Finalist: The Sacramento Bee, by Cynthia Hubert and Phillip Reese

By Cynthia Hubert

 

By the time his Greyhound bus hissed to a stop on Richards Boulevard in Sacramento on the morning of Feb. 12, James Flavy Coy Brown was in a mild panic.

 

It was 6:30 a.m., 15 hours and 11 stops after a taxi had scooped him up in front of Rawson-Neal Psychiatric Hospital in Las Vegas, where he had spent the previous 72 hours, and deposited him at a bus station.

 

During the long ride to Northern California, Brown had rationed the peanut butter crackers and Ensure nutritional supplements that a staff member at the mental hospital had given him, along with his discharge papers and a bus ticket to Sacramento. His food was gone, and he was nearly out of the medication to treat his array of mood disorders, including schizophrenia, depression and anxiety.

 

As the bus door opened in Sacramento, Brown, 48, stepped out into the pre-dawn gloom. It was 30 degrees, and his windbreaker was no match for the chill.

 

Brown, a native of the American South with a distinct accent and a healthy head of salt-and-pepper hair, had arrived in the capital city with no concrete plan for survival. He had no friends or relatives in Sacramento. He had lost his ID, Social Security and insurance cards somewhere in Las Vegas. He had no idea how to fill the prescriptions that helped tame the voices and anxiety that clouded his mind.

 

He wondered if he was destined to die on the streets of this strange new city.

 

Scanning the landscape, he spotted a nearby police station. Desperation drove him inside.

 

"Can you help me?" he asked.

 

Brown's odyssey to Sacramento has raised questions about Nevada's state-sanctioned treatment of mentally ill people.

 

Advocates for the mentally ill in California, including state Senate President Pro Tem Darrell Steinberg, call it a disturbing case of patient dumping. The federal government and Nevada authorities are investigating whether the incident is part of a broader pattern of abuse.

 

Preliminary reports suggest that Nevada has made a habit of discharging mental patients by bus to other states. Rawson-Neal, the state's primary hospital for mentally ill people, bused about 100 state psychiatric patients to California between July 1, 2012, and the end of February, and scores more to other states, according to data provided by Nevada health authorities.

 

Nevada officials admit busing Brown to California with no arrangements for his housing or care, but contend it is not common practice.

 

"I don't think you're going to see discharges like that again," said Nevada's chief of Health and Human Services, Michael Willden. "It's an embarrassment to us."

 

They also acknowledge that, as budget cuts have shrunk and shuttered government mental health programs across the country, it is becoming increasingly difficult to find housing and supervision for severely mentally ill men and women.

 

The Bee first wrote about Brown last month, based on interviews with homeless services workers who tried to help him before he disappeared into Sacramento's streets. Recently he contacted The Bee, and agreed to an interview at the boarding home where he is now getting food and care.

 

Brown was soft-spoken and polite as he sat on a patio, sipping bottled water and answering questions about the latest chapter of his lifelong struggle with mental illness. He repeatedly referred to a reporter as "Ma'am," and occasionally burst into childlike giggles when discussing the troubles that have followed him since childhood.

 

"Maybe my story will help someone else," he said.

 

Brown's memory can be faulty, and details of some portions of his life are fuzzy. Some of the stories he tells about his long-ago background are fantasy, a product of his illness, according to relatives The Bee tracked down. But an array of hospital and social services officials have confirmed what he recounted about what has happened to him since he landed in Sacramento.

 

Brown's experience starkly underscores gaps in the public health care system that plague mental patients across the country, advocates say, including a lack of suitable housing and crisis intervention care.

 

His Sacramento saga began in early February shortly after he landed in Rawson-Neal. Although his hospital discharge papers list his place of residence as Catholic Charities of Las Vegas, Brown said his last real home was a small group facility that shut down.

 

According to a state investigation, he spent 72 hours in the hospital's observation unit before a doctor discharged him to a Greyhound bus to Sacramento. The discharge orders noted he should be given a three-day supply of Thorazine, Klonopin and Cymbalta to treat his schizophrenia, anxiety disorder and depression, plus "Ensure and snacks for a 15-hour bus ride."

 

Brown said a doctor at Rawson-Neal told him to dial 911 when he reached Sacramento.

 

"But I don't want to go anywhere," Brown recalled telling the doctor. "Is this the only option I've got?"

 

He said the physician told him that Nevada had no place for him. "Pick a state," he said the doctor told him. "How about sunny California? They have excellent health care and more benefits than you could ever get in Nevada." The doctor, Brown said, then shook his hand and wished him luck in Sacramento.

 

His sense of the situation, Brown said, was: "If I hadn't left then, I might have had to stay in that hospital for a long time. At least I got my freedom."

 

Willden, the health and human services chief, declined to discuss Brown's case in detail because of patient privacy laws. But in general, he said, Brown's account does not reflect hospital policy.

 

"I don't think we would ever tell a patient, 'There is no room at the inn and you're getting on a bus,' " he said. Brown's discharge notes included that he had mentioned a desire to go to California, according to the state investigation.

 

Upon his discharge to the bus station, Brown said, he spotted four other people with whom he had lived at his former group home. All had been sent to Rawson-Neal when the home closed, he said.

 

"Hey, Ralph," Brown recalled calling out to one of the people. "What are you doing here?"

 

"He told me, 'I'm going to California.' "

 

"I said, 'Gee, they just put us all in separate cabs to send us to California? What's going on here?' "

 

The Greyhound discharge, Brown said, was not the first time he had been cast adrift. He said he has felt that way for most of his life.

 

He was born in Anderson, Ind., to parents unable to care for him, according to family. A couple adopted him when he was a toddler and he spent his early life in Seneca, S.C.

 

There, when he was about 20 and working as a cook at a local hamburger joint, he met and married a cashier at the restaurant. Her name was Sandy. She called him Jamie.

 

"I was young and naive, and I didn't realize the problems he had," said the former Sandra Brown. Remarried with the last name Bandy now, she spoke by telephone from her home in Virginia.

 

Shortly after she married Brown, she said, she started to become concerned about his mental state. She learned that he heard voices inside his head. That animals told him to do bad things. He once killed a family cat that he believed to be evil. He began drinking heavily.

 

"He had been in a mental health facility before, and in jail," Bandy said. "He had a temper." She said she helped sign him up for Social Security disability benefits, "and they accepted him right away."

 

When their daughter, Shotzy Faith Brown, was about 3, Sandy took the girl to Virginia, where her parents lived, and filed for divorce. The next time James Brown saw his daughter, she was 14.

 

Brown said he worked in coal mines and odd jobs over the years but that his mental illness was difficult to control and he repeatedly landed in jail for disorderly conduct and stealing food. In recent years, he has been homeless for long periods, he said.

 

"When I'm without my medications, look out!" said Brown with a nervous laugh. "I get into trouble."

 

Brown left the South a few years ago, he said, at the suggestion of a psychiatrist who said budget cuts were decimating programs there. "He said things were way better out West," Brown said. So, he said, he jumped on a bus, eventually getting off in Las Vegas.

 

Brown stayed in shelters, group homes and "missions," he said, wherever he could find a bed. Often, he got picked up by police as he wandered aimlessly.

 

"I've been bounced around quite a bit along the way," Brown added. "That's what happens when you are mentally ill.

 

"I guess that's why they sent me to Sacramento," he mused. "I guess the people in Las Vegas thought I was some kind of a threat."

 

Brown felt more like a victim than a threat when he walked into the police station on Richards Boulevard in the early hours of Feb. 12.

 

"I was scared," he said. "Really, I just wanted to find a hospital or somewhere to be."

 

He met a friendly officer, he said, and handed him his hospital paperwork.

 

"He told me they would take me to a place where there would be a meal, shelters, showers," said Brown. "He was real nice to me."

 

Brown climbed into the back of a cruiser, and within minutes arrived at the sprawling Loaves & Fishes homeless complex on North C Street on the industrial outskirts of Sacramento's downtown. Someone gave him a cup of coffee while the officers talked to a staff member about his situation, he said.

 

But the agency, which provides a variety of services for homeless people, would be closing in the early afternoon and does not operate a shelter, Brown learned. So after awhile he followed a line of people looking for a place to sleep.

 

Keeping to himself during his stroll, he said, he first went to the Salvation Army on North B Street, but a receptionist told him it was full. He walked until he reached the Union Gospel Mission on Bannon Street. There, he found a bed.

 

The next morning, he ambled four blocks back to Loaves & Fishes, where he met with a young staffer named Molly Simones.

 

By that time, Brown had been off his medications for more than a day, he said. He was confused and agitated, and told Simones he was thinking about throwing himself off a bridge or in front of a car. "I had to somehow get him to a hospital," Simones said. "But in our experience, that is not an easy thing to do."

 

Simones said she was unable to transport him herself because of legal issues. Someone at the agency could fill out papers to place a legal "hold" on him until police could take him to the hospital, but Simones decided that process would take too long.

 

She asked Brown whether he could make it to UC Davis Medical Center on Stockton Boulevard if she gave him directions and a bus pass.

 

"He was more than willing, and I felt he could make it on his own," she said. She made copies of his discharge papers from Rawson-Neal and wrote an account of his journey from Las Vegas. She told him to give the papers to nurses when he arrived at UC Davis.

 

After lunch, Brown recalled, he walked "a long ways" to a light-rail station, which is about five blocks away at 12th and E streets.

 

Brown cannot recall where he got off the light-rail train. He remembers only concrete, horns and clanging bells. Again, an officer came to his rescue.

