A day after that evaluation, a physician ordered him discharged "to Greyhound bus station," with three days' medication and enough snacks and Ensure to get him to Sacramento.
The facility violated state policy by failing to document where he was to live or get care in California, the report states. "There was no documented evidence in the medical record that indicated how the patient could access mental health services," find a psychiatrist or other physician, or locate a place to live, it says.
Since his arrival in Sacramento on Feb. 12, Brown has bounced around among hospitals, clinics and boarding homes. He now is safe and receiving treatment, officials have confirmed.
The Nevada health division report detailed several other instances among the files reviewed in which it found Rawson-Neal to have violated discharge or nursing policies.
In one, a diabetic patient who also had bipolar disorder was bused to Oklahoma without documentation about where to receive treatment in Tulsa, or medication and monitoring equipment for his diabetes. The Ensure supplement that he received was not a healthy choice for someone with diabetes, a nurse told investigators.
Another patient with a diagnosed "mood disorder" was placed on a bus to Boston at his request, according to facility records. But the report noted that his discharge orders failed to document "the quantity of Ensure to be provided" for the trip, a problem identified in eight of the 30 files reviewed.
Similar issues were noted for a patient bused to Los Angeles.
The report does not address whether any of the patients arrived safely at their destinations or received treatment.
"There is no doubt in my mind that those numbers could be multiplied by many times," said Darrell Steinberg, California's state Senate president pro tem, who has called for a federal investigation into Nevada's busing of mental patients.
"What are the policy implications here for possibly hundreds of others who are not accounted for?"
Nevada recently has made a practice of busing mental patients out of state. The state sent 99 psychiatric patients to California between July 1, 2012, and the end of February, Nevada health officer Tracey Green told state lawmakers during last month's hearing. She said 81 percent were California residents who wanted to go home.
By contrast, an official with Arizona State Hospital told The Bee that facility has not sent a patient out of state by bus in recent memory. Oregon State Hospital discharged one patient to family in California between July 2012 and January, according to a hospital spokeswoman.
The federal Center for Medicare and Medicaid Services is working with Nevada authorities to investigate the state's treatment of mental health patients.
Although the agency has the authority to pull funding for lack of compliance with federal rules, it does so only in extreme cases, said spokesman Jack Cheevers. The penalty is potentially severe, as hospitals receive between 30 percent and 70 percent of their funding from federal programs.
"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. On its face, that makes no common sense. ... It's as if no one is managing the cases."
A psychologist and the former director of Southern Nevada Adult Mental Health Services. He resigned last year after the agency endured more than $20 million in budget cuts. Call The Bee's Cynthia Hubert, (916)321-1082
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