Where Abuse May Easily Breed

While California has all but emptied state hospitals of the noncriminal mentally ill, 4,700 people with schizophrenia and other severe mental disease are housed in privately owned asylums where patient abuse and neglect are all too common.

Although oversight is spotty, the state Department of Health Services has issued 200 citations and fines against 35 of the 45 facilities certified to care for mentally ill people since 1992, the year California began moving the bulk of the last noncriminals out of state hospitals. Eight homes amassed half those citations.

Nevertheless, counties trying to save money by avoiding the high cost of state hospitals rely on the private locked facilities to care for ever more troubled people. At some, workers lack training to handle tough patients and can be paid as little as $6.50 an hour, less than teenagers who bag groceries.

Violations have included open sewage near patients and tap water that was too hot; staff failure to stop residents from harming themselves or attacking others; and workers assaulting and sexually abusing people under their care.

In addition, since 1992, citations and fines have been issued in the deaths of 23 patients. There have been six suicides and a homicide. Several other deaths were attributed to staff neglect.

One of those who died was James Foley.

At least operators at Skyview Memorial Lawn in Vallejo thought that was his name when they spread his ashes in a rose garden, with no marker. For many of the 27 years he spent in state hospitals, private sanitariums and jails, authorities believed that he was Edward Heath, though he used other names too.

He had no known next of kin. His parents died when he was an infant. He was raised in foster homes in San Francisco and dropped out of school in the ninth grade. A chronic schizophrenic, he died at a Vallejo nursing home in January of fecal impaction, after complaining of pain for two weeks.

Simple Economics Sway Placements

“This was not a rocket science medical problem,” said Dr. Jerome Lackner, who was chief health officer for California during Gov. Jerry Brown’s administration and read Foley’s file at The Times’ request. “The remedies are small and not expensive. It requires that you care, and that you have an ability to add two and two to get four in terms of the diagnosis.”

When California was paying the tab, people like Foley would have been confined to state institutions, probably for life. Counties can keep patients in state hospitals now. But they must pay $130,000 per patient a year--more than three times the cost of a bed in most privately run wards.

So simple economics lead counties to place their most severely ill patients in private facilities licensed by the state.

Despite the reliance on such operations, state officials cannot say for sure how many mentally ill people are housed in California’s 1,425 licensed nursing homes. Estimates range from 7,000 to more than 10,000.

Among those homes are 45 locked, long-term facilities that have state-certified treatment programs and house about 4,700. The Department of Mental Health certification means that the owners offer some specialized therapy. In exchange, they receive the going state rate for housing indigents in nursing homes--about $90-$95 a day per patient--plus an extra $5.72 per patient per day, an amount that has not changed since 1985.

Ten of the 45 specially certified treatment facilities have received no citations since 1992. But eight have a combined 111 citations.

“I wonder why some of those places are still open,” Dr. Richard Elpers, past mental health director in Orange and Los Angeles counties, said after reviewing the citations at The Times’ request. “I think this is the tip of the iceberg.”

‘I Don’t Have Any Excuses’

View Heights Convalescent Hospital in South-Central Los Angeles has received the most citations, 26, including sanctions for three deaths and an incident last year in which a staff member had sex with a patient, promising money and cigarettes in exchange.

“I don’t have any excuses for anything that happened,” said View Heights’ administrator, David Elliot. He said the 163-bed facility has improved in the year since he arrived. But he also described a job that is not easy.

“This facility has a lot of tough people,” he said of the patients. At the same time, county funding allows the facility to pay its nursing assistants only $6.50 to $6.80 an hour, he said, while counselors receive $8 to $10 an hour.

“We’ve been trying to get more [county money] so we can hire more people,” Elliot said.

Although some facilities pay more than View Heights, wages and training at private homes still lag behind those at state hospitals. At the hospitals, psychiatric technicians must have passed an 18-month college course and are paid as much as $20 an hour. That’s more than some nurses are paid at private facilities.

Dr. H. Richard Lamb, professor of psychiatry at USC, has studied such facilities and concludes that some receive patients who are more difficult than they are equipped to handle.