 

He said he approached the first uniformed person he saw, and handed him the note from Simones. The note said Brown was "suicidal and unable to care for himself," and should go to the hospital.

 

Rick Rivera said he may have been the officer Brown encountered.

 

"I can't be absolutely sure, because there are so many mentally ill people on the train," said Rivera, an RT transit officer for the past 10 years. But Brown's story sounded familiar. "These people get lost quite a bit, and we do whatever we can to help them."

 

Brown walked into UC Davis Medical Center at around 4:30 the afternoon of Feb. 13 with a police escort, joining a growing legion of mental patients seeking refuge in Sacramento's emergency rooms.

 

ERs have seen a spike in mentally ill patients since Sacramento County's mental health facility shuttered its crisis intervention clinic and closed half its beds in 2009 amid budget cuts.

 

At any given time, according to UC Davis staff, three to 10 mental patients are waiting in the facility's emergency room. The hospital has stepped up security to accommodate patients who, in some cases, are psychotic and out of control.

 

Brown was upset but fairly calm when he showed up, said Dr. Peter Yellowlees, a psychiatrist on duty that day.

 

A triage nurse greeted Brown, who handed her his paperwork. She and others took his blood, measured his vital signs and conducted other tests to make sure he was stable, Yellowlees said. A resident psychiatrist, Dr. Jamie Ng, asked him about his mental state and medications.

 

That night, Brown slept restlessly on a gurney as the the ER chaos swirled around him.

 

In the meantime, UC Davis social workers began calling area mental facilities, trying to find a bed for Brown. The task is difficult under the best of circumstances, Yellowlees said, but even more challenging when the patient is from out of state and has neither an ID nor an insurance card.

 

So for the next two nights and part of a third day, the UC Davis emergency room was Brown's home. He had daily visits with a psychiatrist, ate hospital meals and watched Netflix movies, including "Harry Potter" and "Lord of the Rings," on Ng's computer. His panic began to subside, Brown said, as his medications kicked in. He was grateful for small kindnesses.

 

"I felt like I had been rescued," he said.

 

Other rescuers would surface after Brown departed UC Davis.

 

From the medical center, he got a bed at Heritage Oaks, a private mental hospital on Auburn Boulevard. Brown recalls staying there for a couple of weeks before getting moved to Green Pasture, an assisted living facility, where he stayed until he was transferred to a boarding home in early March.

 

Now he lives in a mint-green house in south Sacramento with three other residents and a rotation of caregivers. He has his own small room, with a single bed and a shelf where he props his pipe and tobacco.

 

The home's operator, Joy Ubungen, accepted Brown on the promise of future payment, despite the fact that he "didn't get along" with his housemates at Green Pasture, she said.

 

"My heart went out to him," she said.

 

Turning Point Community Programs, which contracts with the county to provide supportive services to mentally ill people, is overseeing Brown's care.

 

A staff member brings his medications every morning, watching to make sure he swallows them. The organization has provided him with clothing and psychiatric care, said Carolin Funderburg, program director for the group's integrated services agency.

 

Whether the programs will be fully reimbursed for Brown's care is unclear. As of last week, his insurance and Social Security benefits had yet to be transferred from Nevada to California.

 

As word of Brown's experience has spread, other avenues have opened.

 

Sacramento civil rights lawyer Mark Merin said he is planning to pursue a lawsuit on behalf of Brown and others like him.

 

"There is something really wrong here," said Merin, who met with Brown last week. "I have to believe there is a constitutional issue."

 

And on Wednesday, the telephone rang at Brown's boarding home. Another resident told him the call was for him.

 

"Hello?" Brown answered.

 

Shotzy Faith Harrison recognized her father's soft drawl, a voice she had heard only a few times in the last two decades.

 

"Daddy! Daddy! It's me!" said Harrison, now 25 and a nurse. "It's Shotzy. I want to bring you home with me to North Carolina."

 

Brown just smiled, he said, as he listened to his daughter talk "a mile a minute" about her plans for him. It was not the first time she had offered to take him in, he said. But this time, he planned to take her up on her offer.

 

"I never wanted to be a burden," Brown said. "But I guess I'm not. Not to my daughter, anyway."

After locating him in a boarding home in Sacramento, The Bee pieced together James Flavy Coy Brown's story by interviewing him at length, tracking down relatives across the country, and talking to doctors, social workers and caregivers he encountered after his arrival in Sacramento. Brown gave The Bee written permission to access his confidential medical information.

Over the past five years, Nevada's primary state psychiatric hospital has put hundreds of mentally ill patients on Greyhound buses and sent them to cities and towns across America.

 

Since July 2008, Rawson-Neal Psychiatric Hospital in Las Vegas has transported more than 1,500 patients to other cities via Greyhound bus, sending at least one person to every state in the continental United States, according to a Bee review of bus receipts kept by Nevada's mental health division.

 

About a third of those patients were dispatched to California, including more than 200 to Los Angeles County, about 70 to San Diego County and 19 to the city of Sacramento.

 

In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.

 

By last year, Rawson-Neal bused out patients at a pace of well over one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the nation.

 

Nevada's approach to dispatching mentally ill patients has come under scrutiny since one of its clients turned up suicidal and confused at a Sacramento homeless services complex. James Flavy Coy Brown, who is 48 and suffers from a variety of mood disorders including schizophrenia, was discharged in February from Rawson-Neal to a Greyhound bus for Sacramento, a place he had never visited and where he knew no one.

 

The hospital sent him on the 15-hour bus ride without making arrangements for his treatment or housing in California; he arrived in Sacramento out of medication and without identification or access to his Social Security payments. He wound up in the UC Davis Medical Center's emergency room, where he lingered for three days until social workers were able to find him temporary housing.

 

Nevada mental health officials have acknowledged making mistakes in Brown's case, but have made no apologies for their policy of busing patients out of state. Las Vegas is an international destination and patients who become ill while in the city have a right to return home if they desire, the state's health officer, Dr. Tracey Green, told Nevada lawmakers during a hearing last month.

 

She and others insist that the vast majority of patients they are discharging to the Main Street bus station are mentally stable and have family members, treatment programs or both waiting for them at the end of their rides.

 

That was not true in Brown's case. His papers from Southern Nevada Adult Mental Health Services read: "Discharge to Greyhound bus station by taxi with 3 day supply of medication" and provided a vague suggestion for further treatment: "Follow up with medical doctor in California." Brown said staff at Rawson-Neal advised him to call 911 when he arrived in Sacramento.

 

Nevada Health and Human Services Director Michael Willden told lawmakers last month that while health officials "blew it" in their handling of Brown, an internal investigation found no pattern of misconduct.

 

But an investigation by the Nevada State Health Division documented several other instances from a small sampling of cases in February in which the state hospital violated written rules for safely discharging mentally ill patients.

 

Other apparent violations surfaced during The Bee's investigation.

 

At least two patients from the Nevada system arrived in San Francisco during the past year "without a plan, without a relative," said Jo Robinson, director of that city's Behavioral Health Services department.

 

"We're fine with taking people if they call and we make arrangements and make sure that everything is OK for the individual," Robinson said. "But a bus ticket with no contact, no clinic receptor, anything, it's really not appropriate."

 

Robinson said she viewed the practice as "patient dumping," and has reported it to federal authorities. "It's offensive to me that they would show this lack of care for a client," she said.

 

Nevada mental health officials did not respond to repeated requests for phone interviews for this story, nor would they address a list of emailed questions about the origins of the busing policy and the safety protocols in place.

 

Southern Nevada Adult Mental Health Services, the agency that oversees Rawson-Neal, maintains detailed written policies for transporting patients "to their home communities," with the stated goal of providing more appropriate care by the most economical means possible.

 

The policy includes a special section on "Travel Nourishment Protocol," specifying the number of bottles of Ensure nutritional supplement the patient should receive for the bus trip – essentially six per day.

 

Staff members are supposed to fill out a "Client Transportation Request" form, which includes questions about whether the patient is willing to go, whether housing or shelter has been verified, and the cost of the trip.

 

The written policy calls for staff to confirm that a patient has housing or shelter available "and a support system to meet client at destination." They are to provide information about "mental health services available in the home community."

 

Interviews with health officials in California and numerous other states indicate Nevada's practices are unusual. None of the 10 state mental health agencies contacted by The Bee said that placing a psychiatric patient on a bus without support would be permissible. And none recalled being contacted by Rawson-Neal to make arrangements for a patient coming from Nevada.

 

In California, where most public mental health treatment is overseen at the county level, agencies contacted by The Bee said they rarely bus patients and that Nevada's practices seem out of step with the standard of care.

 

Several described the practice as risky, even if patients have someone waiting for them at the end of their journeys.

 

"Putting someone whose mental illness makes them unable to care for themselves alone on a bus for a long period of time could be absolutely disastrous," said Dorian Kittrell, executive director of the Sacramento County Mental Health Treatment Center.

 

Patients could suffer relapses during their trips and potentially harm themselves or other people, said Kittrell and others. They could become lost to the streets or commit crimes that land them in jail.

 

"The risk is just too great," said Dr. Marye Thomas, chief of behavioral health for Alameda County.

 

Southern Nevada Adult Mental Health Services has had an ongoing contract with Greyhound since July 2009, said bus company spokesman Timothy Stokes.

 

Stokes said he was unaware of any serious incidents involving mentally ill patients from Nevada. He said Greyhound has contracts with "a number" of hospitals around the country, but declined to identify them.

 

"We take it on good faith that the organization is going to make certain that patients are not a risk to themselves or others," he said.

