Nevada Patient Busing

Federal probe cites major problems at Nevada mental hospital

A Nevada psychiatric hospital under scrutiny for busing hundreds of patients out of state in recent years suffers from "systemic" problems that compromise the safety of the patients who are being discharged, a federal investigation has determined.

Rawson-Neal Psychiatric Hospital in Las Vegas, Nevada's primary public hospital for mentally ill people, is at risk of losing critical federal funding if it fails to correct problems identified in a report issued Wednesday by the Centers for Medicare and Medicaid Services.

The agency's report stemmed from a specific complaint about the treatment of a homeless man, suffering from schizophrenia and depression, who in February was discharged from Rawson-Neal to a Greyhound bus bound for Sacramento, without any arrangement for his treatment or housing.

But given the concerns raised, the agency has embarked on a second investigation of the hospital's policies and practices, said Rufus Arther, director of hospital operations for the agency's Western region.

That ongoing investigation will determine whether Rawson-Neal violated the federal Emergency Medical Treatment and Active Labor Act, also known as the patient anti-dumping law, which restricts a hospital from refusing treatment to a patient during an emergency just because the costs may be high.

Patient care at Rawson-Neal has come under fire in recent weeks, following a Bee investigation that found the hospital has bused roughly 1,500 patients to states across the nation over the past five years, a third of them to California. By policy, the patients were put on buses alone, with one-way tickets, a small supply of medication and bottles of Ensure nutritional supplement for the journey.

The revelations have raised questions in California and elsewhere about whether Nevada was systematically "dumping" indigent mentally ill patients across state lines. The city attorneys in Los Angeles and San Francisco have launched probes into whether Nevada has violated patient civil rights laws. The Joint Commission, an independent agency that accredits hospitals nationwide, also is investigating.

In the weeks since The Bee published its findings, Nevada health officials have largely defended the aggressive busing practice, saying Las Vegas is an international destination that attracts more than its share of visitors. They maintain the vast majority of patients transported out of state were being sent back to their "home communities," where they had support systems or family to meet them.

Nevertheless, in response to the furor, the hospital revised its discharge policies late last month, requiring that psychiatric patients bused out of state now be accompanied by a chaperone.

The Centers for Medicare and Medicaid survey, conducted in March in conjunction with the Nevada State Health Division, is based on a sampling of 30 patient records. Based on that small sampling, regulators cited multiple instances in which the hospital did not meet conditions for federal funding.

Many of the deficiencies relate to James Flavy Coy Brown, 48, the mentally ill man bused to Sacramento in February without family or shelter waiting for him. Brown arrived in Sacramento confused and disoriented, and ultimately landed in the UC Davis Medical Center emergency room. He told The Bee that a Rawson-Neal doctor had suggested he would like "sunny California" and advised that he call 911 when he arrived.

Brown is identified in the report only as "Patient #1." According to his patient file, the report said, he was admitted to the psychiatric observation unit at Rawson-Neal with symptoms of psychosis, auditory hallucinations and thoughts of suicide.

According to the file, Brown said he wanted to go to California to find a group home, though he had no documented connections there, the report said. Following a 72-hour hold, he was discharged to the Las Vegas Greyhound Station with a ticket for Sacramento. Nothing in the short discharge notes given to Brown before his bus trip told him how to access shelter or services in Sacramento, the report said.

The report, spanning 49 pages, faulted the hospital in three key areas: unsafe discharge of patients; failure to ensure the medical staff was accountable to a governing body for the quality of care provided; and inadequate nursing supervision.

Along with Brown's case, the regulators noted several other patients whose treatment was cause for concern, citing several instances in which patients did not consent to the medications they were given.

"The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients," the report said.

In its formal response to the CMS report, Rawson-Neal submitted a detailed corrective plan. Among the changes: The hospital has implemented "a 100-percent review" of every discharge to another state by the hospital administrator. Officials said they also had reviewed and updated all discharge and medication consent policies.

CMS will determine whether the response is adequate and follow up with another unannounced survey, Arther said. If that survey turns up continued problems, he said, the facility could lose its Medicare funding.

Nevada officials could not be reached Wednesday for comment on the report.

The state has conducted its own internal investigations into the busing controversy. Nevada Gov. Brian Sandoval announced last month that five Rawson-Neal staffers had been disciplined, including two who were fired, in response to the findings. He also said he was bringing in outside consultants to review hospital operations.

Those independent consultants are on the hospital campus this week.

The assessment is being conducted by Joel Dvoskin, a clinical psychologist from Arizona; and Kenneth Appelbaum, a psychiatrist from the University of Massachusetts. Both men have worked as consultants to troubled mental health systems across the country.

Dvoskin has served as acting commissioner of mental health for New York state, and is part of a team that advises the Civil Rights Division of the U.S. Department of Justice on the rights of inmates and patients in confinement.

He said in an interview that he and Appelbaum are digging into "every aspect" of treatment and care at the Nevada hospital.

"We'll look at all of it, including the physical plant, safety and security, cleanliness, treatment planning, and of course, discharge planning," he said. "We were given no direction whatsoever to sugarcoat anything."

Dvoskin said he and Appelbaum have drawn no conclusions about Rawson-Neal's controversial policies for busing patients out of state.

"How people are discharged is much more complicated than whether you bought them a bus ticket. It's a question of that person's capabilities and capacities, and whether they are properly assessed," he said. "For some people, it might be OK" to get on a bus alone, he said.

Dvoskin said he and Appelbaum are interviewing patients and staff, touring the hospital and reviewing files. He said the team's written report will be forwarded to the governor's office and Southern Nevada Adult Mental Health Services, the agency that oversees Rawson-Neal.

"It's a pretty good way of assessing the quality of treatment," he said. "If things are not OK, we will find out. You really can't keep secrets if the assessment is done correctly."

Call The Bee's Phillip Reese, (916) 321-1137.

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