A state inspection investigating the death of a 17-year-old boy at a Mapleton residential treatment center found that the center failed to provide the teen proper supervision or care to protect him from self-harm.

The Utah Department of Health and Human Services found Discovery Ranch Academy to be noncompliant with multiple rules while treating Biruk Silvers, who died at Discovery Ranch on Nov. 5, including services and supervision to meet each client’s needs and protection from abuse.

The Nov. 6 inspection stated, “Throughout the investigation, multiple interviews, provider records and additional documents were reviewed, and professional evaluations were considered. The information gathered substantiated that a client who had expressed suicidal ideation and a plan was not provided with the care required to keep them safe.”

A $10,000 civil penalty was assessed for one of the violations.

The report, provided to the Daily Herald by the attorney representing the Silvers family, also found Discovery Ranch did not follow its suicide prevention policy and claims the center violated critical incident reporting requirements on multiple occasions in the past year.

Kathryn and Joshua Silvers, the parents of Biruk, filed a notice of intent and notice of claim against Discovery Ranch and other respondents last month, alleging gross negligence, medical malpractice and systematic failures at the center regarding the death of their son.

The case has to go through a prelitigation hearing before it can be filed in court. It currently is before the state’s Division of Licensing and Background Checks.

Discovery Ranch currently has a conditional license that runs through the end of February. Alan Mortensen, the attorney representing the Silvers, told the Daily Herald in an email he believes it’s a “possibility” that the teen center’s license will not be renewed due to the noncompliance found.

Randy Spencer, an attorney representing the teen center, acknowledged to the Daily Herald on Thursday that the license currently is conditional but said the academy is working closely with the licensing division to get it reinstated.

“Discovery Ranch has completed all the re-training requirements licensing requested and has striven to learn from the tragedy that occurred,” Spencer said in an email. “Discovery Ranch has hosted a few licensing visits and completed its annual license renewal today, and accordingly, hopes to have its license fully reinstated as soon as licensing sees fit which we hope will be soon.”

Spencer also provided the Daily Herald with a statement from Discovery Ranch on Wednesday.

“Recently, we lost a member of our family when a young man committed suicide,” a portion of the statement read. “This was a trauma to his parents but also to our staff and the young people we serve. We have extended our condolences to his parents and we are working to heal the pain and shock caused to them, our staff, and other residents.

“A lawsuit is being filed by the parents of the young man who took his life. We are advised by legal counsel not to comment on the facts that will now be part of litigation.”

The Silvers allege 14 instances of negligent acts or omissions by Discovery Ranch and other respondents, including failure to supervise, failure to communicate critical information and medication mismanagement.

In the filed claim, the Silvers said Biruk started a new medication, Lexpapro, on Oct. 18 that may heighten a person’s risk of suicide, according to the National Institutes of Health. They also allege that their concerns with him taking the new medicine were dismissed.

The family claims that reports from a University of Utah psychiatrist show Biruk shared a self-harm plan during multiple remote appointments, beginning on Oct. 23, but that the doctor did not share the information with the Silvers or initiate one-on-one supervision.

A Discovery Ranch therapist did not review the initial psychiatric reports, the Silvers claim, and was unaware of Biruk’s suicide plan until Nov. 4, when he signed off on the report.

The family also said they expressed concerns to Biruk’s therapist about his mental state and his participation in a dangerous asphyxiation activity, but the concerns, they allege, were dismissed.

On Nov 4, the complaint alleges, Kathryn Silvers scheduled a follow-up appointment with the psychiatrist, but it was canceled because he reportedly stated that there was “no acute concern requiring a meeting.”

Later that day, the claim states, the Discovery Ranch therapist reviewed a Nov. 1 note from Biruk’s psychiatrist and realized he needed “additional protection from himself as he expressed a desire to commit self-harm and possible harm to others.” But the claim alleges the therapist, “Did not call the Silvers or law enforcement to help in providing this protection to Biruk and others.”

On Nov. 5, Biruk died by strangulation from a belt that the Silvers said was “either provided by or allowed by (Discovery Ranch) for Biruk to possess, while Biruk was left alone with no staff present.”

The claim added: “Biruk died either by the plan of self-harm that he had explicitly disclosed to his psychiatrist and therapists and registered nurses, just days earlier; or, by playing a game that is known to be very dangerous and which (Discovery Ranch) and the other respondents knew he was playing.”

This story has been updated to correct the status of Discovery Ranch’s operational license. It was further updated to correct the name of the body that has authority over the facility’s licensing status.