 

Still, officials in several of California's largest counties said they rarely, if ever, bus patients out of state.

 

"We don't do it, we never will do it, and we haven't done it in recent memory, meaning at least 20 years," said David Wert, public information officer for San Bernardino County. Rawson-Neal has bused more than 40 patients to that county since July 2008.

 

Los Angeles County officials said they have not bused a single patient out of state during the past year, and when they have done so in the past they have supplied chaperones. In the past five years, L.A. County has received 213 people from the Nevada hospital, according to The Bee's review, more than any place in the country.

 

Likewise, in Riverside County, sending patients out of state "happens very infrequently upon request of the family," said Jerry Wengerd, head of the county's Department of Mental Health. "A staff member accompanies the client and it is usually by air." Nevada bused 20 patients to Riverside in the period reviewed.

 

Sacramento County bought bus tickets for five patients during the past year, Kittrell said. In all cases, he said, facility staff confirmed before patients departed that a family member or friend would meet them at their destinations, and provided referrals for treatment.

 

Organizations that advocate for mentally ill people said Nevada's busing numbers seem unjustifiably high.

 

DJ Jaffe, executive director of Mental Illness Policy Org., a nonprofit think tank, said his group often hears anecdotally about patients being "dumped" from one county to another.

 

"Discharging severely mentally ill patients inappropriately is policy in this country," Jaffe said. "But getting rid of them altogether by busing them out of state is, I think, rare. I am shocked by these figures. It seems to be almost routine in Nevada."

 

After California, Arizona has received the most patients by bus from Nevada, at more than 100 over the five years.

 

But Cory Nelson, acting deputy director for the Arizona Department of Health, cautioned against drawing conclusions about Nevada's practices based solely on number of bus tickets issued. In many cases, Nelson said, relatives could have agreed to house patients or made treatment arrangements before the clients left Las Vegas.

 

In rare cases, Nelson said, a hospital can find itself in a Catch-22 situation when a patient no longer needs to be in a hospital but refuses to cooperate with a discharge plan. "It kind of leaves a hospital in a tough situation," he said.

 

Still, the sheer number of patients bused from the Nevada hospital "does seem pretty high," he said.

 

Several people interviewed said the numbers might be explained in part by the unusual nature of Las Vegas.

 

"As the whole country no doubt knows, Vegas is a pretty unique place," said Dr. Lorin Scher, an emergency room psychiatrist with UC Davis Health System.

 

The city's entertainment and casino culture draws people from all over the world, Scher noted, including the mentally ill.

 

"Many bipolar patients impulsively fly across the country to Vegas during their manic phases and go on gambling binges," he said. "Vegas probably attracts more wandering schizophrenic people" who are attracted to the warm weather, lights and action, he added.

 

"I am by no means defending their practices," he said. "It certainly gives cause for concern. But it's one possible explanation."

 

Stuart Ghertner, former director of Southern Nevada Adult Mental Health Services, cited other possible reasons.

 

He said Rawson-Neal has been under siege for years because of state budget cuts, a steady increase in poor people needing mental health services in the Las Vegas area and a revolving door of administrators.

 

He noted the city had a disproportionate number of people displaced by the housing and mortgage meltdown of a few years ago.

 

"The casino boom was over, people were losing their jobs and their homes. They were stressed and they wound up in a mental health crisis," Ghertner said.

 

Between 2009 and 2012, Nevada slashed spending on mental health services by 28 percent to address budget deficits, according to data collected by the National Alliance on Mental Illness. Even before those cuts, Nevada fell well below the national average in spending on mental health services: In 2009, it spent $64 per capita on such services compared with a national average of about $123, according to the study.

 

"You're looking at a tsunami situation," said Ghertner, a psychologist who resigned last year after five years as agency director. "There is more pressure to turn patients over faster, and fewer programs (in which) to place them. Perhaps busing them became the easier solution."

 

It also is cheaper, he noted. Southern Nevada Adult Mental Health Services spent a total of $205,000 putting patients on Greyhound buses during the past five years, according to The Bee analysis. The state hospital admits about 4,000 patients a year to its inpatient unit, and inpatient care runs around $500 per day per client, Ghertner said.

 

He said he was aware during his tenure that Rawson-Neal was busing patients out of state but that he thought the practice was rare.

 

At the time, "I had 800 employees and a $106 million budget," he said. Ghertner regularly reviewed numbers pertaining to admissions, length of stay and other issues at the hospital, but patient busing was never on his radar, he said.

 

"I'm embarrassed to say that this practice was going on to this degree under my leadership," he said. "I had no idea. It just never came up."

 

Ghertner said the state mental hospital has been under stress since it opened in 2006, turning over five hospital directors since that time. That instability has taken a toll, he said.

 

"This busing issue is a symptom that reflects that the care there is not quality care," he said. "Things clearly are being missed."

 

Willden, Nevada's Health and Human Services director, said during last month's legislative hearing that policies have been tightened and disciplinary actions taken to ensure that patients are discharged only after the hospital confirms care and treatment at their planned destinations. The hospital administrator, Chelsea Szklany, now must approve all bus discharges ordered by medical staff, he said.

 

"Southern Nevada Adult Mental Health Services is committed to providing quality mental health services to its patients," said spokeswoman Mary Woods in an emailed statement.

 

But investigations continue into the agency's practices.

 

Rawson-Neal could lose vital federal funding pending an ongoing probe by the federal Center for Medicare and Medicaid Services. California state Senate President Pro Tem Darrell Steinberg has written a letter expressing outrage to U.S. Secretary of Health and Human Services Kathleen Sebelius.

 

The hospital's discharge practices also have prompted a call for action by a member of the U.S. Commission on Civil Rights. Commissioner David Kladney called for a broad investigation by Nevada's governor and Legislature.

 

"As a Nevadan, I am ashamed that my state is failing in its duty toward the neediest residents," Kladney said. Nevada, he said, appears to be "simply hoping that other states will shoulder the responsibility."

By Cynthia Hubert and Phillip Reese

 

In a dramatic change to their controversial discharge practices, Nevada health officials no longer will send state psychiatric patients alone on buses to cities across the country, they said Wednesday.

 

Effective immediately, a chaperone will accompany any mentally ill patient discharged from state facilities "for whom the state is paying transportation costs" to points outside of Nevada, said Mary Woods, spokeswoman for the Department of Health and Human Services.

 

Family members, legal guardians or state employees could serve as chaperones, Woods said.

 

The policy change was announced as the state and its primary inpatient facility for the mentally ill, Rawson-Neal Psychiatric Hospital in Las Vegas, face allegations of "patient dumping" stemming from a Bee report published earlier this month.

 

The Bee's investigation found that Rawson-Neal purchased Greyhound tickets for more than 1,500 patients since July 2008, dispatching people to every state in the continental United States. About a third of those patients were sent to California.

 

One of those patients, James Flavy Coy Brown, who suffers from schizophrenia, was discharged in February to a Greyhound bus bound for Sacramento, a place he had never visited and where he knew no one. He said a doctor at Rawson-Neal told him to call 911 when he got to Sacramento.

 

Brown arrived confused and agitated at a Sacramento homeless services complex after spending 15 hours on a bus with a few bottles of Ensure and three-day supply of medication to sustain him. He spent three days in the UC Davis Medical Center emergency room before social workers found him temporary housing.

 

The Bee's findings have prompted federal probes into patient care at Rawson-Neal, and criminal investigations by the city attorneys in San Francisco and Los Angeles into whether the aggressive busing policy was a form of cross-state patient dumping.

 

An array of psychiatric specialists interviewed have called the hospital's long-standing practice of putting mental patients on buses without escorts troubling and dangerous.

 

"Let me count the ways," Dr. Marye L. Thomas, a physician and head of behavioral health for Alameda County, said earlier this month. "If the person is truly disabled, there would be the possibility that some event could happen ."

 

Nevada health officials have defended the busing policy, saying most patients sent out of state were being returned to their home communities and arrangements were made for their care. They said Brown's case was an exception.

 

Woods said the policy change announced Wednesday stemmed from an internal review of files of the 1,500 patients bused out of state since 2008. She said the review uncovered additional cases in which the facility's discharge policies were not followed.

 

Health and Human Services Director Michael Willden told news media this week that "five or six" such cases had surfaced. But Woods said the analysis is ongoing and "it's too early to tell" how many such violations occurred.

 

"We want to be really thorough, and I'm not comfortable citing numbers," she said.

 

But she reiterated that the problem "does not appear to be systemic."

 

Woods said two employees have been disciplined in connection with Brown's case, but declined to provide details.

 

Both the independent Joint Commission, which accredits hospitals across the country, and the Center for Medicare and Medicaid Services, a watchdog group, are looking into complaints against Southern Nevada Adult Mental Health Services, which oversees Rawson-Neal.

 

The hospital got a visit Friday from Nev. Gov. Brian Sandoval, who has defended the facility while acknowledging it made a mistake in Brown's case.

 

"Improperly discharging one patient is one patient too many," he said in a statement earlier this week. But, he added, "It is not the policy of the State of Nevada to engage in 'patient dumping' Rather, patients have a right, and a desire, to return home to their friends and families."

 

The Nevada State Democratic Party on Wednesday weighed in on the Republican governor's visit to Rawson-Neal and the newly announced changes to the hospital's discharge policies.

 

"Today's announcement is essentially an admission that the Governor's patient-dumping policy is far more widespread than he originally conceded," spokesman Zach Hudson said in a news release. "It is shameful that it took weeks of damaging press coverage for the governor to come close to admitting that his administration's busing policy is reckless and irresponsible."

