Some of them heard voices and saw imaginary people. Some talked of killing themselves by jumping off a building or walking in front of a bus. They suffered from afflictions ranging from cocaine addiction to schizoaffective disorder, and most were homeless and without medical insurance.
About 40 percent of the mental patients whose charts were reviewed recently by a federal agency were discharged from Nevada's primary psychiatric facility to homeless shelters in Las Vegas or destinations across the country without evidence of proper planning for their continuing care.
The U.S. Centers for Medicare and Medicaid Services assessed a sample group of 41 charts for patients at Rawson-Neal Psychiatric Hospital in Las Vegas and found that in 16 cases, patients were discharged without evidence the hospital had made even basic arrangements for their shelter, support or follow-up care.
The majority of those patients were discharged directly to Greyhound buses bound for other states, without documentation of specific instructions about how to find housing or mental health treatment.
Most had been living in Las Vegas shelters or on the streets before being transported to other cities. A few were sent by bus to homeless shelters in the area.
CMS officials said the hospital's handling of the cases violated the Emergency Medical Treatment and Labor Act or EMTALA, sometimes known as the "anti-dumping" law, requiring hospitals to either stabilize emergency patients or, at the patient's request, to transfer them somewhere else. Rawson-Neal, which already has lost its accreditation following investigations into its discharge practices, could face further sanctions for violating the act.
CMS began its investigation after The Sacramento Bee reported in April that Rawson-Neal had bused about 1,500 psychiatric patients to cities and towns across the country during the past five years, including about 500 to California. Among them was a homeless man, James Flavy Coy Brown, who arrived in Sacramento suicidal and disoriented, and ended up in a hospital emergency room.
Mental health practitioners elsewhere in the country said they rarely, if ever, place seriously ill patients on buses without extensive planning and escorts.
The federal report released Monday comes just days after the San Francisco City Attorney's Office made similar accusations and announced it would file a class-action lawsuit against Rawson-Neal unless the hospital repaid California cities for taking care of patients it had "dumped."
San Francisco said it had found more than 20 patients improperly discharged to the city, most of them destitute. That assertion, along with CMS' findings, contrast with Nevada health officials' repeated contentions that only 10 patients bused out of state may have been discharged without adequate plans.
In June, The Bee identified eight mentally ill patients placed on buses by Rawson-Neal. In none of those cases, according to the patients and their families, did staff members fully adhere to the discharge policies outlined by administrators.
Officials have defended the hospital's long-standing busing policy as safe and humane, arguing that the vast majority of patients transported out of state were mentally stable and wanted to leave. They insisted that in all but a handful of cases, staff members confirmed before discharge that patients had relatives and treatment arrangements waiting for them.
They have acknowledged, however, that they have done no follow-up checks to determine whether patients made it to their destinations.
The hospital changed its discharge policy earlier this year to require that chaperones accompany all patients put on buses to other states.
CMS first issued a survey report in April saying Rawson-Neal was out of compliance with conditions for participating in Medicare. After the hospital submitted a plan for correction, CMS conducted additional surveys and found lingering problems, along with the EMTALA violations. They announced the findings earlier this month but released details only Monday.
DJ Jaffe, executive director of the Mental Illness Policy Organization, a nonprofit advocacy group, said the CMS findings are a clear reflection of "patient dumping" that occurs across the country but has gone undocumented prior to The Bee's investigation.
"It's profitable for hospitals to get rid of homeless patients," he said. "These discharges were not mistakes. It's policy."
Among the patients whose cases the federal agency cited as inappropriately handled was a suicidal patient who had "a plan of walking into traffic" upon admission to the facility. That person was discharged two days later for a 2,000-mile bus trip to Daytona Beach, with "no documentation indicating services had been arranged" with county mental health authorities, federal investigators found.
Another client, admitted in January with a diagnosis of schizophrenia, had been discharged days earlier and put on a bus for California but never made it to her destination, and later was found wandering aimlessly. A few days later, hospital officials put her on a bus bound once again for Los Angeles.
A third patient was admitted in March 2012 with a diagnosis of schizophrenia and a positive test for cocaine use. It was the 14th time the patient had been admitted in the previous year. According to the federal report, Rawson-Neal dispatched the patient to San Francisco without providing proper instructions for obtaining services or shelter.
Much of the government's case against Rawson-Neal under EMTALA will depend on whether the hospital meets the legal standard for providing "emergency" services.
In a written response to CMS investigators, Chelsea Szklany, administrator at Southern Nevada Adult Mental Health Services, said EMTALA does not apply to Rawson-Neal's "Psychiatric Observation Unit" because the hospital does not have an emergency room.
"The Psychiatric Observation Unit is licensed as an inpatient unit to serve individuals with acute behavioral needs," the state said in its response. "Individuals cannot walk into the POU for treatment." State health officials also said that, while they don't think the law applies, they believe the hospital met EMTALA standards.
CMS investigators pointed to hospital literature stating it "offers rapid screening and stabilization for consumers in an acute psychiatric crisis." The state will appeal CMS' findings, Szklany said.
Szklany acknowledged that the CMS surveys "did identify some areas where our inpatient hospital could improve" and that "discharge and aftercare processes have been sufficiently enhanced." She said the hospital now diligently arranges care for patients following discharge and notes all contacts in patient records.
In separate survey results released Monday, CMS cited Rawson-Neal for failing to meet the conditions of participation in Medicare, a decision that could cost the hospital millions.
During that survey, investigators found the hospital didn't have a process for informing its doctors about the status of requested consultations with medical specialists. They also found that contract nursing staffers were not properly evaluated and that two patients were given medication without signing a consent form.
Rufus Arther, director of hospital operations for CMS' Western division, said surveyors review "a sample selection of cases that can give us an accurate representation of what is happening. We want to know, 'Is this an isolated incident, or is it a systems issue?' " Based on what surveyors found, he said, Rawson-Neal's situation reflects the latter.
The federal agency will review the hospital's plans to correct the highlighted problems, Arther said. If the plans are deemed satisfactory, investigators will make another unannounced visit.
The results will determine whether the hospital will continue to be eligible to receive federal reimbursement for care of Medicare patients.
Call The Bee's Phillip Reese, (916) 321-1137.