Official acknowledges error with handling of mentally ill patient
March 16, 2013
Carson City, Nev. (AP) — The head of the Nevada Department of Health and Human Services has acknowledged that his agency "blew it" by discharging a patient from a Las Vegas mental hospital to a bus station before he turned up disoriented at a California homeless center last month.
The acknowledgement came at a legislative hearing Thursday, two weeks after the Sacramento Bee reported on the case of 48-year-old James Flavy Coy Brown, and after officials in two states called for a federal probe.
"Policies were not followed," said Mike Willden, director of the state agency. "We own it in this case. We blew it. We're taking corrective action."
Richard Whitley, administrator of the Nevada State Health Division, told lawmakers that officials are trying to determine who's responsible for letting Brown go to Sacramento, where he apparently had never been before.
The officials also have changed policy so two doctors must sign off on a patient discharge, Whitley said, and the director of the Rawson-Neal Psychiatric Hospital must sign off on out-of-state trips to ensure proper care is available at the destination.
Nevada health officer Tracey Green said psychiatric patients are allowed to go out-of-state after discharge if they like, but policy requires staff to ensure there is shelter and a support system waiting for them at their destination.
Staffers said Brown appeared confused and frightened when he arrived Feb. 13 at the Loaves & Fishes homeless center.
Discharge papers from Southern Nevada Adult Mental Health Services, obtained by the Bee, state, "Discharge to Greyhound bus station by taxi with 3 day supply of medication. … Follow up with medical doctor in California."
After he arrived in Sacramento, Brown contacted police, who told him to leave the center because it was closing for the day. The Bee said he stayed at an overnight shelter before returning to Loaves and Fishes the next day, and then was sent to the emergency room by bus.
Loaves and Fishes staffers have since lost track of him, and the Bee reports it doesn't appear he was ever admitted to the Sacramento County Mental Health Treatment Center.
The story prompted California state Senate President Pro Tempore Darrell Steinberg, D-Sacramento, to request a formal federal investigation into what he called Nevada's "Greyhound therapy."
"Interstate dumping of society's most vulnerable population is unconscionable and irresponsible," Steinberg said in a letter to U.S. Secretary of Health and Human Services Kathleen Sebelius. "Instructing an individual with schizophrenia to take a 15-hour bus journey to an unfamiliar city with insufficient medication and resources is a clear violation of the patient's civil rights, tantamount to abuse."
Mary Woods, spokeswoman for the Nevada health department, said her agency also requested the investigation.
Nevada officials contend there's no evidence of systemic patient dumping.
"This is not a widespread issue," Willden said in an interview with the Las Vegas Sun. "This is an isolated, rare incident where staff did not follow our policies."