James Flavy Coy Brown was not the only patient in recent weeks to be dispatched from a Nevada state psychiatric hospital to far-off cities with little regard for their safety, a state investigation confirms.
In February alone, at least three other mental patients were discharged from Rawson-Neal Psychiatric Hospital in Las Vegas to far-flung destinations, including California, with a small supply of medications and a few cans of Ensure for nourishment, according to a report issued Monday by the Nevada State Health Division.
Those four represent just more than 10 percent of the 30 sample files reviewed by state investigators in response to concerns about Brown's care.
Brown, 48, wound up in Sacramento carrying his walking papers from Rawson-Neal and a schedule detailing his 15-hour bus ride from Las Vegas. Upon arrival, he told a worker at the Loaves & Fishes homeless complex near Sacramento's downtown that he knew no one in California, had nowhere to go and had run out of medication to treat his schizophrenia, anxiety and depression.
After his case surfaced in The Bee, California officials called for an investigation into whether Nevada was "dumping" mental patients in California via Greyhound. The matter sparked a hearing by Nevada state legislators, and has prompted state and federal investigations.
At the legislative hearing last month, Nevada Health and Human Services director Michael Willden acknowledged that mistakes were made in Brown's case but contended that an internal review showed no pattern of misconduct. Willden said patients can choose to leave Nevada for other locales and that the psychiatric hospital's staff are supposed to confirm they have a place to live and receive treatment.
Willden did not return calls for comment Monday on the report by state investigators.
But a former Nevada health official who reviewed the report said he was alarmed by the practices uncovered. Stuart Ghertner resigned last year as director of Southern Nevada Adult Mental Health Services, which oversees Rawson-Neal, after the agency endured more than $20 million in budget cuts.
"You cannot just give someone who is seriously mentally ill a plane or bus ticket and a little food, and expect them to fend for themselves," said Ghertner, a psychologist. "On its face, that makes no common sense."
The investigation "suggests that a lot of people are not doing their jobs over there right now," he said. "Social workers, psychologists, the medical staff, the administrators. No one is attending to detail. It's as if no one is managing the cases."
The report by the Nevada State Health Division, which oversees public health care in the state, confirms allegations of "unsafe discharges" of patients from Rawson-Neal, the state's primary hospital for mentally ill people.
The report says investigators reviewed 30 recent patient files and found five cases, all during the first two weeks of February, in which patients were discharged without proper planning to ensure their safety. One of the cases cited clearly involves Brown, although he is not identified by name.
According to the report, that patient was in the hospital's psychiatric observation unit in early February for symptoms of "psychosis, auditory hallucinations and suicidal ideation." He was homeless and "at a high risk of psychosocial problems which included housing, living situation, isolation and social problems."
A day after that evaluation, a physician ordered him discharged "to Greyhound bus station," with three days' medication and enough snacks and Ensure to get him to Sacramento.
The facility violated state policy by failing to document where he was to live or get care in California, the report states. "There was no documented evidence in the medical record that indicated how the patient could access mental health services," find a psychiatrist or other physician, or locate a place to live, it says.
Since his arrival in Sacramento on Feb. 12, Brown has bounced around among hospitals, clinics and boarding homes. He now is safe and receiving treatment, officials have confirmed.
The Nevada health division report detailed several other instances among the files reviewed in which it found Rawson-Neal to have violated discharge or nursing policies.
In one, a diabetic patient who also had bipolar disorder was bused to Oklahoma without documentation about where to receive treatment in Tulsa, or medication and monitoring equipment for his diabetes. The Ensure supplement that he received was not a healthy choice for someone with diabetes, a nurse told investigators.
Another patient with a diagnosed "mood disorder" was placed on a bus to Boston at his request, according to facility records. But the report noted that his discharge orders failed to document "the quantity of Ensure to be provided" for the trip, a problem identified in eight of the 30 files reviewed.
Similar issues were noted for a patient bused to Los Angeles.
The report does not address whether any of the patients arrived safely at their destinations or received treatment.
"There is no doubt in my mind that those numbers could be multiplied by many times," said Darrell Steinberg, California's state Senate president pro tem, who has called for a federal investigation into Nevada's busing of mental patients.
"What are the policy implications here for possibly hundreds of others who are not accounted for?"
Nevada recently has made a practice of busing mental patients out of state. The state sent 99 psychiatric patients to California between July 1, 2012, and the end of February, Nevada health officer Tracey Green told state lawmakers during last month's hearing. She said 81 percent were California residents who wanted to go home.
By contrast, an official with Arizona State Hospital told The Bee that facility has not sent a patient out of state by bus in recent memory. Oregon State Hospital discharged one patient to family in California between July 2012 and January, according to a hospital spokeswoman.
The federal Center for Medicare and Medicaid Services is working with Nevada authorities to investigate the state's treatment of mental health patients.
Although the agency has the authority to pull funding for lack of compliance with federal rules, it does so only in extreme cases, said spokesman Jack Cheevers. The penalty is potentially severe, as hospitals receive between 30 percent and 70 percent of their funding from federal programs.
Call The Bee's Cynthia Hubert, (916) 321-1082. Follow her on Twitter @cynthia_hubert.