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Westside Observer  
June 2013 at www.WestsideObserver.com


Patient Dumping:
City Attorney’s Hypocrisy, Laguna Honda Hospital’s Shame
Who’s Dumping Grandma?

by Patrick Monette-Shaw

In an act of history repeating itself, the Department of Public Health (DPH) has proposed reconfiguring yet again San Francisco’s mental health rehabilitation facility and appears to be planning to place 34 of its “behavioral health” patients into Laguna Honda Hospital, possibly placing more psychotic patients into the mix with the frail elderly and disabled.

On April 20, San Francisco City Attorney Dennis Herrera launched an investigation into whether Nevada’s primary state psychiatric center, Rawson-Neal Psychiatric Hospital, had engaged in patient “dumping” by sending patients out of state using one-way bus tickets. A San Francisco Chronicle article on April 23 quoted Herrera as saying that the practice of psychiatric patient dumping is “shockingly inhumane and illegal.”

Herrera’s concern appears limited to in-bound patient dumping and the increased costs to San Francisco for caring for psychiatric patients. But Herrera has been strangely silent regarding out-bound patient dumping from San Francisco to other jurisdictions, and potential patient dumping between San Francisco facilities. His hypocrisy is breathtaking.

This is the same hapless Herrera featured in the article “High Costs of City Attorney’s Advice” in last month’s Westside Observer.

The Chronicle article also reported that Paul Boden, the director of a nonprofit that highlights civil rights abuses against the homeless, the Western Regional Advocacy Project, said “it’s a little hypocritical of San Francisco officials to feign shock at the Las Vegas hospital’s [patient dumping] practice when [San Francisco officials] too, hand out one-way bus tickets to homeless people.”

Given news that DPH is proposing to re-configure the Mental Health Rehabilitation Facility on the San Francisco General Hospital campus — which was renamed as the Behavioral Health Center in order to be politically correct — into a residential care and respite care facility, and transferring 34 “behavioral health patients” to Laguna Honda Hospital (LHH), the second question is whether history is repeating itself.

That’s because the first question that comes to mind involves whether transferring behavioral health patients to LHH is a form of patient dumping into a setting where they may not receive the appropriate level of mental health care.

Vanishing Mental Health Rehabilitation Facility

In May 2008, Westwide Observer columnist George Wooding reported in “Should Voters Trust the Department of Public Health?” that appeared in the West of Twin Peaks Observer that in 1985 voters approved a $26 million bond measure to construct a state-of-the-art 147-bed psychiatric facility — the Mental Health Rehabilitation Facility (MHRF) — on the grounds of San Francisco General Hospital. [Editor’s Note: The bond measure was actually passed in November 1987. The voter handbook said 185 beds — not 147 — would be built for a “mental health skilled nursing center,” and that the measure would end up costing $39.7 million, including interest on the bonds.] Wooding noted that it took 11 years before the MHRF was built and opened in 1996.

The November 1987 Prop. C measure was supported by then Mayor Diane Feinstein, then State Senator Quentin Kopp, and then City Attorney Louise Renne — who later formed but eventually dissolved her “Laguna Honda Foundation” after being ordered by the State of California to stop using Community Initiatives as a fiscal sponsor, since Renne simultaneously held official 501(c)(3) IRS non-profit designation — among a host of other supporters and members of now Mayor Ed Lee’s so-called “City Hall Family.”

They asserted that building the MHRF as a long-term care facility for the mentally ill would close a gap in San Francisco’s mental health care system, and would permit patients to remain near friends and families to facilitate recovery. Will Mayor Lee reverse course and widen that mental health system gap, by accepting DPH’s budget proposal? If he does, Mayor Lee will be no better than Governor Ronald Reagan who shut down California’s mental health hospitals in the 70’s, and ended federal community mental health centers while President in the 80’s.

The National Alliance on Mental Illness (NAMI) fought hard to pass Prop. C in 1987 to build the free-standing mental health facility at SFGH. Vivian Imperiale, a past president of NAMI San Francisco and NAMI California, says as a private citizen “We wanted our family members and friends to receive appropriate care here in San Francisco, rather than being shipped out-of-county making it difficult for visitors to travel. We won that when the MHRF was built. Part of the rationale was that we wanted skilled care, provided in-county, by specialists in the field.”

Imperiale subsequently worked as the Vocational Rehabilitation Coordinator at LHH for over a decade before retiring earlier this year.

