Federal review of Rawson-Neal Psychiatric Hospital criticizes improper discharge practices

A diabetic, mentally ill patient was bused to Oklahoma from the Rawson-Neal Psychiatric Hospital in February without medication or the equipment needed to check blood sugar levels during the trip.

It joins the much publicized case of former Rawson-Neal patient James F. Brown, who was bused to Sacramento, Calif., the same month and had no family or support services waiting for him.

Brown’s case and others involving improper patient discharges raised concerns that galvanized federal and state officials into examining practices at the Las Vegas hospital, which was inspected last week by federal investigators.

Those findings have not yet been released, but a 49-page report detailing a March hospital review by federal officials was released Wednesday by the federal Centers for Medicare and Medicaid Services. The March report detailed examples of poor practices, faulting the facility’s discharge planning and its inadequate governing body.

The report says “the hospital failed to provide an appropriate safe discharge plan for patients,” a problem that was identified in an earlier review by Nevada officials. Hospital officials “failed to ensure a comprehensive discharge plan was implemented.”

The hospital must have a discharge planning process that applies to all patients, according to the report.

Investigators also found the hospital’s governing body, or administration, was not fully meeting its obligation to supervise staff and practices at the mental health care facility, said Rufus Arther, survey and certification branch manager for the western division of the Centers for Medicare and Medicaid Services.

The hospital’s governing body “failed to ensure the medical staff was accountable … for the quality of care provided to patients,” according to the report.

“The facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital.”

The problems with discharge planning and administration put Rawson-Neal out of compliance with two of 23 conditions that hospitals are required to meet to participate in Medicare, Arther said. Rawson-Neal received $3.2 million in Medicare funding in 2011-12.

On April 25, the federal centers sent a letter to the Southern Nevada Adult Mental Health Services, the agency that oversees Rawson-Neal, giving it 10 days to submit a plan of correction or risk losing its federal funding. The deadline was Monday.

Officials at the federal centers will now review the plan of correction to ensure that the proposed corrective measures will get the hospital back into compliance, Arther said. The hospital, at 1650 Community College Drive, near Charleston and Jones boulevards, will receive another unannounced visit from federal officials to determine whether the problems have been resolved.

If the state’s plan is not accepted, the hospital will be told to amend it, Arther said.

Federal officials also are conducting a separate survey of Rawson-Neal to see if it’s meeting requirements of the Emergency Medical Treatment and Active Labor Act, which has its own set of conditions, Arther said.

Allen Lichtenstein, general counsel for the American Civil Liberties Union of Nevada, said the hospital has to do whatever it takes to ensure proper oversight at the facility. “The fact that is not taking place indicates a serious lack of public trust and responsibility,” he said.

On Tuesday, Brown and his daughter, Shotzy Harrison, 25, said they were starting to settle back into a normal life in South Carolina.

But he recalled wanting to stay in Nevada.

According to the report, the social worker assigned to Brown’s case reported calling an assisted living facility in Las Vegas, but the facility refused to accept the patient. The social worker “acknowledged no other group homes or assisted living facilities were contacted for possible placement in Las Vegas, Nev., prior to the decision being made to discharge the patient to Sacramento.”

Brown recalled being very scared. “I’ve never been in California,” he said.

Dr. Tracey Green, Nevada state’s health officer, said state officials are confident that the corrections being enacted will bring the hospital back into compliance.

“This organization has and will continue to identify all opportunities for improvement relating to the quality of services provided for the population it serves,” according to the hospital’s plan of correction.

Mary Woods, spokeswoman for the Nevada Department of Health and Human Services, said the plan details

“many activities already underway to strengthen policies, enhance over site, ensure compliance, formalize communications, increase staff training, monitor competencies, evaluate performance, and ultimately provide an improved service to our clients.”

The hospital has already implemented a new discharge policy that requires a second doctor to review a discharge plan before being approved by an administrator. Two Rawson-Neal physicians also were terminated for their involvement in cases of improper patient discharge. Three other staff members will be disciplined in the cases.

A national mental health expert arrived at Rawson-Neal on Wednesday and another one has been there since Monday, Green said. Both experts are with the National Association of State Mental Health Program Directors.

They will assess all areas of the hospital, including admissions and discharges, Green said, and will provide a report highlighting areas of improvement.

The state is using part of a federal grant to pay the $50,693 fee for the consulting services.

Contact reporter Yesenia Amaro at or 702-383-0440.

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