Years before a Las Vegas psychiatric hospital bused a homeless, schizophrenic man to Sacramento without arranging contacts or a plan for care, a different hospital ditched Gabino Olvera on Skid Row in Los Angeles.
Olvera, homeless and paraplegic, still dressed in his hospital gown and connected to a catheter bag, was found dragging himself along a gutter in 2007.
The case and others like it motivated the city of Los Angeles to adopt one of the toughest "patient-dumping" laws in the nation.
"It's just an abhorrent practice," said Gil Cedillo,a candidate for Los Angeles City Council and former state senator who played a role in shaping his city's law. "You can't just take someone from a facility and dump them downtown."
Multiple agencies, including the Los Angeles city attorney's office, are investigating whether Rawson-Neal Psychiatric Hospital in Las Vegas, Nevada's primary public mental health facility, has been systematically dumping patients across state lines for years.
A Bee investigation found that the hospital had bused roughly 1,500 psychiatric patients to cities across the nation over the past five years, a third of them to California. By policy, those patients were put on buses alone, with one-way tickets out of town, a small supply of medication and several bottles of Ensure nutritional supplement for the journey.
Nevada health officials maintain that the bulk of those patients were shipped to communities where they had family, friends or treatment waiting. Late last month, following The Bee's report, the hospital revised its policy to require psychiatric patients bused out of state to be accompanied by a chaperone.
But questions linger about the safety of the busing practice – both for patients and the public – and whether Rawson-Neal was routinely sending patients out of town without arrangements for their care and treatment. That was the case with James Flavy Coy Brown, the 48-year-old homeless man who was bused to Sacramento though he knew no one in the city and had never visited.
In response to The Bee's findings, the city attorneys in Los Angeles and San Francisco have launched probes into Rawson-Neal's busing practices. The U.S. Centers for Medicare and Medicaid Services, following its own investigation, cited the hospital for "systemic" problems that compromise patient safety and has put the facility on notice that it risks losing critical federal funding if the issues are not addressed.
The Joint Commission, an independent agency that certifies hospitals nationwide, is considering whether to pull Rawson-Neal's accreditation.
All of those investigations could result in steep financial penalties for Rawson-Neal and its umbrella agency, Southern Nevada Adult Mental Health Services.
But Los Angeles is the only agency that has announced a criminal investigation.
Los Angeles is able to take a hard line because it has an ordinance that defines patient-dumping explicitly and lays out criminal penalties for violations. Other agencies are making use of state and federal laws that apply more broadly to hospital discharge practices – often targeting emergency rooms – or that don't list specific penalties.
"Doesn't this represent to you a crime?" asked Los Angeles City Attorney Carmen Trutanich, soon after the investigation was launched.
Rawson-Neal bused about 150 patients to the Greyhound bus station near Los Angeles' Skid Row in the past five years, far more than were sent to any other city.
To build their case, Trutanich's investigators are searching for former Rawson-Neal patients to learn if the circumstances of their discharges violated the city's ordinance against patient-dumping. That ordinance says patients cannot be transported from hospitals to anywhere but their homes, or the location they give as their home, without written consent.
Investigators have contacted area homeless agencies and will interview Greyhound, the company that transported the patients.
They've also put up fliers across parts of the city asking anyone who has been discharged from Rawson-Neal to call investigators.
If the investigation ends like several others, the hospital could settle with the city, be forced to adopt stringent discharge protocols and pay a fine.
Alternatively, the case could go to court, potentially leading to a misdemeanor criminal conviction for the hospital or some of its employees, Trutanich said.
"This is 150 people allegedly on the streets of L.A.," Trutanich said. "We're already stretched as it is."
L.A. noticed in '07
The issue of patient-dumping caught fire around 2007 as Los Angeles homeless shelters noticed hospitals increasingly leaving patients on Skid Row.
Most of the hospitals accused of dumping patients were traditional medical facilities, not mental hospitals. Advocates for the homeless contended that the patients often still needed medical care – or something better to sleep on than a cold bench on Skid Row – when they were dumped.
After Hollywood Presbyterian Hospital, through a contractor, drove Olvera to Skid Row, the city attorney at the time, Rocky Delgadillo, launched a civil investigation that resulted in a $1 million settlement. Over the years, his office also reached large settlements with Kaiser hospitals andMethodist Hospital in nearby Arcadia.
The city worked with Cedillo to draft a bill introduced in the California Senate that sought to criminalize patient-dumping and impose large fines on hospitals that repeatedly engaged in the practice.
The bill was opposed by many hospitals, which argued that the penalties were onerous. The bill passed the Legislature but was vetoed by then-Gov. Arnold Schwarzenegger, who said existing law was strong enough to curb the practice.
Another bill by then-Assemblyman Dave Jones, D-Sacramento, did become law. It requires California hospitals to develop a plan in consultation with homeless services providers for discharging patients between counties.
It banned the transport of homeless patients who require services from one county to another county without written authorization from the agency that would be providing those services. But it did not set explicit penalties for violating the law.
"The purpose was to try to get hospitals to put in place policies for busing homeless people," Jones, now the state's insurance commissioner, said last week, adding that he believes patient-dumping has decreased since the bill passed.
Los Angeles wanted more. So it used Cedillo's bill as a template for a local ordinance.
"We realized there wasn't really a good statewide law that just dealt with the practice as it was being done," said Deputy City Attorney Michael Dundas.
The city law sets a penalty of up to $1,000 for violations. Los Angeles also began stipulating in settlements with hospitals that they adopt strict policies regulating patient discharges.
Other cities' strategies
Other agencies will take a different path toward investigating and possibly prosecuting Rawson-Neal.
San Francisco will pursue financial damages from Rawson-Neal if it confirms that public services were provided to patients improperly discharged to the city, said Matt Dorsey, a spokesman for the city attorney.
San Francisco is pressing, along with the city attorneys in Los Angeles and Sacramento, and county counsels in Alameda and Santa Clara counties, for a meeting with the Nevada Attorney General's Office to review discharge practices at Rawson-Neal.
Dorsey said San Francisco's civil investigation could make use of a federal law called the Emergency Medical Treatment and Active Labor Act, which requires hospitals to evaluate and stabilize patients before transferring them.
The federal Centers for Medicare and Medicaid Services are also investigating possible violations of that act.
Melissa Brown, supervising attorney in the Elder Law and Health Clinic at the University of the Pacific's McGeorge School of Law, said the federal law usually applies only to traditional emergency rooms, which could make building a case difficult.
But Rawson-Neal's practice of treating patients in an observation unit for up to 72 hours before admitting or discharging them could leave it open to prosecution, she added. Such a prosecution would hinge on whether patients left Rawson-Neal too soon.
Patients "have to be properly screened and stabilized," she said.
Nevada State Health Officer Tracey Green said last month that an internal review at Rawson-Neal showed that staff members consistently made informed decisions about when to bus patients.
"The clients are stable. They are ready for discharge," she said. "We see a coordinated discharge plan."
L.A.'s Trutanich said he hopes his investigators find nothing wrong with the hospital's discharges but that he is skeptical given the large numbers of patients sent to his city.
"To me," he said, "this is very base conduct."