Just seven short years after the MHRF opened, a so-called “Blue Ribbon Committee” split the three-story MHRF into multiple uses in 2003, reducing the 147 psychiatric beds to just 47 by 2008; Wooding noted many of the MHRF patients were discharged out-of-county. Now five years later, the DPH is recommending cutting the “Mental Health Rehab” psychiatric beds from 47 down to just 24.

Twenty-six years after voters approved the 1987 bond measure, it appears the $40 million investment has gone up in smoke, or was flushed down the toilet.

“To transfer this difficult population to LHH raises concerns,” Imperiale says. “Patients deserve to be treated by specialists — like those at the BHC — rather than by LHH staff who may bid on a unit solely for a better work schedule, new co-workers, or different patients. Expertise and passion for those with mental illness are not part of the bidding equation, and that cannot be altered due to the union process.”

“DPH’s plan to transfer so many of these patients to LHH is of great concern, particularly since LHH does not have a psychiatric license,” Mr. Wooding observes.

DPH Budget Plan

DPH budget initiative “B-1” for Fiscal Year 2013-2014 — apparently with the approval of San Francisco’s Health Commission — proposes to convert one wing of the third floor at the MHRF/BHC to add 23 “respite” beds by reducing the Mental Health Rehab beds from 47 to just 24. DPH claims the main purpose of the budget initiative is to add bed types that are in short supply in the City, and to improve so-called “patient flow” within DPH — mostly “flow” to Laguna Honda Hospital.

This ignores that psychiatric beds are also in short supply already in San Francisco, which will worsen if the Board of Supervisors approves DPH’s budget proposal to reconfigure the MHRF/BHC, creatively titled “reprogramming.”

During the City Planning Commission’s hearing on California Pacific Medical Center’s application for its Cathedral Hill Hospital project, the San Francisco Chronicle reported on May 24 that Planning Commissioner Hisashi Sugaya proposed an amendment to require that CPMC agree to maintain a certain number of psychiatric patient beds; he was rebuffed by fellow Commissioner Michael Antonini who didn’t “want to require changes to the agreement at this point.” [As a point of reference, the same battle is looming regarding CPMC’s continuing erosion of skilled nursing beds, and regarding the lack of sufficient dialysis services citywide, since the rebuild of SFGH doesn’t include dialysis in its new hospital.]

It’s painfully clear that our “City Hall Family” knows all too well about the cuts to psychiatric beds in San Francisco, but appear not to be doing anything to preserve them, while bleating about Nevada.

Of interest, although DPH claims it will “transition” the MHRF/BHC patients to the “least restrictive” community setting or to other skilled nursing facilities including LHH, Laguna Honda staff already report that 34 behavioral patients will be sent to LHH.

We’re back to the 2003-2004 “patient flow” debacle that resulted in the 2006 ballot measure to protect Laguna Honda Hospital for the frail elderly and disabled, which measure originated from the disastrous effects of violence that resulted by inappropriately mixing psychotic patients with elderly demented patients, two patient populations that rarely thrive well together. Mixing patients who need a locked psych unit in with patients who need a locked dementia unit in a single locked unit is a poor idea, and has been considered unethical for a long time.

Overall, the MHRF/BHC will go from 122 to 145 beds. DPH proposes closing the Skilled Nursing Facility (SNF) on the MHRF’s second floor and replacing it with a Residential Care Facility for the Elderly (RCFE), changing the 34 SNF beds to 57 RCFE beds, and converting single-rooms into shared two-person rooms.

Although DPH claimed there would be no change to the first floor, 22 of the 41 Adult Residential Care Facility (RCF) beds on the first floor will be re-licensed as RCFE beds. DPH asserts the 79 RCFE beds will be used for non-ambulatory patients. One wonders whether the 79 non-ambulatory beds are being created by slashing mental health programming beds, in part as an unintended consequence of the decision to eliminate 420 long-term care skilled nursing beds from the LHH rebuild project.

DPH asserts that any costs to provide “minor modifications” to architecturally remodel the MHRF for the change in use will come out of SFGH’s general facilities budget, presumably its facilities maintenance budget. We’ll see how long it takes for DPH to provide a budget itemizing the actual costs to remodel the facility.

DPH claims it is pushing this change to transition patients to the “least restrictive, most appropriate level of care,” and claims that the “mixed use” of the building was recommended by a Blue Ribbon Committee in 2003. Clearly, the Blue Ribbon Committee negotiated in 2003 to keep at least 47 of the Mental Health Rehab beds, so DPH may be stretching the truth.  DPH did not reconvene its 2003 Blue Ribbon Committee in 2013 to seek consensus — or even input — on further slashing services to convert the MHRF into, essentially, housing.

