James Flavy Coy Brown was not the only patient in recent weeks to be dispatched from a Nevada state psychiatric hospital to far-off cities with little regard for their safety, a state investigation confirms.
In February alone, at least three other mental patients were discharged from Rawson-Neal Psychiatric Hospital in Las Vegas to far-flung destinations, including California, with a small supply of medications and a few cans of Ensure for nourishment, according to a report issued Monday by the Nevada State Health Division.
Those four represent just more than 10 percent of the 30 sample files reviewed by state investigators in response to concerns about Brown's care.
Brown, 48, wound up in Sacramento carrying his walking papers from Rawson-Neal and a schedule detailing his 15-hour bus ride from Las Vegas. Upon arrival, he told a worker at the Loaves & Fishes homeless complex near Sacramento's downtown that he knew no one in California, had nowhere to go and had run out of medication to treat his schizophrenia, anxiety and depression.
After his case surfaced in The Bee, California officials called for an investigation into whether Nevada was "dumping" mental patients in California via Greyhound. The matter sparked a hearing by Nevada state legislators, and has prompted state and federal investigations.
At the legislative hearing last month, Nevada Health and Human Services director Michael Willden acknowledged that mistakes were made in Brown's case but contended that an internal review showed no pattern of misconduct. Willden said patients can choose to leave Nevada for other locales and that the psychiatric hospital's staff are supposed to confirm they have a place to live and receive treatment.
Willden did not return calls for comment Monday on the report by state investigators.
But a former Nevada health official who reviewed the report said he was alarmed by the practices uncovered. Stuart Ghertner resigned last year as director of Southern Nevada Adult Mental Health Services, which oversees Rawson-Neal, after the agency endured more than $20 million in budget cuts.
"You cannot just give someone who is seriously mentally ill a plane or bus ticket and a little food, and expect them to fend for themselves," said Ghertner, a psychologist. "On its face, that makes no common sense."
The investigation "suggests that a lot of people are not doing their jobs over there right now," he said. "Social workers, psychologists, the medical staff, the administrators. No one is attending to detail. It's as if no one is managing the cases."
The report by the Nevada State Health Division, which oversees public health care in the state, confirms allegations of "unsafe discharges" of patients from Rawson-Neal, the state's primary hospital for mentally ill people.
The report says investigators reviewed 30 recent patient files and found five cases, all during the first two weeks of February, in which patients were discharged without proper planning to ensure their safety. One of the cases cited clearly involves Brown, although he is not identified by name.
According to the report, that patient was in the hospital's psychiatric observation unit in early February for symptoms of "psychosis, auditory hallucinations and suicidal ideation." He was homeless and "at a high risk of psychosocial problems which included housing, living situation, isolation and social problems."
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