 

In California, where most public mental health treatment is overseen at the county level, agencies contacted by The Bee said they rarely bus psychiatric patients to other states and never without an escort.

 

In Los Angeles County, "staff are required to escort the client," said county Department of Mental Health spokeswoman Kathleen Piche. "They are never alone when they travel."

 

Several political leaders and former agency administrators in Nevada traced Rawson-Neal's unusual discharge practices to a mental health budget that has been steadily dismantled in recent years. The number of psychiatric patients bused out of Nevada grew 66 percent from calendar year 2009 to 2012. During that period, Nevada slashed its mental health budget by 28 percent to address deficits.

 

In published news reports, Willden has denied budget was a factor, attributing the steady rise in busing numbers to a policy change in 2009 that removed administrative oversight from the decisions.

 

Following The Bee's report, Rawson-Neal tightened its discharge practices by having two additional people, including hospital administrator Chelsea Szklany, review transfers to other states, officials said.

By Phillip Reese and Cynthia Hubert

 

Nevada state officials said Monday that two employees at Rawson-Neal Psychiatric Hospital in Las Vegas have been fired and another three will be disciplined as a result of an internal investigation into the hospital's practice of busing mentally ill patients to other states.

 

The investigation found that 10 out of roughly 1,500 patients may have been placed on buses during the last five years without "a support system/family/friends/housing at the destination," according to a statement from Mary Woods, spokeswoman for the Nevada Department of Health and Human Services.

 

"All individuals who violated release policies have been or will be disciplined," Nevada Gov. Brian Sandoval said in a prepared statement. "These disciplinary actions include terminations effective today."

 

Rawson-Neal and its umbrella agency, Southern Nevada Adult Mental Health Services, have been under fire following a report in The Bee earlier this month showing that since 2008, the hospital has transported about 1,500 mentally ill patients out of southern Nevada, dispatching them via Greyhound to cities and towns across the nation. About 500 of those patients were sent to California, and 19 of them to Sacramento, according to The Bee's review of Greyhound bus receipts.

 

One of those patients was James Flavy Coy Brown, a homeless, schizophrenic man who was bused from Las Vegas to Sacramento two months ago despite having no connections to the region.

 

He said Rawson-Neal staffers gave him a one-way ticket and told him to call 911 when he arrived.

 

The Bee uncovered his story after he turned up confused and suicidal at a Sacramento homeless services agency, having exhausted the three-day supply of medications the hospital gave him for his journey.

 

Nevada officials have acknowledged that Brown should never have been sent to Sacramento, but contend that his case does not represent a "systemic" problem.

 

State health authorities declined Bee requests Monday for copies of their internal investigation. Instead Woods, the spokeswoman, sent an email that she said summarized its contents.

 

She also declined to provide details about the employees disciplined, or the specifics of the 10 busing cases identified as problematic.

 

Woods said that in all 10 cases "insufficient documentation" made it unclear whether a patient had been properly bused. Of the 10 patients, nine were discharged directly from the hospital's psychiatric observation unit after treatment for substance abuse issues, she said.

 

The state's investigation determined that nine Rawson-Neal medical staff members were responsible for those 10 cases. Five no longer work at the hospital, two were fired, and three will be disciplined.

 

During the five-year period reviewed, Rawson-Neal maintained an aggressive practice of discharging patients to the Greyhound terminal in Las Vegas, sending them off, unaccompanied, with Ensure nutritional supplements and a limited supply of medications.

 

The policy called for staffers to "confirm client has housing/shelter available and a support system available to meet client at destination," according to a copy provided by Woods.

 

"While the investigation showed the vast majority of patient releases were done correctly, it also revealed policies were not followed by certain individuals," Sandoval said. "I will continue to evaluate the need for further action if necessary."

 

Neither Woods nor the governor addressed the larger issue of whether the practice itself – sending mentally ill patients alone on bus trips that often spanned multiple days and states – was an acceptable form of patient care.

 

An array of mental health experts have described the practice as both dangerous and unusual. None of the 10 state mental health agencies contacted by The Bee said that placing a psychiatric patient alone on a bus would be permissible.

 

After defending their policy for several weeks, Nevada health officials changed course last week, announcing that they would no longer pay to bus patients to other states without a chaperone.

 

Sandoval also said Monday that the state has "obtained proposals from national experts in the mental health field to provide an objective and comprehensive analysis of our state facilities to ensure that best practices are being implemented and followed."

 

Nevada's mental health system remains under investigation on several fronts. The federal Centers for Medicare and Medicaid Services last week sent a letter to Nevada authorities saying Rawson-Neal, the state's primary mental health facility, is out of compliance with federal regulations and risked losing critical federal funding if the hospital failed to submit "evidence of correction."

 

Meanwhile, the city attorneys in Los Angeles and San Francisco have opened probes to see if Nevada engaged in systematic "patient dumping."

 

Former Nevada State Sen. Sheila Leslie, a Democrat who focused on mental health issues during more than a decade in the Legislature, said the governor's actions are likely more about damage control than fixing a problem.

 

"I think clearly the governor's office wants this to go away," she said. "They are reacting with whatever practical solution will accomplish that."

 

The state should discipline those who put patients on a bus without a family member or friend waiting at the other end, Leslie said. But it's more important, she said, to reverse some of the mental health cuts that may have motivated Rawson-Neal employees to bus patients out of state.

 

"Our public mental health system is in shambles," she said. The problem, she said, "is us. It's not a single staff person."

By Cynthia Hubert and Phillip Reese

 

LAS VEGAS – In the darkness of early mornings during his graveyard shift at Nevada's primary state psychiatric hospital, Gilbert Degala regularly walked patients outside and watched them climb into taxis bound for the Greyhound bus station on Main Street.

 

The scene made him uneasy.

 

Many of the patients, burdened with mental illnesses that caused them to become delusional, suicidal or violent, were being discharged from Rawson-Neal Psychiatric Hospital in Las Vegas to buses that would ferry them hundreds of miles away. They carried their discharge paperwork, enough medication to last them a few days, and up to a case of Ensure nutritional supplement for the journey.

 

Some of the men and women knew why they were traveling to places like Miami or Sacramento or Los Angeles, Degala said. They were returning to family or friends. But for a troubling number "there was no one to pick them up," he said.

 

Some patients, he and other current and former workers told The Bee, appeared disoriented or unstable and not ready to leave the hospital.

 

"I felt bad for these patients," said Degala, who as a mental health technician helped social workers and nurses manage clients. He wondered whether the men and women ever got on their assigned buses, he said, and what happened to them if they did.

 

He resigned last year along with many of his colleagues, he said, as working conditions became more stressful.

 

Patient care at Rawson-Neal – and its discharge practices specifically – have come under scrutiny in recent weeks amid revelations that the hospital has bused roughly 1,500 patients to states across the nation over the past five years, a third of them to California.

 

Since mid-2008, as the economy worsened and Nevada slashed mental health spending, the number of psychiatric patients getting one-way tickets out of Rawson-Neal steadily rose, according to a Bee review of Greyhound bus receipts purchased by the state agency that oversees the hospital. By last year, Rawson-Neal was busing patients out of Las Vegas at a pace of more than one per day, shipping nearly 400 patients to 176 cities in 45 states, according to The Bee's review.

 

The sheer scope of the busing program has raised questions in California and elsewhere about whether Nevada was systematically "dumping" indigent mentally ill patients across state lines, prompting criminal probes in Los Angeles and San Francisco, as well as federal regulatory investigations.

 

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

 

Nevada's Health and Human Services chief has said that the increased pace of busing over the five-year period was not related to state funding cuts, and instead stemmed from a change in the hospital's internal approval process that has since been remedied.

 

Several current and former Rawson-Neal staff members interviewed tell a different story.

 

Though the employees offered different perspectives on the wisdom of sending psychiatric patients alone on bus trips across state lines, most described increased pressure in recent years to move patients out. And budget cuts, they said, were a driving factor.

 

"There is so much pressure now to get people out as soon as possible," said one longtime Rawson-Neal nurse, who requested anonymity for fear of losing her job.

 

"The administration has a meeting every week to talk about length of stay," she said. "Doctors are told, 'You need to get these patients out of the hospital.' "

 

According to the nurse, the pressure is most acute within the hospital's psychiatric observation unit, where patients are assessed to determine whether they need to be admitted for inpatient care.

 

Nevada cut mental health spending 28 percent between 2009 and 2012, cuts that brought furlough days, staffing shortages and widespread reductions in outpatient services and housing for the mentally ill, according to employees and area social services workers.

 

"The problem is that we don't have a place to send people," said the nurse. Mentally ill patients are filling hospital emergency rooms all over town, she said, and the ERs are sending patients to Rawson-Neal.

 

Many of Rawson-Neal's patients, she said, are chronically ill "frequent fliers" whose faces are familiar to staff members. Others are one-time visitors who had a mental break or abused drugs and "went off" while on their trip to Vegas.

 

At least once per shift, the nurse said, patients are so out of control that "we need to take them down" by force.

 

"Patients are being jammed down our throats," she said. "Sometimes the psychiatric observation unit will take in 10 patients all at once. You'll have ambulances backed up with patients. It's extremely stressful."

 

As pressures have mounted, busing patients from Rawson-Neal to locations out of state has become more common, workers said.

 

Toward the end of his tenure at Rawson-Neal, Degala said, "they were seeing too many patients coming in."

 

"They could pay the Greyhound bus station, set up a treatment plan and ship," he said. "It would be cheaper to give them a bus ticket than to keep them in the facility."