A decade later — without forming a new Blue Ribbon Committee or reconvening the initial 2003 Blue Ribbon Committee to re-evaluate this new change in building use — DPH is simply re-arranging deck chairs on the Titanic even further without concurrence of the initial Blue Ribbon Committee or anyone else, and is creatively twisting the 2003 mixed-use recommendation to turn the MHRF into any mixed use that the DPH may now want, any needs for in-county Mental Health Rehab beds be damned.

Battery Against SLHH taff

Alerted this April that LHH had accepted transfer of about 11 BHC patients during 2012 and that an Institutional Police Officer had informed SEIU members at LHH in October 2012 that assault cases at LHH had drastically increased, this reporter became concerned after learning that an LHH food service worker had been assaulted on the job in May 2012, subsequently required shoulder surgery following the battery, and has yet to return to work 10 months after being attacked. She was so badly beaten that SFGH emergency room staff who treated her were shocked by her injuries, including obvious emotional trauma.

She had entered a locked dementia unit at LHH — the North Mezzanine, which serves patients at risk of wandering, elopement, or harm — when she encountered a patient who was supposed to be being watched by a “sitter,” and was assaulted. The North Mezzanine unit has traditionally housed and cared for demented, but ambulatory, patients, a locked unit implemented to protect patient safety.

But LHH had placed behavioral health care patients on the North Mezzanine, possibly agitating demented patients. The patient who assaulted her was finally sent on a “5150” psychiatric hold to SFGH after going on another rampage. A separate patient who had been discharged from LHH to the MHRF was eventually readmitted to LHH, despite being a sexual predator.

On investigation, it turns out the injured staff member is now suing the City, possibly alleging negligence and mishandling of the situation following her assault and battery. The lawsuit appears to be sealed, most likely due to protect patient privacy, even though the patient has by report since died. As a reminder, assault is any reasonable threat of physical harm to another person; battery is actual physical contact and actual harm.

Her battery case may not be the only one, but her assault was a big deal in LHH. Multiple meetings were held to calm staff, and hospital administration spent a lot of money to have all employees go through SMART training — staff training presented by a licensed Psychiatric Technician on how to remain safe around violent patients.

SMART training is definitely not part of training typically provided to staff in long-term care skilled nursing facilities; it is more typically presented to staff working in psychiatric and mental health settings. The SMART training at LHH was introduced in 2005 to deal with its then-“new” patient population during the ruckus over implementing the “psycho-social rehabilitation” model of care exported to LHH when Mozietta Henley, RN, PhD was shunted from the MHRF to LHH, toting along her “BioPsychoSocialSpirtual (BPSS)” model of care proposal that was never tested — and never implemented — at the MHRF.

Henley’s model of care comically became the basis for a small California HealthCare Foundation grant Hirose was awarded for “Social Rehabilitation.” [I was there: Hirose’s January 2005 grant ended as a notorious flop, probably an embarrassment to the California HealthCare Foundation, and created a ruckus at City Hall.]

This followed on the heels of former Director of Public Health Mitch Katz’s nervous announcement on October 20, 2004 during LHH’s Executive Committee meeting that his “vision” was that LHH would become a “social rehabilitation facility for the homeless poor,” a statement the City soon denied had been made, but the cat was out of the bag since numerous LHH staff had heard Katz speak clearly. Previously, the not-too-esteemed Dr. Katz had lured the MHRF Blue Ribbon Committee into believing that the ”future LHH” would provide “the same kind of services as offered at the MHRF.” If the City accepts DPH’s proposal to reconfigure the MHRF and dump more psych patients into LHH, we’ll have come full circle to Katz’s prediction of offering MHRF services at LHH.

Uptick in Sheriff’s Statistics

Alerted that an uptick in assaults at LHH may have occurred between calendar years 2011 and 2012, this columnist placed a records request to the San Francisco Sheriff’s Department, knowing that asking LHH’s administrators for this data — in particular asking LHH’s Executive Administrator Mivic Hirose or her public information spin doctor, Marc Slavin — would have met with dead silence, no pun intended, if not endless delays and denials.

