to Utah? She’s still there. Until you start realizing that she’s not.”
Duenez’s parents, stepparents, grandmothers and younger sister drove from southern California to St. George for the first time Saturday ahead of the one-year anniversary of her death on Tuesday.
They wore purple, Duenez’s favorite color, and decorated the entrance of Vive with photos of her and a handmade, heart-shaped wreath. They played music, shared memories and joined together in prayer.
“We pray in your name that we find some kind of answers for what happened to Arianna," her grandmother, Gricelda Bejarano, said as the family bowed their heads and held onto one another. “We need some closure. The family needs closure. The family – mom and dad – they need closure.”
A FOX 13 News investigation into Duenez’s death previously found:
- 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 the morning of her death, 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.
- St. George police later estimated Duenez was dead for up to 10 hours before staff realized something was wrong.
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. But her family continues to believe the outcome may have been different if the facility had checked to ensure Duenez was breathing throughout the night.
“Do I think that her life was cut short? Absolutely,” Montelongo said outside Vive on Saturday. “Do I think that it could have been prevented? Absolutely.”
After an investigation into Duenez’s death, the state Department of Health and Human Services fined Vive $1,000. The department 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.
It all still feels insufficient for Duenez’s family.
“When you make the decision to seek professional help, and you put your trust and your faith into a facility – which is the highest level of care – for this to happen in this environment is incomprehensible,” Duenez’s father, Aaron Duenez, said outside Vive on Saturday. “And I’d like honesty – to know exactly what happened so that another family doesn’t have to live through this.”
Duenez's parents spoke with Vive staff after the vigil on Saturday to ask again for copies of their daughter’s medical records. They told FOX 13 News that they received a call later that night promising those documents would be made available to them early next week.
Her family had also hoped to visit the room Duenez was in when she died, so they could say a prayer for her there. But because another client was in that room, staff said they couldn’t take them inside.
Vive previously declined multiple interview requests, instead releasing a statement that said the facility was “heartbroken” at Duenez’s death and stressing its 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.”
After Duenez’s death, Vive told state regulators that 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.
As they stood outside Vive on Saturday, Duenez’s family laughed and cried in equal measure as they remembered the 16-year-old girl who loved butterflies and painting and who once dreamed of becoming an advocate for children who struggled with their mental health.
Montelongo said that of all the memories she has of her daughter, her fondest recollections are of the day Duenez was born.
“Because she gave me life,” Montelongo said. “It took me a long time to figure it out, but she gave me life. And I just want to thank her. Thank you, Arianna. And I want to thank God for the beautiful 16 years that he gave me with such a beautiful soul.”
Duenez’s family expressed peace Saturday in the belief that they’ll be able to see their daughter again in heaven. But as they released white balloons into the sky in her honor, they pledged to also continue fighting for answers for her here on Earth. “Justice for Arianna!” they chanted as the balloons floated up toward the sky.