The psychiatric emergency room at Los Angeles County-USC Medical Center is so crowded that it violates patients' rights and puts them and staff members at serious risk for injury, according to doctors, nurses and a county grand jury report to be released this week.
Hospital officials acknowledged that they have been aware for at least a year that the eight-bed psychiatric emergency room at the West's largest public hospital regularly houses more than double the number of patients it is designed to accommodate. But these administrators contend that they haven't been able to fix the problem because the remedies are too costly and remain largely outside their control.
"It is nuts, and it's unacceptable," said County-USC chief executive Roberto Rodriguez, who discussed the cramped conditions in an interview before stepping down from his post last week.
Mental patients are left dangerously unsupervised, staff members say. Amid the chaos in the ER, one young psychotic man recently noticed a loose acoustic ceiling tile, hoisted himself into the crawl space above and fell through the ceiling into a nearby trauma patient holding area, said psychiatrist Catherine Ehrlich.
Psychiatric patients who need sensitive treatment are jammed together indiscriminately, Ehrlich added. She recalled a suicidal 17-year-old girl who had been raped cowering in the corner in a room full of older male mental patients who were there because police or relatives had judged them dangerous.
The grand jury report, obtained by The Times, finds that patient rights were violated and that the ER creates "unsafe conditions for patients, visitors and staff."
The report generally echoes the concerns of staff members such as Ehrlich. It is, in fact, the latest in a series of warnings to county officials about conditions in the psychiatric ER. The hospital was recently cited by state monitors and even the county's own Department of Mental Health for violating psychiatric patients' rights.
The grand jury findings arrive at a difficult time for the county's cash-strapped health system. The county's health director, Mark Finucane, departed last week after a tumultuous five-year stint. Rodriguez left as well. At the same time, County-USC, the system's flagship hospital, has been hit with complaints from doctors and nurses that patient care is compromised by dangerous delays in critical services and by poor leadership.
Grand jurors cite a number of woes in the county health care system, including the poor physical condition of its six public hospitals and problems in patient care. But the panel devotes the most space to the problems in County-USC's psychiatric emergency room, noting that these troubles are not shared by the three psychiatric ERs in other county hospitals.
The panel, made up of county residents, urges swift corrective action by county supervisors.
The problems have been brewing for several years. Since the Northridge earthquake shut a separate county psychiatric hospital building at the medical center, County-USC has made do with a tiny suite that often houses 20 patients or more.
The emergency room is designed as a pit stop for patients on the way to psychiatric hospital beds. But as the number of those beds for the uninsured has dwindled in the last decade, County-USC's psychiatric emergency room has had to house these patients for longer and longer periods--in some cases for more than three days.
Patients with insurance move out quickly because there is a surplus of private hospital psychiatric beds in Los Angeles willing to take them. Those who are uninsured often get stuck.
"We're begging for more resources and more beds," said Dr. Marius Campeanu, director of the psychiatric emergency room.
Police Are Often Called for Disturbances
Campeanu said he is haunted by the prospect that crowded emergency room conditions might harm rather than help patients and could lead to violence. As things stand, county police say, they are called to the psychiatric emergency room up to a dozen times a day to keep disturbances in check.
Campeanu recalled that two decades ago, when so many pregnant women were jammed into the hospital that some were giving birth in hallways, the county Board of Supervisors found enough money to place the mothers-to-be in private hospitals.
"We're facing a [similar] crisis," he said. "I hope the politicians and administrators will give us the resources to treat these people better."
For a year, doctors say, they have been unable to get those resources despite repeated warnings to administrators. Last summer, an internal hospital committee said in a report that the conditions in the psychiatric emergency room put patients and staff at risk and damaged the reputation of USC's psychiatric residency program.
In January, unions representing resident physicians and nurses sent petitions to hospital administrator Rodriguez urging him to correct what they termed "institutional malpractice."
Staff members said they were afraid of losing control over patients in such an environment. They cited a January incident in which a violent woman who had been strapped to a gurney was freed from her bonds after she fell asleep. When she awoke, she jumped a doctor who was busy drawing blood.
Patient care is also jeopardized, doctors said. "No one can deny that there are instances in the psychiatric emergency room where we maybe aggravate the conditions that place [patients] there," Campeanu said.
Ehrlich said it is not unusual for suicidal patients to ask doctors: "'Why are you keeping me here? This is not going to make me feel any less like killing myself." Ehrlich is vice president of the County-USC chapter of the Joint Council of Interns and Residents, an affiliate of the Service Employees International Union.
Hospital administrators said they are acutely aware of the ER crowding problem and are trying to fix it. They have ruled out constructing a new emergency room or adding onto this one because they say the price of complying with modern building codes in a 1920s-era hospital is too high. They note that there will be a more spacious psychiatric emergency room in a replacement hospital slated to open in seven years.
The immediate solution, Rodriguez said, would be to create more treatment centers for mentally ill patients outside County-USC--but that, he said, is something over which hospital officials have little control.
Since its psychiatric hospital was closed after the quake, County-USC has sent some indigent patients to other county and private hospitals, which have about 100 beds reserved for the uninsured. Officials say they are trying to contract for about 25 more beds. Last month, county supervisors approved a contract for about five beds at a neighboring private hospital.
Shortages of Beds Affect Other Patients
Still, there is a shortfall. And that means psychiatric patients are sometimes stashed on medical wards at County-USC, aggravating the shortage of beds for the patients who sometimes wait days in the regular emergency room.
The grand jury recommends that the county's Department of Mental Health come forward with more money for extra beds to alleviate the crisis.
In other findings, the grand jury notes that the county's six public hospitals, of which County-USC is the largest, are in poor physical condition and violate patient rights in ways that are not spelled out. The jury found that it is only when outside medical inspectors visit that the hospitals clean up their act.
Staff members at County-USC talk openly of scurrying to address problems before inspectors from the Joint Commission on Accreditation of Health Care Organizations arrive.
Bureaucratic stagnation and a cumbersome county budget process block internal reforms at the facilities, the panel writes. The county lacks a specific plan for how to provide medical care to residents, and its health department has several systemic problems, including a lack of leadership, the report says.
The jury recommends that supervisors lift a hiring freeze in the health department, despite facing an $884-million deficit in five years and is in the midst of contemplating severe cuts.
The panel warns in its report that the deficit will devastate the county health system, which is the safety net for the area's nearly 3 million uninsured residents.
Times staff writer Hector Becerra contributed to this story.
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