SACRAMENTO, Calif. - Since July 2008, Rawson-Neal Psychiatric Hospital in Las Vegas has transported more than 1,500 patients to other cities via Greyhound bus, sending at least one person to every state in the continental United States, according to a Sacramento Bee review of bus receipts kept by Nevada's mental health division.
About a third of those patients were dispatched to California, including more than 200 to Los Angeles County, about 70 to San Diego County and 19 to Sacramento.
In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from calendar years 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.
By last year, Rawson-Neal bused out patients at a pace of well over one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the nation.
CASE DRAWS ATTENTION
Nevada's approach to dispatching mentally ill patients has come under scrutiny since one of their clients turned up suicidal and confused at a Sacramento homeless services complex. James Flavy Coy Brown, who is 48 and suffers from a variety of mood disorders including schizophrenia, was discharged in February from Rawson-Neal to a Greyhound bus for Sacramento, a place he had never visited and where he knew no one.
The hospital sent him on the 15-hour bus ride without making arrangements for his treatment or housing in California; he arrived in Sacramento out of medication and without identification or access to his Social Security payments. He wound up in the UC Davis Medical Center's emergency room, where he lingered for three days until social workers were able to find him temporary housing.
Nevada mental health officials have acknowledged making mistakes in Brown's case but have made no apologies for their policy of busing patients out of state. Las Vegas is an international destination, and patients who become ill while in the city have a right to return home if they desire, the state's health officer, Dr. Tracey Green, told Nevada lawmakers during a hearing last month.
She and others insist that the vast majority of patients they are discharging to the Main Street bus station are mentally stable and have family members, treatment programs or both waiting for them at the end of their rides.
That was not true in Brown's case. His papers from Southern Nevada Adult Mental Health Services read, "Discharge to Greyhound bus station by taxi with 3 day supply of medication" and provided a vague suggestion for further treatment: "Follow up with medical doctor in California." Brown said staff at Rawson-Neal advised him to call 911 when he arrived in Sacramento.
Nevada Health and Human Services director Michael Willden told lawmakers last month that while health officials "blew it" in their handling of Brown, an internal investigation found no pattern of misconduct.
But an investigation by the Nevada State Health Division documented several other instances from a small sampling of cases in February in which the state hospital violated written rules for safely discharging mentally ill patients.
Other apparent violations surfaced during the Bee's investigation.
At least two patients from the Nevada system arrived in San Francisco during the past year "without a plan, without a relative," said Jo Robinson, director of that city's Behavioral Health Services department.
"We're fine with taking people if they call and we make arrangements and make sure that everything is OK for the individual," Robinson said. "But a bus ticket with no contact, no clinic receptor, anything, it's really not appropriate."
Robinson said she viewed the practice as "patient dumping," and has reported it to federal authorities. "It's offensive to me that they would show this lack of care for a client," she said.
Nevada mental health officials did not respond to repeated requests for phone interviews for this story, nor would they address a list of emailed questions about the origins of the busing policy and the safety protocols in place.
Southern Nevada Adult Mental Health Services, the agency that oversees Rawson-Neal, maintains detailed written policies for transporting patients "to their home communities," with the stated goal of providing more appropriate care by the most economical means possible.
The policy includes a special section on "Travel Nourishment Protocol," specifying the number of bottles of Ensure nutritional supplement the patient should receive for his or her bus trip - essentially six per day.
Staff members are supposed to fill out a "Client Transportation Request" form, which includes questions about whether the patient is willing to go, whether housing or shelter has been verified, and the cost of the trip.
The written policy calls for staff to confirm that a patient has housing or shelter available "and a support system to meet client at destination." They are to provide information about "mental health services available in the home community."
Interviews with health officials in California and numerous other states indicate Nevada's practices are unusual. None of the 10 state mental health agencies contacted by the Bee said that placing a psychiatric patient on a bus without support would be permissible. And none recalled being contacted by Rawson-Neal to make arrangements for a patient coming from Nevada.
In California, where most public mental health treatment is overseen at the county level, agencies contacted by the Bee said they rarely bus patients and that Nevada's practices seem out of step with the standard of care. Several described the practice as risky, even if patients have someone waiting for them at the end of their journeys.
"Putting someone whose mental illness makes them unable to care for themselves alone on a bus for a long period of time could be absolutely disastrous," said Dorian Kittrell, executive director of the Sacramento County Mental Health Treatment Center.
Patients could suffer relapses during their trips and potentially harm themselves or other people, said Kittrell and others. They could become lost to the streets or commit crimes that land them in jail.
Southern Nevada Adult Mental Health Services has had an ongoing contract with Greyhound since July 2009, said bus company spokesman Timothy Stokes.
Stokes said he was unaware of any serious incidents involving mentally ill patients from Nevada.
"We take it on good faith that the organization is going to make certain that patients are not a risk to themselves or others," he said.