 

Rawson-Neal, a collection of squat brick and stucco buildings in an arid landscape a few miles from Las Vegas' glittering Strip, opened in 2006 to great expectations for improving care for mentally ill people in southern Nevada.

 

The hospital has four 40-bed inpatient units along with the 30-bed observation unit. The buildings surround a large, open courtyard with basketball hoops and patches of grass. Patients typically arrive via the ambulance bay at the side of the facility.

 

Interviews with state officials have left unclear exactly when the hospital put in place its patient busing policy. A long-standing written policy calls for transporting patients back to their "home community in order to provide more appropriate care and to remove the burden of treatment from the State of Nevada."

 

The wording was revised in recent weeks, as concern over the busing practice spread, to remove the phrase "burden of treatment," and the state announced late last month that patients no longer would be bused without chaperones.

 

Whatever the origins, Rawson-Neal clearly was issuing bus tickets to patients in earnest by 2008. Its umbrella agency, Southern Nevada Adult Mental Health Services, has had a standing contract with Greyhound since 2009, said a spokesman for the bus company. That year, the hospital bused 238 people. By 2012, the number had grown to 396.

 

By hospital policy, social workers and doctors are supposed to work together to come up with a plan for discharging patients, with a psychiatrist signing off on the discharge. But in recent years, as budget pressures increased, the process became more haphazard, according to some current and former employees, with staff members employing a loose definition of friends or family when deciding where to send patients.

 

Bryan Peralta worked as a mental health technician at Rawson-Neal for eight months, ending in November of last year. One of the reasons he left the hospital was its discharge of patients "who were not ready" to be released, he said.

 

Peralta recalled one young woman who was sent to the Greyhound station while "she was still foaming" at the mouth and talking to herself. She had a ticket to California, but was sent back to Rawson-Neal by a bus driver before she crossed the state border, he said.

 

Staffers typically made a cursory effort to connect patients with relatives or friends, Peralta said. But "half the time it's not a mother or a sister, it's a friend or a distant relative," he said.

 

Krystal Chadwick is another former technician who left Rawson-Neal three years ago. Patients discharged to the bus station used to get fresh fruit, juice and other snacks to sustain them for the trip, she recalled. Now they receive bottles of Ensure.

 

"I didn't want to give them Ensure," she said. "They had a lot of travel ahead of them. Some person is going to Florida and all they have to eat is Ensure?"

 

Chadwick said she often worried that patients would relapse during their trips.

 

"These people are lost," she said. "They can't take care of themselves."

 

In reporting this story, The Bee reached out to dozens of current employees to get their perspective on operations at Rawson-Neal. The vast majority did not respond or declined to comment. Those who did talk asked for anonymity for fear of being fired.

 

One current technician who spoke anonymously echoed Degala's description of patients leaving without a treatment plan in place.

 

"Sometimes they say, 'I'm just going,' " he said. "It's wrong."

 

Brian Little, who left the hospital in 2012 after eight months, had a different recollection. He said that in his "limited experience" patients "were not shipped off without a plan."

 

The longtime nurse who requested anonymity said she also believed most patients bused out of state were stable enough to leave the hospital and had some kind of help waiting at their destination.

 

Her concern was what might happen along the way.

 

"A lot of them are not going to stay on the bus," she said. "They're going to get off and be on the streets, and maybe end up here again."

 

The spotlight turned on Rawson-Neal after one of its patients, James Flavy Coy Brown, showed up suicidal and confused at a Sacramento homeless services complex earlier this year. Brown, who is 48 and suffers from schizophrenia, had been living in Las Vegas shelters for years.

 

He ended up in Rawson-Neal's psychiatric observation unit in February with symptoms of psychosis that suggested he was a danger to himself or others. After 72 hours, he was discharged to the Las Vegas Greyhound station with a one-way ticket to Sacramento, where he knew no one. He said Rawson-Neal doctors suggested he might like "sunny California" and told him to call 911 once he arrived.

 

He arrived in Sacramento out of both medication and food. With the help of police and homeless services workers, he landed in the UC Davis Medical Center emergency room. He has since reunited with his daughter from North Carolina.

 

Nevada officials have acknowledged making mistakes in Brown's case, saying the hospital "blew it" in busing him to Sacramento. But they insist his case was an exception and that the problems are not systemic.

 

"The most concerning thing to me is a narrative that we are dumping people," said Dr. Tracey Green, Nevada's state health officer. "We don't dump people."

 

Green defended the state of care at Rawson-Neal and said staffing ratios have remained consistent during her tenure. The hospital's staffing levels are subject to independent and federal review, she said, and have not been found lacking.

 

"I believe we do excellent work here," she said. "The bottom line is we will continue to do better."

 

Since the April policy change requiring that all patients bused out of state now be accompanied by an escort, no patients have been bused from the hospital, Green said last week.

 

"We think the transportation policy is right where it needs to be," she said.

 

As the furor over the busing policy has spread, Nevada state health officials conducted an internal investigation, which they say found 10 of 1,500 patients may have been placed on buses without support during the past five years. Two employees were fired following the investigation, and several others disciplined, said Mary Woods, spokeswoman for the Nevada Department of Health and Human Services.

 

The hospital's discharge policies remain under scrutiny. City attorneys in Los Angeles and San Francisco have launched criminal probes to determine whether Nevada has been dumping its indigent psychiatric patients across state lines. They, along with Sacramento's city attorney and county counsels from Alameda and Santa Clara, have demanded a meeting with Nevada's attorney general to get more information on the patients bused to their jurisdictions in recent years.

 

In a letter to Attorney General Catherine Cortez Masto last week, the attorneys said their preliminary investigations have found that Brown's case was not isolated.

 

The investigations "have confirmed that Nevada's practice of transferring mentally ill patients to California without an escort and without prior arrangement for an institution or responsible person to receive the patient is more widespread," the letter stated.

 

Late last week, an independent accreditation agency dispatched a team of investigators to Rawson-Neal in response to concerns about patient care. Its report will determine whether the state hospital can keep its federal funding and "gold star" accreditation status.

 

Several former administrators and staffers blame the controversial busing practices on a lack of oversight, caused in part by instability at the top.

 

In its short lifetime, Rawson-Neal has had five administrators, one of whom lasted less than a week and another a few months. The turnover has created confusion about policies for admitting and discharging patients, current and former staffers said. The hospital's current administrator, Chelsea Szklany, is an occupational therapist who has been on the job since January 2012.

 

Jonna Triggs, who served as director of Southern Nevada Mental Health Services between 2002 and 2006, said busing patients "was never a standard or routine" on her watch. "Certainly we did send some people back home, but not hundreds a year and not the way it's being done now," she said.

 

Others say Rawson-Neal's problems reflect a broader fraying of the safety net for the mentally ill in southern Nevada.

 

Cuts to programs funded by the government have had a trickle-down effect on hospital emergency rooms and private agencies that run programs for needy people, observers said.

 

Last September, the Salvation Army in Las Vegas closed a 42-bed group home for chronically mentally ill people after grant funding was slashed, said spokeswoman Leslee Rogers.

 

A recent survey counted more than 14,000 homeless people living in Las Vegas, up from about 9,000 four years ago, she said. Many of the men and women living on the streets are mentally ill and end up in hospitals including Rawson-Neal, said Rogers.

 

"Yes, we get people all the time who have been dumped," she said. Some arrive by taxi wearing hospital gowns and slippers.

 

Maj. Robert Lloyd, the Salvation Army's Clark County coordinator, said the number of mentally ill people that the agency serves has risen dramatically during the past three or four years.

 

"We have folks show up from hospitals, completely unable to take care of their basic needs," Lloyd said. "When we get someone who is self-mutilating, who is eating glass or pounding their head against the wall, we are in over our head. We're not capable of dealing with it."

 

Lloyd said he understands the plight of hospitals that are overextended.

 

"They can only hold someone for so long and then they've got to do something with them. But if they're releasing them into a situation that's not stable, it's unacceptable."

 

Lloyd said staffers have tried to get such patients readmitted to hospitals but usually are unsuccessful.

 

"So we call the police, and the next thing you know they're out on the street again," he said.

 

"It's a revolving door."

Feb. 12: James Flavy Coy Brown, homeless and suffering from schizophrenia, arrives on a Greyhound bus in Sacramento following a stay at Rawson-Neal Psychiatric Hospital in Las Vegas. He has no family or friends in Sacramento and doesn't know why the hospital sent him.

 

March 14: Michael Willden, director of the Nevada Department of Health and Human Services, tells a legislative committee "we blew it" in Brown's case but that no "systemic" problem exists.

 

April 14: The Bee publishes a story based on Greyhound bus receipts showing that Rawson-Neal has bused about 1,500 patients to other states over the past five years.

 

April 18-23: An independent accreditation agency and the cities of San Francisco and Los Angeles announce investigations into patient busing at the hospital.

 

April 24: Rawson-Neal changes its policy to require that a chaperone accompany all patients on buses.

 

April 29: Nevada officials announce that 10 out of 1,500 patients may have been improperly bused without support or housing at their destination in the last five years. They also announce the firing of two "medical staff" at Rawson-Neal.

LA PLATA, Md. – If you happened to be riding an eastbound Greyhound bus in late February, you might have encountered Nicholas Attilio Caroleo.

 

You probably would remember him.

 

Caroleo, a former light-heavyweight professional boxer with a nose that is slightly off-kilter, had just been released from Rawson-Neal Psychiatric Hospital in Las Vegas, one of hundreds of mentally ill people the facility has discharged to buses headed out of Nevada in recent years.

