Tuesday, May 7, 2013 | 2 a.m.
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 such as 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 Sacramento 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. 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," the nurse said.
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 Las 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 the 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 2012. 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 technician 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 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 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 after the investigation, and several others were 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 about 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, spokeswoman Leslee Rogers said.
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, Rogers said.
"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."