State investigation into patient ‘dumping’ finds three were unsafely discharged

A Southern Nevada state psychiatric hospital unsafely discharged three patients this year, including a homeless man who was given a Greyhound bus ticket to Sacramento, Calif., with nobody to help him in the city where he had never been before, according to a state investigation released Monday.

The case involving James F. Brown, the mentally ill man who disappeared after getting dropped off Feb. 13 in Sacramento, prompted the investigation by the Bureau of Health Care Quality and Compliance.

While conducting the monthlong probe, the bureau reviewed 30 medical records from Southern Nevada Adult Mental Health Services, which runs the Rawson-Neal psychiatric hospital in Las Vegas.

It concluded that in three cases — or 10 percent of cases reviewed — the hospital did not follow its own policies and procedures, which require doctors and social workers to ensure discharge plans include proper medication and follow-up care. The investigation also cited missing information in five other cases that suggested sloppy work.

In Brown’s case, the social worker acknowledged to investigators that the schizophrenic man was bused to Sacramento at his request, although no specific programs were set up to receive him. The social worker tried but failed to place Brown in a Las Vegas adult care home and so opted to send him out of state by Greyhound, the probe found.

The doctor who examined Brown acknowledged to investigators that he signed the discharge papers sending the patient on a 15-hour bus ride to California with a three-day supply of medication, although “he was aware the patient was homeless and had no family or contacts in Sacramento.”

In the second case, a suicidal patient with a mood disorder, substance abuse and alcohol dependence was discharged Feb. 11 after one day in the hospital without receiving any information about how to get help, including information about Alcoholics Anonymous and Narcotics Anonymous meetings, the investigation found.

In the third case, a patient with a history of drug abuse, diabetes and a bipolar disorder was discharged by Greyhound to his home state of Oklahoma for treatment. But investigators said there is no evidence the patient was discharged with insulin to treat his diabetes or was provided the address of the Tulsa treatment center.

“Based on interview(s), clinical record review and policy and procedure review, the facility failed to follow and carry out established discharge planning policies and procedures and discharge planning standards of care to ensure patients were safely discharged from the facility in three (3) out of thirty (30) patients sampled,” the 23-page investigative report concluded.

The Rawson-Neal psychiatric hospital is budgeted for 190 beds and has more than 8,000 patient discharges a year.

In the five cases that turned up minor discrepancies in paperwork, all involved providing patients with Ensure for nutritional needs during trips home, including two to California and one to Massachusetts. The other locations weren’t specified in the investigative report, which didn’t use names to maintain patient privacy.

Southern Nevada Adult Mental Health Services is expected to respond to the report with a plan to correct procedures, according to Nevada State Health Division officials. The state already has implemented some changes, including requiring the head of the Rawson-Neal hospital to sign off on out-of-state discharges.

In March, Nevada health officials acknowledged at a legislative meeting that proper discharge policies weren’t followed in the case of Brown after California accused Nevada of patient dumping.

“We own it. We blew it. And we’re taking corrective action,” Mike Willden, director of the Nevada Health and Human Services, told the Senate Health and Human Services Committee.

Contact Laura Myers at or 702-387-2919. Follow @lmyerslvrj on Twitter.

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