 

With a history of schizophrenia and bipolar disorder, a long rap sheet of misdemeanor offenses and a roiling anger in his gut, Caroleo had a one-way ticket to Fort Lauderdale, Fla., courtesy of Nevada's largest state psychiatric hospital.

 

It is unclear whether Caroleo, 32, ever made it to his destination, where relatives said he had no family or friends but has lived on the streets.

 

Before he left Las Vegas, he let a former girlfriend know he was on the move, sending a text message and photo of himself sitting at the Greyhound station. Shaggy and bearded, he is showing off his bus schedule and discharge papers from Southern Nevada Adult Mental Health Services, the state agency that oversees Rawson-Neal.

 

"You will repent!!!" his text warns. "I gotta ticket."

 

Alarmed, the girlfriend forwarded the message to Caroleo's parents, Pat and Robert, in Maryland. Within hours, they sought a court order barring their son from contacting them.

 

"Nicholas has threatened to kill myself, my husband, himself and my grandchildren," Pat Caroleo told the court in a written statement. "He is en route from Las Vegas by bus."

 

Asked whether he had access to a firearm, she answered, "Do not have any idea."

 

The Charles County court granted the protective order.

 

A few days later Nicholas' parents, who live in a quaint southern Maryland town of about 9,000 people, got a call from an Atlanta mental hospital where he had been admitted. Later, they received a series of chilling phone and text messages from him. "You'll be dead by summer," one of them said.

 

Now, with summer upon them and armed only with court papers, the Caroleos are not letting down their guard.

 

Every day, his mother said in a recent interview, she braces for the possibility of Nicholas showing up at the family's pristine colonial-style home, which is perched on a street of towering oaks and manicured lawns studded with American flags.

 

"They put people like him on a bus?" asked Pat Caroleo, a petite, no-nonsense retired schoolteacher.

 

"He is 200-percent unstable. He's angry. He's psychotic. He's a boxer. His fists are weapons."

 

Nicholas Caroleo is one of about 1,500 patients in the past five years who were discharged from the Nevada state mental hospital to Greyhound buses bound for cities across the country, according to a Bee review of receipts for bus tickets purchased by the state. The patients traveled alone, typically with a small supply of psychiatric medications and liquid nutritional supplements for their journeys.

 

Between July 2008 and March this year, according to The Bee's review, the hospital shipped patients to every state in the continental United States, at a pace that steadily increased and last year hit more than one patient per day. About a third of the patients were sent to California.

 

Since mid-February, when Rawson-Neal bused a mentally ill homeless man to Sacramento without making arrangements for his treatment or housing, officials in California and across the nation have questioned whether Nevada has been "dumping" mentally ill patients into other states. Earlier this month, Sacramento civil rights lawyer Mark Merin filed a lawsuit seeking class-action status against Nevada and Rawson-Neal, contending the busing policy violated patients' constitutional rights.

 

Following a series of Bee reports, Rawson-Neal revised its policy and no longer discharges people to buses without an escort.

 

But questions still loom about the fate of the hundreds of mentally ill patients sent off alone over the past five years.

 

Administrators defend the hospital's long-standing policy as safe and humane, arguing that the vast majority of patients transported out of state were mentally stable and wanted to leave. They insist that in all but a handful of cases, staff members confirmed before discharge that patients had relatives and treatment arrangements waiting for them at the other end of their bus trips.

 

They acknowledge, however, that they have done no follow-up checks to determine whether patients actually made it to their destinations.

 

During the past two months, through a painstaking process of tracking down former patients whose records are protected by privacy laws, The Bee sought first-hand accounts of patient treatment at Rawson-Neal and how the aggressive cross-state busing policy played out. The newspaper was able to identify and obtain the stories of eight people placed on buses by the hospital in recent years.

 

In none of those cases, according to the patients and their families, did staff members fully adhere to the discharge policies outlined by administrators.

 

Only one passenger completed his bus journey at the scheduled time, with a friend or relative waiting at the bus station. None of the patients had firm treatment plans in place at their destinations. At least two were bused to cities where, according to family, they had no personal ties.

 

Only three of the eight described their mental and housing situations today as healthy and stable.

 

One of the patients was a vacationer who had a mental breakdown while in Las Vegas. The others were living in the city, in some cases for years, and without jobs or stable housing. They were drawn by the balmy weather and the promise of a better life.

 

All ended up at Rawson-Neal in despair.

 

"People are trying to kill me," Joshua Soules told a social worker after he arrived at Rawson-Neal Psychiatric Hospital in May 2011. "I see invisible people that you can't see."

 

Two weeks later, Soules was discharged via Greyhound to Sacramento, near the home of his mother, Sharon, in Elk Grove. The trip should have taken about 15 hours. Instead, it turned into a three-day odyssey.

 

Contrary to Rawson-Neal's stated policy, Soules' mother said she never received a call from staffers prior to his bus trip. If she had, she said, she would have advised against allowing Joshua to take a long bus ride alone.

 

"He's got a heart of gold when he's stable and sober, but how do you know that he's going to stay that way?" she said. "It's absolutely not safe."

 

Instead, it was Joshua who called his mother in early June and asked her to meet him at the bus station the next day. But he was nowhere to be found when she arrived to pick him up at the Greyhound depot in downtown Sacramento.

 

More than two days later, he showed up on her doorstep, dirty, disheveled and soaked with perspiration.

 

Soules, in a recent interview, said he is unsure why he and his mother never connected at the bus station. But once he realized he had missed her, he said, he started walking to her home in Elk Grove, a journey of more than 20 miles.

 

"I had no money or ID or phone," he said, standing in the backyard of the dingy boarding home where he now lives. "I left the hospital with nothing but the clothes on my back."

 

Joshua, 25, was adopted by Sharon Soules as a toddler and diagnosed in his teens as bipolar. In the winter of 2010, he drove to Las Vegas with a girlfriend on a whim, and spent about eight months drifting around the city.

 

Unemployed, homeless and off his medication, Soules entered Rawson–Neal voluntarily in May 2011, he said. He was in the throes of a romantic breakup, and recently had been mugged in the streets. "I knew I needed help."

 

His medical records, which The Bee reviewed with his permission, show Soules was admitted to Rawson-Neal with "active paranoia" and auditory and visual hallucinations of people following him and wanting to kill him.

 

After two weeks of treatment, according to the records, he was discharged in "stable but guarded" condition. "They offered me a bus ticket, and I grabbed it," he said. "I'm a Cali boy, and I wanted to go home."

 

The staff offered him the name and number of a "recovery house" where they said he could seek care when he got home. But Soules said he never had an appointment and had no intention of going there.

 

Once released from Rawson-Neal, Soules got into a waiting taxi and headed to the bus station. He had no cash, no identification other than his Medicare card, and none of the liquid nourishment that hospital policy mandates for such trips, he said. He did have a supply of anti-psychotic medications, but "I threw them away," Soules said, believing they were spiked with heroin.

 

The bus ride, Soules recalled, "was strange. I remember someone in the back of the bus staring at me, trying to mess with me." But he said he made it to Sacramento without incident.

 

Sharon Soules said she was reluctant to take her son into her home, on a quiet street where she lives with her disabled adult daughter. She agreed, she said, after he promised for the umpteenth time to stay away from drugs and alcohol and take his medications.

 

Instead, she said, he resumed his drug habit and started getting into trouble.

 

"He was flailing around, not making sense, yelling and screaming," she said. "He broke furniture, he broke the door. He was sweet one minute, and out of control the next."

 

Since returning from Las Vegas, Soules has been detained by Elk Grove police at least eight times for minor offenses ranging from public intoxication to disorderly conduct, records show.

 

In the most recent case, on April 30, officers took him in after reports that he was "yelling and cursing at people in the streets" in Old Town, said police spokesman Christopher Trim. "Officers determined he was off of his meds and unable to care for himself," Trim said.

 

He ended up at Heritage Oaks, a private psychiatric hospital, and now lives in a boarding home in south Sacramento where he is struggling to remain sober and stay on his psychiatric medications.

 

Sharon Soules speaks with her son by phone almost every day, but has taken out a restraining order that bars him from coming to her home.

 

Tall and solidly built, with piercing blue eyes, elaborate tattoos on both biceps and a black loop earring in his left lobe, Joshua spoke of his life in a recent interview at the sparsely furnished boarding home he shares with four other people.

 

During a rambling, disjointed discussion, he ranted about crooked police officers and others he believes have wronged him. He disclosed that people on TV spy on him, and that the wind whispers messages. In the course of a 90-minute interview, he rapped and danced to an Eminem tune, burst into tears over the loss of a friend, and laughed hysterically at the absurdity of his situation.

 

Still, he said, he is happy to be back in Sacramento and believes the hospital treated him fairly.

 

"What are they going to do with me?" he asked. "They can't keep me forever. So they said, 'Let's get this guy out of here. Let's send him home.' I was fine with that."

 

Matt Hartford barely remembers his Greyhound trip from Las Vegas to Portland, Maine, a distance of 2,411 miles.

 

When he boarded the bus, he said, he was "completely disoriented" by medications for a mental illness he insists he does not have.

 

"I was so doped up when I left there that I was drooling on myself," said Hartford, 26. "It was scary."

 

Hartford wound up at Rawson-Neal in November 2011 following an altercation with a police officer, he said.

 

He had moved to Las Vegas about 18 months earlier, with high hopes of finding a job and living with a cousin. "But Vegas wasn't what I thought it would be," he said.

