Report: Dozens Denied Inpatient Mental Evaluations

April 18, 2012

People who show the potential of seriously harming themselves or others have failed to get the inpatient emergency mental-health evaluation and treatment they need because of a lack of space in state-run and private psychiatric hospitals, a state report shows.

The Department of Behavioral Health and Developmental Services study found that over a three-month period, 72 people who were suffering mental-health crises and qualified for a temporary detention order received less than the emergency hospitalization to which they were entitled under Virginia law because no state-run or private facilities would admit them.

Such denials of service represent "a failure of the system to address the needs of that individual and places the individual, his family, and the community at risk," according to G. Douglas Bevelacqua, the agency's inspector general.

The 72 who weren't admitted for treatment represent about 1.5 percent of the estimated 5,000 people who were hospitalized under temporary detention orders, or TDOs, over the period. The report also said an additional 273 people received the orders but it took longer than the six-hour timeframe prescribed by state law for them to be placed in facilities.

In one case, a 22-year-old man with intellectual disabilities landed in the local hospital's emergency department after biting, hitting and kicking employees at his group home, pouring antifreeze and other substances on himself and displaying psychotic symptoms such as hearing voices telling him to harm himself. He'd met the criteria for temporary detention, but private hospitals who were consulted all turned down admission because of his severe symptoms, his aggressive behavior, or a lack of space, the report said.

He was involuntarily committed in the local hospital's psychiatric unit and released a few days later. Less than two weeks later, police returned him to the local hospital's emergency department after he assaulted staff and damaged property at the group home, which evicted him because of his dangerous behaviors, the report said. A mental health pre-screener contacted 16 private hospitals to find a spot for the man but was turned down at each. The state-run psychiatric hospital also didn't admit him, so again he was admitted to the local hospital, where he injured a nursing aide. He was again placed in the psychiatric unit, about three days after he showed up in the emergency department.

People who meet the state criteria for temporary detention in Hampton Roads or southwest Virginia have the most difficulty finding a facility that's able to admit them, the report said. Both regions have state-operated hospitals — Eastern State Hospital in Williamsburg and Southwestern Virginia Mental Health Institute in Marion — that frequently operate at or beyond capacity, and are unable to offer space for those needing temporary detention and further evaluation.

"Particularly troubling is southwest Virginia, which is home to only 7 percent of the state's 8 million residents, but accounted for 45 percent of failed TDOs," the report said.

The review also found that patients are staying longer on average at the Southwestern Virginia Mental Health Institute, reducing that facility's capacity to handle emergency cases by more than 40 percent over the last 18 months.

The report suggested that increased funding to help the hospitals in those two regions discharge stabilized patients and the creation of community-based treatment facilities would help open up space for those in crisis and "reconstruct a viable public safety net."

Virginia's decline in psychiatric beds, coupled with a statewide population increase, hasn't been matched by a corresponding expansion of community-based programs and resources — so some state facilities can't discharge people and return them to their homes. The report says state-operated facilities and community-service mental health boards should work together on transitioning people from the facilities back into the community to free up space for those with more acute psychiatric needs.

Bevelacqua said hospital medical directors and community services boards' emergency directors have agreed that the mental-health screening and assessment procedures should be standardized to promote better treatment outcomes for people in mental-health emergencies.

The report, issued in February, also recommends designating regional managers who would be responsible for finding state-operated or private facilities to admit people who meet the criteria for temporary detention. It also recommends creating "intensive psychiatric beds" at private hospitals in Hampton Roads and southwest Virginia "until a reliable state-operated safety net is recreated for these regions."

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