State Audit Assails Edgemoor, Mental Hospital

Despite recent improvements made by the county, the health and safety of patients at Edgemoor Geriatric Hospital and the San Diego County mental health hospital in Hillcrest may be in danger, a state audit released Wednesday said.

Adding his voice to a chorus of criticism already heaped upon the county’s Health Services Department, state Auditor General Thomas Hayes said three recent deaths of patients treated at the mental health hospital “may have been preventable.”

In addition, Hayes said in the 25-page report, the county’s General Services Department has taken far too long to make critically needed repairs at Edgemoor, the aging and deteriorating Santee hospital.

Although the county has already corrected many problems pointed out by the state Department of Health Services and has plans to correct others, state regulators need more power to oversee the county’s handling of the mentally ill, Hayes said.

County officials were quick Wednesday to criticize the state audit, charging it fell short of the county’s own efforts to find problems and correct them.

The report “identifies virtually no new problems,” Chief Administrative Officer Clifford Graves said in a prepared statement released by a spokesman.

Supervisor Susan Golding, who has taken a lead role on county health issues, also said there was little that was new in the audit, but she said she welcomed it anyway.

“We have problems,” Golding said. “It doesn’t take the auditor general to tell us that. But I don’t mind being told again.”

Assemblyman Larry Stirling (R-San Diego), who called for the audit and has carried on a running feud with the county over its handling of health services, said the report confirmed allegations made to him by employees at the two institutions. He said the audit would help prod the county into making improvements.

“I think it’s outrageous that when something is reported, the county denies it, and then when someone confirms it, the county says it’s old news,” Stirling said. “Of course it’s old news, but why did it take almost the entire press corps of San Diego County and the work of three state agencies to get the county to recognize they were killing people?”

Stirling repeated his call for the firing or resignation of Graves and James Forde, director of the Department of Health Services.

The three deaths involving CMH, as the 92-bed emergency mental health hospital is known, included a suicide, a homicide and a drug overdose, the report said. The county said the cases are among several referred to the San Diego County Psychiatric Society for review.

In September, 1984, the report said, a patient who had earlier been admitted to CMH for threatening suicide was taken to the institution by police after threatening to jump from the Coronado Bridge. CMH determined the patient was not suicidal and refused to admit her. She jumped to her death from the bridge 12 hours later.

The report quoted the former medical director at CMH as saying that “people say they are going to kill themselves all the time; if someone really wants to kill (himself), there isn’t much that we can do about it.”

In another incident, a patient brought to CMH on a Friday night in January strangled his hospital roommate the following Monday. Because of inadequate weekend staffing, the report said, the patient was neither seen by a psychiatrist nor given medication for 56 hours after his admission to CMH.

The third case involved a man who was brought to CMH in March by the National City Police Department. The patient, diagnosed by a psychiatrist as intoxicated, was placed in a seclusion room and restrained to a bed at 2 a.m. He was found dead about four hours later, apparently from an overdose of methamphetamine he had taken before he was brought to CMH.

At Edgemoor, the audit said, the county has taken too long to respond to requests for repairs, including the removal of overhead sprinkler pipes used by a mental patient to hang himself in February, 1984. Although county supervisors recently approved funds to make the repairs, the pipes remain exposed, the report said.

A September, 1983, request for the installation of an electronic system to allow clients in seclusion to summon nurses has still not been fulfilled, the report said, and locks to prevent mental patients from walking into a room where medication is kept were installed seven months after they were requested.

Hayes recommended that the Legislature give the Department of Health Services the authority to issue citations and levy fines against facilities such as CMH. The department now has that authority over so-called “skilled nursing facilities” such as Edgemoor.

Stirling said he plans to introduce legislation to provide state regulators that power over mental hospitals.