 

One day he was "walking down the street asking people for change" when an officer confronted him. "The next thing I knew I was in the mental hospital with a needle of Haldol in my arm, being told I had a severe illness and that I was hearing voices," he said.

 

After a few days, he said, staffers asked him whether he wanted to leave Las Vegas, and he opted for a bus ticket to Maine, where his parents live. He said he got no referrals for counseling or treatment.

 

He remembers asking if he could stay in the hospital another day "to get the drugs out of my system," he said, but he got a Greyhound ticket instead.

 

"They wanted to kick me out because I didn't have money," Hartford said. "They doped me up with meds, gave me a big plastic bag of Ensure and some saltines and they put me on a bus."

 

Hartford's cross-country trip "is a blur," he said. He remembers little about it other than "waking up in places like Pittsburgh and Ohio and Boston" for transfers.

 

Although a Rawson-Neal social worker told him that his father would be waiting at the bus station, he said, his dad never got a call and no one was there when he arrived.

 

Nevertheless, Hartford said, he made it and now is healthy and stable.

 

"I was so out of it when I left," he said. "I can't believe I made it home."

 

Ryan Weatherman said he received neither medications nor therapy when he found himself at Rawson-Neal last year following an episode of severe depression while he was visiting the city.

 

After a brief stay, "a doctor asked me if I wanted to go home" to Indiana, he said. He did. He endured a "long, boring" ride, and his mother was waiting for him upon his return.

 

But he is bitter, he said, that the hospital seemed more concerned with "passing me off to someone else" than offering him treatment.

 

"I was in full despair and misery," he said, and had threatened suicide.

 

"All they did was give me a place to sleep for the night," he said. "No food, no medicine, no psychiatry, no referrals, no follow-up. Just four bottles of Ensure" and a hefty bill.

 

Weatherman, 34, said he sought help after arriving home and is doing well.

 

Life is more precarious for another former Rawson-Neal patient, Tommy Veith of Lake County.

 

Veith, 34, who has a history of disabling depression, moved to Las Vegas in 2000 hoping to become a musician. But it never worked out, he said.

 

He said he worked odd jobs, and mostly lived with his father. Earlier this year, he wound up at Rawson-Neal after a fight with his dad.

 

Veith was at the hospital for "three or four days," he said, and received medication for his depression but no counseling. When the hospital was ready to discharge him, he told doctors that he wanted to move back in with his dad.

 

Within minutes, he said, a staffer took him outside and pointed him to a Metro bus stop.

 

"I was in flip-flops from the hospital," said Veith. "I didn't have a cellphone or wallet or anything. But I wanted out of there. So I walked across Vegas for 24 miles."

 

After a short stay with his dad, he said he ended up in a low-rent motel, where he lived until relatives from Long Beach found him in late April. Shortly after that, Veith decided to move in with a sister in Lake County.

 

"I'm never going back to Vegas," he said.

 

By the time she learned that her son Nicholas had been dispatched out of Las Vegas by bus in early February, Pat Caroleo had lost track of him.

 

She had not seen him in years, she said, since he had adopted a transient lifestyle and begun lashing out at his family for his failures and disappointments.

 

"This mental illness, it's terrible," Caroleo said. "We tried everything to help him, but nothing worked.

 

"I've cried and cried and cried for 12 years," she said, shaking her head. "I don't cry anymore."

 

Since she learned of her son's discharge from Rawson-Neal, Caroleo said, she and her family have been living on a razor's edge.

 

The simple act of picking up the phone is a source of stress. Bills from mental facilities across the country arrive on a regular basis. Collection agencies call morning and night. Pat Caroleo cannot step outside without a pang of worry that Nicholas might be waiting.

 

"Of course I am afraid," she said during a lengthy interview in an elegant home decorated with photos of children and grandchildren. "I believe that he wants to hurt us."

 

Nicholas Caroleo was "a sweet kid" with athletic potential, his mother said. Family photos show him romping with his sisters on the beach, riding ponies, posing in a Superman costume. He was a standout pitcher in youth baseball. A quarterback. A boxer who turned pro and has three technical knockouts to his credit.

 

"He was a natural athlete like you wouldn't believe," Pat Caroleo said, "and we went to every one of his games and practices."

 

But somewhere along the line, Nicholas' mind began to falter. After he attempted suicide at 16, Pat said, her son entered a mental facility for the first time. He has been diagnosed by various doctors as having bipolar disorder, depression and schizophrenia, she said.

 

Between periods of stability, Nicholas Caroleo has been in and out of jails and hospitals, his mother said. He had been living off and on in Las Vegas, where he hoped to make a living as a boxer, for the past seven years.

 

In February, Nicholas was arrested for ignoring traffic signals as he wandered around the city, according to police records. He was sent to Rawson-Neal.

 

On Feb. 27, unknown to his family, the hospital discharged him with a Greyhound ticket to Fort Lauderdale, where he once lived on the streets but where his mother said he has no family or friends.

 

Pat Caroleo learned of his bus trip when she received the text message from Nicholas' former girlfriend. The news sent a shudder of fear through her, she said, both for her son and the people he might encounter on his trip.

 

"Nicholas thinks he's the son of God, the prince of peace," she said. "We don't know what he might be capable of."

 

After reading her son's text message, the Caroleos contacted a relative who is a police officer, filed for a protection order and discussed exit routes from the house should Nicholas show up without warning.

 

The last time they heard from him, about three weeks ago in a phone call from somewhere in Florida, Nicholas ranted at his father and demanded money.

 

The next day, Robert Caroleo suffered a heart attack.

 

"I can't say that Nick's call was the reason," Pat said. "But it sure didn't help."

 

The man whose story sparked the recent scrutiny of Nevada's state psychiatric hospital was homeless and psychotic when he landed in the facility earlier this year.

 

Seventy-two hours later, James Flavy Coy Brown was discharged via Greyhound to Sacramento. He arrived 15 hours later, on a cold February morning, at the downtown bus station.

 

Brown, 48, who has schizophrenia, said he had never been to California, and had not a single friend or relative in the capital city. After police delivered him to a homeless services complex in an industrial section of the city, he told a social worker he was terrified and was thinking about killing himself.

 

According to his records from the Nevada hospital, Brown wanted to go to California. But he told The Bee that it was his doctors who suggested he travel to "sunny California," and that he had no ties to the state. "They put me on a bus and sent me to a place I didn't know anything about," he said.

 

After spending time in the UC Davis Medical Center emergency room and a Sacramento boarding home, Brown was reunited with his daughter in North Carolina. He now lives in her family's home and is faring well, she said recently.

 

Brown's case prompted The Bee's investigation of Rawson-Neal's busing practices, as well as internal reviews by the state of Nevada, ongoing probes by the cities of San Francisco and Los Angeles, and investigations by the independent agency that accredits hospitals nationwide.

 

Two staff members were fired in response to the controversy, and the hospital has added a layer of oversight to oversee files of patients to be bused to other cities. Under the new policy, any patients bused out are to be accompanied by a chaperone.

 

Officials have admitted that they "blew it" by sending Brown to Sacramento, but say a limited review of patient files found only a few cases in which discharge policies were clearly violated.

 

"That means the essence of the policy was followed, and the real difficulty in a small number of cases was a lack of documentation," said Nevada's state health officer, Dr. Tracey Green.

 

Green and other state officials have explained the busing policy in part by noting Las Vegas is a destination city that draws people from around the globe, including transients and mentally ill people.

 

"If they want to go back to their home cities," Green said, "we think it is humane to send them home. We really believe this is a compassionate program."

 

Green would speak specifically only about Brown and Soules, both of whom signed off on release of their records.

 

Brown's treatment was unacceptable, she said.

 

As for Soules, "I don't see any problems," said Green. "He was stabilized and on medication. He wanted to go to California. When treated, people who are mentally ill do have resolution of their symptoms and can perform normal functions, including taking a bus ride."

 

John Kurtz, a professor of psychology at Vanderbilt University in Pennsylvania and a specialist in assessing mentally ill people, agreed with her general philosophy, as long as proper arrangements for treatment and care are made on the other end.

 

"If that person is OK to be discharged and is not a danger to themselves or others, putting them on a bus is better than just turning them loose in Las Vegas," he said. "On the face of it, it's not a bad idea."

 

But the large number of patients who received bus tickets from Rawson-Neal give reason for pause, he said.

 

"I suspect that a lot of these people had no place to go in Las Vegas and the hospital wanted to send them as far away as possible so they didn't come back."

 

Merin, the attorney suing Nevada over the busing policy, said he is convinced that the state, in the midst of a budget crisis, sacrificed the care of mentally ill people to save money.

 

"Rawson-Neal's policy was, 'Get 'em out as soon as possible, and send them as far away as possible,' " Merin said. "That's why the busing program works for them. If you get sent to Maine or Michigan, it's not likely you're going to end up back in a hospital in Las Vegas."

A Nevada state psychiatric hospital under fire for busing hundreds of mentally ill patients to cities across the nation over the past five years will not appeal a decision stripping it of its accreditation.

 

A committee of the Joint Commission, an independent agency that accredits hospitals nationwide, last week issued a preliminary denial of accreditation for Rawson-Neal Psychiatric Hospital in Las Vegas, citing multiple violations of quality care standards, many related to patient safety.

 

The hospital had the option to appeal, and keep its accreditation during the process, but officials announced late Thursday they would waive that right and that the hospital and affiliated programs would lose accreditation as of today.

