Troubles Abound at Psychiatric Hospital : Medicine: Patient’s family is suing the county over a death from a heart attack. In all, two have died from drugs and two committed suicide.

The last time nurses saw Carol Ann Gonzales alive, she was vomiting and screaming from a painful headache. When they checked in on her three hours later, she had suffered a heart attack.

None of her nurses at the county mental hospital in Ventura knew that the medication they gave her for schizophrenia could cause headaches, vomiting and cardiac arrest, state investigators found.

What’s more, the inpatient psychiatric unit lacked the proper equipment--a face mask, suction machine and defibrillator--to revive the 43-year-old woman, a state report showed.

Gonzalez’s family is suing the county and its psychiatric unit over the death in September, 1993. But the case is just one of many incidents that have plagued the troubled psychiatric hospital.

According to the state Department of Health Services:

In the past three years, two patients have died from drugs they received there. Two have escaped from the open-air hospital near Ventura County Medical Center and killed themselves. One suicidal patient slashed her wrist with a razor blade. Another was left with a cigarette lighter and burned her arm. A third swallowed a bed spring.

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In May, a former patient filed suit charging nurses strapped her down, failed to check on her for four hours and left her to urinate on herself.

In all these cases, state health department licensing inspectors and lawyers representing former patients have raised questions about the training and procedures the county unit is using.

“If you look at all of these reports, the common theme is, nobody is trained and nobody knows what is expected of them,” said Andrew Koenig, an attorney representing Rhonda Murrieta, the woman restrained for hours.

County officials defend the facility, saying state inspectors hold the staff responsible for an overwhelming maze of rules and regulations.

“We have four books of policies and procedures for the inpatient unit,” said Penny Matthews, who directs the county’s acute care services for the mentally ill. “There is no way every employee can know every policy.”

Complicating their task, she said, is the layout of the inpatient unit--built in the 1960s and never intended for the seriously mentally ill.

“It’s a big open space for them to wander in,” Matthews said. “The staff just really suffers with trying to keep up with them.”

That is little comfort to Sally Hubbard, whose 28-year-old daughter, Murrieta, charges that she was strapped down an entire afternoon without food, water or toilet facilities.

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The treatment Murrieta received at the hands of the mental health providers, Hubbard argued, is really no different from what society has shown her since she was diagnosed as a paranoid schizophrenic at age 20.

“It’s that stigma of mental illness,” Hubbard said. “If professional people can treat them that way, can you imagine how people who aren’t educated react?

“Why is it that we have to sue in order to change things?”

The building on Hillmont Avenue looks more like a school or a courtyard hotel than a psychiatric unit. Built in the 1960s, when the most seriously ill patients were locked away at Camarillo State Hospital, the inpatient unit features the open-campus setting in vogue among psychiatrists at the time.

Since then, evolving theory and declining state finances have released the mentally ill from state hospitals. Many live in the community, receiving medication and counseling from county mental health workers.

Those in need of acute care because of psychotic episodes or suicidal tendencies often end up in one of the 35 beds at the inpatient unit.

The building was never designed for this purpose. The rooms have waist-high windows and doors that cannot be locked from the outside because of fire regulations. The patients, then, are free to wander at all hours in the large, grassy courtyard.

The center erected a five-foot fence after a January, 1992, incident, in which a mentally ill patient stabbed a 90-year-old woman in the neighborhood.

Kevin Kolodziej, the patient, had actually escaped from the nearby Ventura County Medical Center, not the inpatient psychiatric unit. But the incident raised residents’ fears about their mentally ill neighbors.

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Mental health officials assured Ventura residents they were taking all precautions necessary to keep their patients in the psychiatric hospital.

Even so, two months later, 28-year-old Michael Merriman walked away from the center. He was found days later at the Ventura River bottom, where police believe he hanged himself.

Six months later, it happened again. A suicidal patient was seen climbing out his window and returned to the unit 15 minutes later. The next night, staff members noticed at about 2:30 a.m. that he was gone again.

“Probably outside” read the notation in his file, according to state reports. At 3 a.m. the file reported that he was not in bed or on the grounds. At 3:30, staff members called the Ventura Police Department.

It was too late. The patient was killed by a train at 3:25.

More than two weeks later, state inspectors found that the inpatient unit was still using sliding glass windows with screens that could be easily removed. The center secured the windows in the weeks that followed.

But the problems go beyond the patients who escape. Many of those who remain complain of neglect or mistreatment.

In many cases, state licensing inspectors agree. They have substantiated five of 15 complaints in the past 18 months and have three pending, according to state records.

Two of them involve deaths--that of Gonzalez and of a man who died in April after being administered drugs.

“We’re watching that facility very carefully,” said Lana Pembley, director of the licensing and certification office of the state Department of Health Services.

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The problems, she said, have never risen to the level where she considered shutting down the inpatient unit. But she has asked two teams of inspectors to work together in monitoring it.

In case after case, investigators have cited the hospital for violating its own policies.

For instance, the regulations require staff members to set up a psychiatric and medical care plan for every patient.

Yet inspectors found no evidence of such a plan for Gonzalez, despite the decision to use a drug with potentially dangerous side effects. Indeed, nurses said that they did not even know the side effects and that the information was not readily available.

The state report also found nothing to show that a registered nurse or physician had been informed about the severe headaches and vomiting that Gonzales experienced.

Another policy requires more intensive staffing for the high-risk patients. Yet state inspectors say records showed that Murrieta did not receive the attention she required when she was restrained at the center.

Matthews acknowledges that the center has had problems, but said that many of the state’s citations are for minor glitches.

In addition, the state reports recommend changes that the facility may already have performed.

Pembley agreed that could happen in some cases, but said the problems go beyond simple nit-picking.

The biggest weakness, she said, seems to be with the staff’s inability to assess situations and choose the best way to deal with crises. That incapacity could be a function of poor training, inadequate policies or a variety of factors, Pembley said.

She added that the unit seems to be improving and that many of the recent complaints have been disproved. The death in April, she said, seemed to be a medical error, rather than a staff policy mistake.

Matthews said administrators have been trying to simplify the myriad policies and ensure that subordinates have up-to-date training.

Staff members, though, are waiting for the day the county builds its new inpatient unit.

With funding already approved by the state, the county hopes to break ground on the 43-bed center in December and complete it by 1996. It will have doors that lock and courtyards insulated from the outdoors.

Staff writer Miguel Bustillo contributed to this story.