Vegas mental hospital goofed on patient's discharge to Sacramento, official concedes

Published: Friday, Mar. 15, 2013 - 12:00 am | Page 1A
Last Modified: Tuesday, Feb. 4, 2014 - 4:35 pm

CARSON CITY, Nev. – A state psychiatric hospital in Las Vegas "blew it" by discharging a mentally ill patient to a Greyhound bus bound for Sacramento last month without ensuring he had care and housing in California, Nevada health officials admitted Thursday.

"We own it. We blew it, and we are taking corrective action," Michael Willden, director of the Nevada Department of Health and Human Services, told a legislative committee.

Nevada lawmakers scheduled the hearing in response to a story in The Bee this month about James Flavy Coy Brown, who arrived in February at the Loaves & Fishes homeless services complex in Sacramento carrying his walking papers from a Nevada state mental hospital and a schedule detailing his 15-hour bus ride from Las Vegas.

Staffers at the homeless agency described Brown, 48, as confused and frightened, and said he told them he had never been to Sacramento before his arrival Feb. 13.

From what she could glean, staff member Molly Simones said, "he had absolutely no reason to be here," other than instructions from personnel with Southern Nevada Adult Mental Health Services, who gave him a bus ticket to Sacramento and told him to dial 911 for help when he got to the capital city.

Simones was among those who called it an extreme case of "patient dumping" – in this case busing a mentally ill man across state lines without showing that he had a place to stay or receive care in California.

In testimony Thursday before a legislative panel led by Nevada state Sen. Justin Jones, who chairs the Health and Human Services Committee, Willden said mistakes were made in Brown's case but that he saw no pattern of misconduct in the discharge of patients from state mental facilities.

Based on a preliminary investigation, "we believe that this is not systemic" within the state's mental health system, Willden said.

Nevada health officer Tracey Green said the state's policies allow for psychiatric patients to be sent to other states if they desire, but require that staff make sure that each client has "housing or shelter available and a support system" to meet the person at the destination.

There was no evidence of such arrangements in Brown's case. The discharge papers prepared for Brown last month at Rawson Neal Psychiatric Hospital in Las Vegas list his address at discharge as "Greyhound Bus Station to California."

"Discharge to Greyhound bus station by taxi with 3 day supply of medication," said the discharge letter that he handed to Loaves & Fishes staffers. "Follow up with medical doctor in California."

The paperwork shows he is to take three powerful psychiatric medications daily, one that is commonly used to treat schizophrenia and another for depression.

Upon his arrival in Sacramento, Brown contacted police, who directed him to the Loaves & Fishes complex. Staffers there have since lost track of him.

Nevada sent 99 state psychiatric patients to California between July 1, 2012, and the end of February, Green told lawmakers. She said 81 percent were California residents who wanted to go home.

Nevada's numbers stand in contrast to figures from other neighboring states.

Between July 2012 and January, Oregon State Hospital discharged one patient to family in California, and that patient's family paid the fare, hospital spokeswoman Rebeka Gipson-King said in response to The Bee's inquiry.

Donna Noriega, chief operating officer at Arizona State Hospital, said in a statement, "We have not purchased any patients any bus tickets to California or any other city during this timeframe or as long as I can remember."

Nevada health leaders said they respect the rights of patients to go where they choose when sending them to California or anywhere else.

An internal investigation of discharge policies at Nevada state hospitals should be completed this week, Willden said. Separate probes by the Office of Health Care Quality and Compliance and the Center for Medicare and Medicaid Services are ongoing.

Brown reportedly told homeless advocates in Sacramento that four other mental patients were given bus tickets out of Nevada at the same time he was released. Willden said the internal probe so far has uncovered no evidence of those discharges.

He said the review has included "hundreds" of files, none of which show someone was improperly discharged to the bus station.

"I'm not saying it never happened," he said in an interview. "We don't see a pattern."

Richard Whitley, administrator of the Nevada State Health Division, told the legislative panel that officials are trying to nail down who is responsible for the improper discharge of the patient who ended up in Sacramento.

The staff members responsible face possible discipline ranging from loss of pay to termination, Wellden said.

Under questioning by Jones, Whitley said nurses and social workers act on "a doctor's order" in discharging patients out of state. In the future, he said, the hospital administrator will approve all discharges outside of Nevada.

Green told the panel that Nevada is "under a tight budget" and that beds for mentally ill patients are sometimes hard to find.

"There is a lack of sustained housing options" for psychiatric patients, she said. "We truly have a gap in that area."

Call The Bee's Cynthia Hubert, (916) 321-1082. Follow her on Twitter @cynthia_hubert.

© Copyright The Sacramento Bee. All rights reserved.

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