 

“Rather than pursue an appeal, Southern Nevada Adult Mental Health Services plans to request a new accreditation review in the near future when the hard work and great effort to improve services for our patients will be considered and recognized by the Joint Commission,” Mike Willden, director of the Nevada Department of Health and Human Services, said in a statement.

 

The hospital will remain open, Willden said. Most of its funding comes from the state, and the loss of accreditation does not automatically affect the flow of federal Medicare dollars. The hospital for now remains certified with the Centers for Medicare and Medicaid Services. But the loss of accreditation -- a rare step taken against fewer than 1 percent of hospitals each year -- will be a stain on the hospital’s reputation, particularly as it tries to retain and recruit staff to fix myriad problems identified by internal and external audits.

 

“It’s a very big deal,” said Troy Lair, CEO and president of The Compliance Doctor, a Los Angelesbased firm that consults with health organizations across the country on accreditation.

 

Private insurance companies generally will not pay for patient care in a hospital that is not accredited, Lair said. “They will not be able to see any type of private insurance patient,” he said. In a best case scenario, Lair said, it generally takes a hospital up to a year to regain accreditation. Many hospitals that lose accreditation end up closing.

 

Joint Commission surveyors visited Rawson-Neal twice in May, following a series of Bee reports examining patient discharge practices at the facility, which serves as Nevada’s primary hospital for the mentally ill.

 

The Bee launched its investigation after Rawson-Neal bused a mentally ill homeless man to Sacramento in mid-February without making arrangements for his treatment or housing.

 

James Flavy Coy Brown, 48, who suffers from schizophrenia, had been living homeless in Las Vegas for years when he ended up at Rawson-Neal earlier this year with symptoms of psychosis. Seventy-two hours later, he was discharged via Greyhound to Sacramento.

 

Brown told The Bee he had never been to Sacramento and had no friends or family in the city, but that a Rawson-Neal doctor had suggested he would like “sunny California.” He arrived 15 hours later, confused and suicidal, and spent three days in the UC Davis Medical Center emergency room before staffers there were able to find him shelter.

 

A subsequent review of Greyhound bus receipts purchased by the state for Rawson-Neal patients 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, those patients were put on buses alone, with one-way tickets, a small supply of medication and Ensure nutritional supplement.

 

In the months since The Bee published its findings, Nevada health officials have largely defended the hospital’s busing practices 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 at the other end of their bus trips.

 

But Bee interviews with current and former Rawson-Neal staffers, as well as eight former patients, found multiple cases in which that protocol was not followed.

 

In April, Rawson-Neal revised its policy and no longer discharges people to buses without an escort.

 

The Joint Commission did not detail the specific conditions or treatment that prompted the denial of accreditation. Its statement simply lists numerous agency standards the hospital did not meet.

 

During their first May visit, they found 23 standards had not been not met. Among them: ensuring staff are competent to perform their responsibilities; educating patients during discharge about follow-up care; and giving adequate information to other service providers who will care for patients following discharge. During a subsequent visit, Joint Commission inspectors cited Rawson-Neal for failing to meet 35 standards, many related to patient safety.

 

Willden said Thursday he was disappointed in the Joint Commission’s decision, arguing it “is not an accurate reflection of the hospital’s current practices and policies.”

 

The appeal process, he said in his statement, “does not allow the consideration of new information such as changes and improvements to discharge processes, treatment programs, and oversight accountability. The appeal process also does not take into account the follow-up surveys conducted by the Joint Commission itself which concluded the facility is in compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation.”

 

A spokeswoman for Nevada Gov. Brian Sandoval said Thursday the governor “continues to evaluate the progress of Rawson-Neal.”

 

Spokeswoman Mary-Sarah Kinner said Sandoval has requested special legislative action to get budgeted funding to the hospital more quickly “and to address any outstanding concerns with the facility.”

 

The hospital remains the subject of several outside probes. The city attorneys in Los Angeles and San Francisco are investigating whether Rawson-Neal has been systematically dumping patients across state lines for years. Last month, Sacramento civil rights lawyer Mark Merin filed a lawsuit seeking class-action status against Nevada and Rawson-Neal, contending the busing policy violated patients’ constitutional rights.

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.

The state of Nevada and its primary psychiatric hospital “intentionally and wrongfully” foisted the cost of caring for indigent mentally ill people onto California cities and counties by issuing patients bus tickets out of town without making proper arrangements for their care, a lawsuit filed Tuesday in San Francisco charges.

 

San Francisco City Attorney Dennis Herrera filed the class-action lawsuit against Nevada, Rawson-Neal Psychiatric Hospital in Las Vegas and state mental health administrators, seeking reimbursement for the care of indigent patients he said the system “dumped” onto California in an effort to save money.

 

“What the defendants have been doing for years is horribly wrong on two levels,” Herrera said in a written statement announcing the lawsuit. “It cruelly

victimizes a defenseless population, and punishes jurisdictions for providing health and human services that others won’t provide.”

 

In addition to unspecified financial damages, the suit asks for a permanent injunction preventing Nevada from dispatching psychiatric patients to California unless they are residents of the destination city or county, are being sent to family members who have agreed to care for them, or are being sent to a medical facility where arrangements have been made for their treatment.

 

Mary Woods, spokeswoman for the Nevada Department of Health and Human Services, said Tuesday afternoon that her agency would have no immediate comment on the suit.

 

The action follows a formal demand that Herrera issued last month to Nevada officials. He said he planned to take legal action within weeks unless the state reimbursed San Francisco $500,000 for care of patients he maintains were improperly bused to the city since 2008.

 

Herrera said an investigation by his office had identified 24 patients who had been bused to San Francisco over the past five years, 20 of whom Herrera said required emergency treatment upon arrival.

 

Nevada’s attorney general responded this week with a letter arguing that San Francisco had offered insufficient evidence to justify its claim.

 

Records gathered by state health officials and given to Herrera “demonstrate that the policies are appropriate and that only proper discharges were made,” reads the letter, sent Monday and signed by Chief Deputy Attorney General Linda Anderson. Nevada’s mental health system has been in the spotlight for months, following a Sacramento Bee report published earlier this year that found Rawson-Neal had bused 1,500 mentally ill patients out of Southern Nevada from July 2008 through early March 2013. About 500 were given one-way tickets to California.

 

The Bee undertook its investigation after one of those patients, James Flavy Coy Brown, turned up suicidal and confused at a Sacramento homeless services complex after a 15-hour bus ride from Las Vegas to the capital city. Brown said he knew no one in Sacramento and that Rawson-Neal doctors advised him to dial 911 once he arrived in the city. Nevada health officials have acknowledged that they erred in shipping Brown to Sacramento without any arrangements for care. But they contend his case was an exception and that the vast majority of patients bused from Rawson-Neal had family or treatment waiting for them on the other end of their journeys.

 

They said many of the patients bused to their “home states” were vacationers who suffered breakdowns or abused drugs. A Herrera spokesman disputed that explanation.

 

“This is about Nevada’s state-sanctioned practice of improperly transporting indigent psychiatric patients,” said Matt Dorsey. “It’s not about patients who travel voluntarily between Nevada and other states.”

 

The lawsuit filed Tuesday charges that Nevada sent mentally ill people to California in a manner that placed patients, their fellow Greyhound passengers and residents of the places where they landed in peril.

 

“All of the patients were transported without escorts,” and often without “adequate food, water and medication” to sustain them during lengthy bus trips. Because the hospital failed to make proper arrangements for their care, many of the patients “ended up on the streets of their destination cities without funds or means of support, shelter or medication,” the suit reads.

 

Although Nevada is required by state law to care for its poor and indigent, it sent patients out of state “and avoided expending its own public resources” to provide for them, it says. The state’s aggressive busing practices coincide with funding cuts that slashed Nevada’s mental health budget by 28 percent between 2009 and 2012. During the same period, the number of psychiatric patients bused from Rawson-Neal grew by 66 percent.

 

Since Brown’s case became public, the hospital’s discharge practices have been under scrutiny by an array of regulatory groups. Recently, Rawson-Neal lost its coveted accreditation with the private Joint Commission and remains under investigation by the U.S. Centers for Medicare and Medicaid Services, which has threatened to pull its Medicare reimbursements. In addition, Sacramento attorney Mark Merin has filed a class-action lawsuit on behalf of Brown and others, charging that Nevada’s busing policies violated patients’ constitutional rights.

 

The lawsuit that was filed on Tuesday offers detailed information about several previously unpublicized cases that Herrera said illustrate improper practices by the Nevada system. In one, a homeless man with schizophrenia and a history of visits to Rawson-Neal was bused to San Francisco even though he “had no stable support system there,” the suit says. Upon arrival, he received five days of crisis care.

 

After returning to Las Vegas, the man again wound up at the psychiatric hospital and got another bus ticket to San Francisco. Police brought him to San Francisco General Hospital after he “expressed thoughts of homicide and suicide,” according to the suit.

 

Other patients shipped to the city from Nevada received public housing and cash assistance funded by San Francisco in addition to costly health care, the suit claims.

 

If successful, San Francisco’s claim for reimbursement would establish a precedent for awarding restitution to cities and counties across California “able to demonstrate claims for damages” from improper transfers of patients from Nevada, Herrera said in his statement.

 

Lisa Ikemoto, a professor at UC Davis School of Law and a specialist in health care law, called the litigation very unusual. “I haven’t seen anything like it,” she said.

 

A judge first would have to certify the suit as a class action, said Ikemoto. To win in court, San Francisco would have to prove that Nevada intentionally “dumped” patients and the cost of caring for them onto the city, she said.