Data provided by the Sheriff’s Department on May 21 shows that between 2011 and 2012, battery incidents — by definition involving actual physical harm — increased at LHH by 18.2%, from 22 to 26 such cases, which is statistically significant. Across the same time period, “disturbances by resident” incidents summarized on the monthly Sheriff’s Activity Reports increased 227.8%, from 115 to 337 at LHH, and “disturbances by visitors” increased 309.4%, from 32 to 131 cases.

It’s no wonder that in October 2012 an Institutional Police officer from the Sheriff’s Department advised SEIU members working at LHH that assault cases had drastically increased.

Three Questions Lead to Bullying

Laguna Honda staff brave enough to ask questions are — like Drs. Maria Rivero and Derek Kerr before them — frequently targeted for retaliation. Indeed, the culture of staff intimidation was increased soon after Hirose was appointed CEO in 2009 and after Slavin came on board in 2007 to “stop the negative news about Laguna Honda” for his benefactress, former City Attorney Louise Renne. The intimidation was designed to silence and weed out any remaining staff who dared to question agendas that violated State laws and existing hospital policies.

Randy Ellen Blaustein, a therapeutic recreation therapist on the North Mezzanine unit who had worked at LHH for eight years, raised three questions about the mixing of ambulatory demented patients with patients having psychiatric diagnoses from the BHC transferred to the North Mezzanine. She and the physician assigned to the North Mezzanine raised concerns and protested placement of inappropriate patients, indicating the two patient populations don’t thrive well together because the behaviors of people with dementia agitate psychotic people, and then psychotic patients want to harm the demented ones.

Blaustein notes the North Mezzanine physician had complained to hospital administration about no longer being able to provide input to admission decisions to their unit, and protested inappropriate placements, but was ignored.

During a key meeting with hospital administration, Randy apparently asked three questions that landed her in a lot of trouble: 1) Why hadn’t LHH’s Administration honored its vow not to place residents with histories of physical aggression and violent behaviors on the North Mezzanine?; 2) Why did the unit no longer have input into admission processes?; and 3) Why wasn’t their unit granted a lower census, since they had been afforded that in the old facility, given their patient population?

Apparently, someone reported to her supervisor, Bill Frazier the Director of the Activity Therapy Department, that Randy had “overstepped boundaries; was negative and didn’t offer solutions; wasn’t supportive of the new LHH; and (gasp!), had insinuated that Administration didn’t know what they were doing.” Instead of supporting Blaustein, Frazier asked her to cease asking contentious questions in meetings. Randy says she had previously gotten into “trouble” for upsetting Dr. Colleen Riley, LHH’s Medical Director, in another meeting.

“With severe dementia, less is more. I’ve never heard of any other facility that places nearly 60 ambulatory people with severe dementia in the same living area, with psychotic people in the mix,” Blaustein says. “The North Mezzanine received new admissions that required 1:1 ’sitters’ at all times, because of their physically aggressive behaviors, placing other residents and staff at risk.”

After Clarendon Hall closed, LHH never re-created the three locked psych units that had been on the second floor of Clarendon. Many of LHH’s staff, including Blaustein, believe that’s, in part, why the new LHH is such a mess.

Another source reports that the staff member who was assaulted, subsequently required shoulder surgery, and is now suing, was assaulted by the North Mezzanine patient who was supposed to have a 1:1 sitter, but somehow got out of the inner door to the unit and attacked her before the outer door. So much for sitters.

Randy says that after being repeatedly bullied, she chose to resign. Shortly before she left in mid-December 2012, a discussion began to consider changing the admission criteria to the North Mezzanine from “dementia” to using “cognitive impairment,” but she doesn’t know the outcome of that discussion. Like many former employees — including this author — Blaustein still cares deeply about LHH’s residents and staff, and their safety.

Earnining His Comeuppance

Frazier appears to be his own worst enemy. Comeuppance was bound to catch up with him, since what goes ’round, typically comes back ’round. All staff at LHH are required to take sexual harassment prevention training annually. It was widely known throughout LHH that during his 15 years as Director of Activity Therapy, a number of complaints were filed against Frazier by subordinates for such things as sexual harassment, unequal treatment, and failure to comply with union agreements. It is unclear how LHH’s Administration responded to these voiced concerns, since the reported pattern was observed to continue from year to year.

The training may have been lost on him, since in early 2013 he was overheard screaming in his office at an Activity Therapist for over ten minutes, and allegedly called her a “selfish bitch” — clearly a sexist term that has no place in public service from a high-level public official.

