Report: Patients Harmed at Mental Hospitals

The state mental hospitals in San Bernardino and Atascadero are plagued by widespread problems, including inadequate diagnoses and treatment, improper and excessive medication, and a boilerplate approach to care that leads to unnecessarily prolonged hospitalization, according to scathing investigative findings released Thursday by the U.S. Department of Justice.

Investigators also found that San Bernardino’s Patton State Hospital suffered from high rates of patient-on-patient violence, repeated suicide attempts by hanging and care so inadequate that visible signs of irreversible side effects from psychotropic medications had escaped notice.

The findings were made public two days after federal officials sued California’s mental hospital system and filed a detailed consent decree designed as a court-monitored road map for reform over the next five years.

Although only Metropolitan State Hospital in Norwalk and Napa State Hospital in Napa were named in the lawsuit and consent decree, federal and state officials say both documents will be amended to include Patton and Atascadero State Hospital in the corrective plan.

The litany of systemic breakdowns did not surprise hospital administrators or state Department of Mental Health officials. Rather, they are many of the same problems detected by federal investigators when they visited Metropolitan in 2002 to launch the first of four civil rights probes.

Rather than wait for the federal probe’s findings, state officials promptly hired a former U.S. Justice Department consultant to help them convert California’s outdated system to a new model of care that involves patients more actively in their recovery.

“For the last two years, we were basically doing what we thought would meet their needs,” Patton Executive Director Octavio Carlos Luna said of federal justice officials who are charged with safeguarding the constitutional rights of mental patients. “Basically now they are fine-tuning the direction they think we should be going.

In a statement, Atascadero’s clinical administrator, David Bourne, called the findings “painful when balanced against what we believe to be our good reputation,” but “an important milestone” that would help improve the hospital.

Patient’s rights advocates were cautiously optimistic that the federal attention would lead to reform. “The consent degree, at least on its face, is a positive step and these investigations are a positive step,” said Matt Fishler, a staff attorney with Protection & Advocacy Inc., a state contractor that advocates for mental patients’ rights. “The key is going to be how it’s implemented and what kind of oversight there’s going to be.”

The bulk of patients at Atascadero and Patton have entered through the criminal justice system. While many are docile, others are violent or sociopathic, presenting a challenging patient mix. The system has also been struggling with staff shortages and forced overtime, a burden that investigators noted in their report on Atascadero.

Despite the concerted efforts at reform, the investigative findings show just how far the hospitals are from meeting accepted standards of care.

Among them: initial assessments are “cursory and not individualized,” and lead to inappropriate prescriptions and treatment planning; pharmacy, nursing and other services are subpar; and inappropriate sexual relations occur between patients and staff.

Rather than tailoring treatment to individual patients, the findings noted, Atascadero focuses on “symptom reduction,” contributing to “a perpetual cycle of chronic disability and repeated hospitalization.” Short-term medications to control behaviors are administered in place of treatment, and rehabilitative therapy “is essentially diversionary, such as playing ‘bingo.’ ”

Although the report praised many staff as “dedicated,” it chided the medical and psychiatric departments for excluding other professionals -- such as psychologists and other therapists -- from diagnoses and treatment decisions. It also said nurses often lack knowledge of mental health diagnoses and move between units so often that they are not familiar with individual patients.

Gregory Peters, 48, a former Atascadero patient who has been moved to the state’s newest facility at Coalinga, welcomed the findings and consent decree.

“We’ve been working a long, hard time on this,” he said. “They overused the seclusion room for a control mechanism for people who were just not going along with the program. They overused the restraint room for the same thing. ... They put mental disorders on you that aren’t even close.”

The findings revealed seemingly deeper and more harmful breakdowns at Patton, including a long-standing problem with illegal drugs and inappropriate sexual conduct, and cursory psychiatric assessments that routinely lead to misdiagnoses.

Vulnerable patients are “on high doses of psychiatric medications without a diagnosis that would justify such use, nor any evidence that the prescribed dose provides any benefit to the patient,” the report noted.

Investigators were startled in December when they observed Patton patients with tardive dyskinesia, a generally irreversible side effect of long-term use of haloperidol and other psychotropic drugs. Symptoms can include grimacing, tongue protrusion, rapid blinking, and movements of arms and legs.

Hospital staff “failed to detect these symptoms and even consider prescribing other medications with less harmful side effects,” they wrote.

Luna said investigators brought only one such patient to his attention, though he said, “One is too many. We’re setting up systems to review that.”

Investigators also noted that short-term medications were repeatedly used “as a form of chemical restraint, but without the documentation and monitoring that use of chemical restraint requires.” Physicians were often not notified of the medications, even though some patients received them every four hours.

The frequency of such medications is now being monitored more closely systemwide, Luna said.

Perhaps Patton’s biggest problem, however, was safety, with more than 500 patient-on-patient assaults noted in the six months before the December investigative visit, two 2005 homicides, and a series of suicides and suicide attempts by hanging “that appear to be part of a trend.”

Luna said staff in the last month had begun moving wardrobe lockers in the bedrooms to more visible locations, because patients had used the furniture to hang themselves or as cover for assaults. The lockers, he said, would be replaced with shorter ones.

Still, investigators criticized the hospital for its lack of insight into such problems. Investigations merely document harmful incidents, rather than explore their cause, the findings noted. They also routinely exonerate staff members, a result that investigators said “strains credulity and suggests that such reviews are not reliable.”

Investigators even criticized Patton’s attempt to shift to the so-called “recovery model” and use cutting edge “treatment malls” where patients attend a range of vocational and life-skills classes as a means of self-empowerment. The classes often do not address patients’ specific needs, patients are sometimes assigned to classes they did not select and class leaders lack training, the report noted.

Patients who refuse to participate are sent to the “enhancement room,” a crowded enclosure where they are required to sit in chairs without any activity for the duration of the session.

“This is not therapeutic and may aggravate the condition of patients already in distress,” investigators noted.

Still, Luna called the findings “as positive as a negative thing can be.”

“Up to this point we’ve been working on what we think we ought to be doing,” he said. “Now we have some rules to focus on.”