“You can’t provide the kind of care many of these people need at a facility that is being reimbursed at that level. You just can’t do it,” he said.

Fines levied by the state range from a few hundred dollars to $30,000. Citations involving deaths generally bring the highest fines. In virtually every case, the facilities dispute the findings. Most fines are reduced after appeals to a health department panel or to the courts.

The state health department keeps no central repository of citations it issues. However, California Advocates for Nursing Home Reform, a nonprofit group in San Francisco, gathers the documents, and permitted The Times to cull through its files.

Death After Drug Overdose

The 23 deaths that resulted in citations against the specially certified facilities included one homicide in which a patient beat another to death at a facility in Alameda County. The county pulled its residents out in 1997 and the facility closed.

Among the other deaths:

* Herman Nelson died Jan. 14, 1992, at View Heights after he was given an overdose of Thorazine, an anti-psychotic drug that heavily sedates patients.

Nelson was born 28 years earlier at Napa State Hospital, where his mother, who suffered from mental illness, was confined. Through his teens and early 20s, Nelson was in and out of locked facilities, including Camarillo State Hospital and Metropolitan State Hospital in Norwalk.

His sister, Verrell, held out hope that he would recover. “Where there is life, there is hope,” she said. She would visit her brother regularly, delivering clothes that were smartly pressed, and take him to lunch. He’d call on Wednesdays to confirm their Friday dates.

In one of those calls, he told her: “You better get me out of this place; these people are trying to kill me,” she said. “I didn’t take it seriously--until it did come true.”

The state fined View Heights $25,000, concluding that it failed to properly administer medication, “specifically, the injection of Thorazine in doses unknown.” View Heights appealed, persuading a hearing officer to reduce the fine to $12,500.

* Carlos Asencio, 26, stood 5-foot-6 and weighed 238 pounds. On May 31, 1996, at Royale Health Care Center in Santa Ana, he lashed out at a nurse when the staff tried to persuade him to take a shower.

As many as seven staff members struggled to subdue him. To keep him from biting, they wrapped a towel around his head. In the struggle, he vomited and choked and his heart gave out, partly because of “poisoning” from an anti-psychotic drug, the Orange County coroner ruled.

The state fined Royale $10,000, saying the staff should not have used a towel to subdue him. Royale ultimately paid $6,500.

“We will not be able to discuss any issues of that situation, due to the confidentiality and sensitive nature of the situation,” a Royale spokesman said.

Homes with special certification were not the only ones where patients died. Frederick W. Richardson died Dec. 5, 1997, at Miller’s Progressive Care in Riverside, a locked nursing home. An autopsy showed that he had ingested rocks, rubber bands, string, AA batteries, washers, nuts, bolts, pens, pencils and paper clips--8 pounds in all.

Concluding that the home had failed to take adequate steps to guard against such behavior, the Department of Health Services imposed a $10,000 fine. An appeal is pending. The nursing home operator declined to comment, citing pending lawsuits.

California Mental Health Director Stephen Mayberg, who also reviewed the citations compiled by The Times, said he was taken aback by instances of staff abusing patients. He requested that all counties review their policies about placing individuals in some of the homes.

“The most troublesome was the physical and sexual abuse,” he said. “We need to address that immediately. We have a zero tolerance. When the institution causes people to get worse, that is upsetting.”

Additionally, Mayberg requested that the Department of Health Services begin sending him copies of all future citations.

State health investigators spend the bulk of their time inspecting the far more numerous nursing homes that care for the elderly. Some of those homes have lengthy records of citations too, often for neglect. But at facilities for the mentally ill, inspectors find more violence among patients and more abuse by staff.

“In these places, the abuse is active--citations for sexual battery or fights, pushing, hitting,” said lawyer Prescott Cole of California Advocates for Nursing Home Reform. “These facilities are not being maintained.”

Obstacles to Finding Out About Violations

Few experts believe that the state finds out about every incident. Investigations are difficult. Violations occur behind locked doors. Patients are less than competent witnesses.