This might have been brushed under the carpet as a “he said, she said” situation, except it was overheard and reported by a witness willing to come forward. This may have been the straw that broke the camel’s back, when Frazier suddenly vanished in February; some of his duties assigned to an acting director, and other duties split to other departments.

But a month after his disappearance — amid reports he would not be back — Frazier resurfaced in LHH’s Accounting Department in a newly-created position as “liaison” to Friends of Laguna Honda (formerly known as Laguna Honda Volunteers, Inc., the non-profit dedicated to LHH’s patients, that never needed for 50 years any “liaison” on LHH’s staff paid from taxpayer funds).

Frazier is — tah-dah — now in charge of LHH’s Patient Gift Fund, which should not be a 40-hour full-time job. It’s akin to having the fox guarding the hen house. That LHH created the position as a soft spot for him to land may mean the hospital is worried about potential shenanigans with the gift fund, or worried that he knew too much about the great gift fund scandal of 2010. After supervising approximately 40 staff for over a decade and a half, he no longer has direct reports or anyone to supervise.

Out of County, Out of Mind

As just one example of out-of-county patient dumping, consider the case of a middle-aged gay patron of the Cinch Saloon who suffered a stroke one evening while at the tavern, and was taken to SFGH where he languished for months. His close friends tried to get him admitted to LHH, but were rebuffed when told he needed “too much” physical rehabilitation therapy and couldn’t be sent to LHH. It’s well known that delays in receiving rehabilitative therapy following strokes leads to poorer patient outcomes and progressive functional decline.

He languished at SFGH for more months until being discharged out-of-county to a facility in Antioch that principally houses patients with dementia and Alzheimer’s. Since he is not demented, he now languishes in an environment in which he has nobody to communicate with, and his friends are unable to endure the obstacles of travelling to Antioch to visit him. His family is now trying to get him discharged to take him back to Ohio for care.

There are many other similar stories of patients needing skilled nursing care who are being dumped out of county. Why isn’t City Attorney Dennis Herrera concerned about the dumping of skilled nursing patients out of county? Isn’t that just as inhumane?

Although a few brave employees who have not been cowed into silence apparently brought up parallels to the Prop D ballot measure in 2006, Hirose and other hospital administrators brushed them off. Sounds like we’re right back to the 2003 to 2004 flow project, history repeating itself involving inappropriate patient placements into LHH. This patient dumping into LHH has gone on for a decade.

Many of LHH’s department heads are concerned about DPH’s decision to reconfigure the MHRF/BHC and place the 34 BHC patients into LHH. But they remember that when former LHH Executive Administrator Larry Funk opposed admission of violent patients to LHH, he was replaced and demoted.

Other staff who opposed admission of unsafe patients — including former Medical Director Dr. Terry Hill; Dr. Maria Rivero, LHH’s former admitting physician; and others — were all forced to resign, or bullied until they resigned. Rivero had also served on the patient screening committee performing pre-admission assessments for appropriate placements to LHH until she was removed from the committee in 2005 and the committee was disbanded for some length of time.

Many dedicated staff want to make LHH a safe place for staff and patients, and they’re concerned Herrera may not know LHH doesn’t have a psych license.

There are huge human costs to patients and staff from patient dumping, and Herrera is correct that the practice is “shockingly inhumane and illegal” — and obviously unethical. But where is Herrera’s concern for out-bound patient dumping to other counties, or internal dumping between DPH’s facilities? Is he concerned only about the cost of in-bound dumping, not the costs of out-bound dumping? How does Herrera’s ethical barometer work? Will Herrera ever look in the mirror and investigate patient dumping occurring in his home town’s back yard, or is he just grandstanding?

One test of Herrera’s ethics may involve how quickly the lawsuit filed by LHH’s battered staff member is resolved. Hopefully, Herrera’s underlings won’t introduce a flaky motion for summary judgment to stall her case and delay justice in a misguided attempt to scuttle her settlement, since that would only add further insult on top of injuries.

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Monette-Shaw is an open-government accountability advocate, a patient advocate, and a member of California’s First Amendment Coalition.  Feedback: monette-shaw@westsideobserver.com.


Postscript #1: Frazier Maintains His Salary

After this story was submitted for publication, the City Controller confirmed that Mr. Frazier has retained his previous job classification code — a 2593 Health Program Coordinator III — and has maintained his annual salary of $95,186, despite the fact that he was suddenly stripped of his job as the director of LHH’s Activity Therapy Department supervising approximately 40 subordinates after finally being caught bullying employees. Frazier now supervises nobody in hi