The difficulty of such investigations became apparent at Monterey Care Center, a nursing home in Rosemead without a certified treatment program. An incident occurred in August 1998, but did not come to authorities’ attention until 10 months later, after a staff member mentioned it during an inspection.

According to the citation, three patients--a woman and two men--were having sex. That’s not against state regulations. But in this incident, investigators alleged, two nurses aides and one nurse looked on. One staff member allegedly went so far as to coax patients into having different types of sex. A staff member reported the scene to a supervisor, only to be threatened by staffers who had participated, the citation says.

When inspectors questioned the patients, they could not recall the incident, said Ernest Pooleon, a state health official who oversees nursing home inspections in the San Gabriel Valley. Adding to the difficulty, he said, is the fact that regulations on such conduct between staff and patients are unclear.

“You know there is something wrong with this picture,” he said. “But if you look for a regulation, it is not there per se.”

As investigators looked into the incident, Monterey Care Center’s owners fired the staff members involved and brought in a new administrator, Marcel Morales.

“We did everything we could to correct this issue and to make sure that nothing like this ever happens again,” Morales said. “. . . We do have residents who are able to engage in a variety of activities, any type of activity they wish. They have the right to do so. Perhaps the individual staff members didn’t act professionally about it.”

Investigators fined Monterey Care $5,000, charging that the center failed to notify the state about the incident and that the staff’s actions “had a substantial probability that serious physical harm could have resulted to all three residents, especially [the woman].”

Monterey is contesting the fine.

An appeal also is pending in the death of James Foley.

Mental health officials in San Francisco, who were responsible for Foley’s care, would not discuss his case. However, Superior Court Judge Laurence Kay, alarmed by the death, unsealed Foley’s files at The Times’ request.

‘Inadequate Care . . . Led to His Death’

When he was not in locked wards, Foley would wander through San Francisco and run into trouble. His arrest record from the 1970s and early 1980s spans seven pages--burglary, begging, drug possession, and, in one instance, molesting a 3-year-old boy in a public restroom, though he was not sane enough to stand trial for that crime.

In 1992, Foley was on his 11th and final stay at Napa State Hospital. He would cover his ears to keep from hearing voices. He wore a soiled cap, and had long hair and a scraggly beard, often damp with drool. Caseworkers had modest goals for him. They hoped he would improve so he could be sent to a private locked facility.

As late as September 1992, however, a state physician wrote that Foley had “not achieved the discharge criteria,” and a county caseworker described him as “angry, hostile and suspicious.”

Nevertheless, facing fiscal pressure, San Francisco moved Foley in November 1992, first to a place in San Jose, then in 1995 to Crestwood Manor in Vallejo, owned by Crestwood Behavioral Health Inc., a Stockton firm that operates several facilities in California.

Although San Francisco mental health officials would not discuss Foley, they praised Crestwood, as did other county mental health officials who send patients there.

“The Crestwoods in comparison fare better than a lot that are out there,” said Liz Gray, who helps oversee long-term patients for San Francisco.

At Crestwood, a pleasant-looking place on a hill above San Pablo Bay, Foley rarely joined group therapy, and didn’t shower unless staffers told him to. He had no visitors other than caseworkers.

He came to the attention of state health investigators only after he died. They chronicled his final days in a citation assessing a $30,000 fine, one of 11 against the home since 1992. The chain has appealed. Crestwood executives did not respond to requests for interviews.

For two weeks in January, the three-page citation says, Foley complained of cramps. The cocktail of drugs he was prescribed to quell his psychosis had side effects, one of which was constipation.

By Jan. 19, Foley was too ill to get out of bed. Nurses responded by giving him Maalox, according to the citation. By midmorning, they realized an emergency was at hand. Paramedics arrived and rushed him to a hospital across the street. But his pulse had stopped.

The Solano County coroner listed the cause of death as large bowel obstruction, due to fecal impaction.

Lackner said nurses should have monitored Foley’s bodily functions more closely, and should have called a doctor when he continued to complain of pain. It was “inadequate care that led to his death,” Lackner said. “He didn’t die of anything else.”