Investigation of Napa State Hospital - MindFreedom International (MFI)

Date Published:

Jun 27, 2006 01:00 AM

Author: Assistant General Northern District of California

Source: Government of California

June 27, 2005

to:

The Honorable Arnold Schwarzenegger

Governor of CaliforniaState Capitol Building

Sacramento, CA 95814

Re: Napa State Hospital, Napa, California

Dear Governor Schwarzenegger:

On January 6, 2004, we notified then-Governor Gray Davis ofour intent to investigate conditions at Napa State Hospital(“Napa”), in Napa, California, pursuant to the Civil Rights ofInstitutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. I write now to provide the statutorily required findings of thatinvestigation, the bases for those findings, and the minimumremedial measures that we believe are warranted to correctdeficiencies contributing to conditions that violate the federalrights of individuals residing in this facility.

As a threshold matter, we note that State officials havedeclined to cooperate with this investigation. In particular,they repeatedly have refused to allow the Department access tothe facility, most recently stating that access will not beprovided before sometime in 2006. The State’s conduct is unusualin this regard. Most government officials cooperate with CRIPAinvestigations because they recognize that protecting the rightsof institutionalized citizens warrants a thorough and impartialreview. Indeed, the State cooperated with the Departmentregarding a previous CRIPA investigation of Napa that wasresolved via a consent decree in 1990.^{1 The State alsocooperated with our investigation of Metropolitan State Hospitalin June and July 2002 (“Metropolitan”). Since then, however, theState has declined our requests for access to Napa and to the State’s other mental health care facilities that we areinvestigating, Patton State Hospital and Atascadero StateHospital.2Consent Decree, United States v. California, No. C902641, (N.D. Cal. Sept. 17, 1990).In May 2005, the State did permit Department staff tointerview certain Patton patients and has agreed to provide us- 2 We use pseudo-initials to refer to individual patients,in order to protect their privacy. – 3}

Consent Decree, United States v. California, No. C902641, (N.D. Cal. Sept. 17, 1990).In May 2005, the State did permit Department staff tointerview certain Patton patients and has agreed to provide us- 2
As we understand it, the State’s position is that permittingthe Department access to Napa, and its other facilities, beforesometime next year would excessively divert limited resources ata time when the State is undertaking significant reforms. Weattempted to address the State’s concerns by offering to conducta streamlined tour of Napa, and we reminded the State that wewere committed to providing technical assistance during the tourand to working in a transparent manner. If the State had agreedto our proposed investigation procedures, State officials wouldhave had an early opportunity to work directly with our expertsand staff. They also would have had an opportunity to addressany identified problems on a voluntary basis at an early stage ofthis investigation. Regrettably, the State has maintained itsopposition to permitting the Department access.

As we repeatedly advised State officials, however, ourinvestigations proceed regardless of whether officials choose tocooperate. Indeed, when CRIPA was enacted, lawmakers consideredthe possibility that local officials might not assist a federalinvestigation. Such non-cooperation is a factor that may beconsidered adversely when drawing conclusions about a facility. See H.R. CONF. REP. 96-897, at 12 (1980), reprinted in 1980

U.S.C.A.A.N. 832, 836. We now draw such an adverse conclusion.

The State’s non-cooperation is only one factor that we haveconsidered in preparing our statutorily-required findings andrecommendations. We have also considered information fromseveral recent on-site surveys conducted by the Centers forMedicaid and Medicare Services (“CMS”) and by the State’sDepartment of Health Services (“DHS”), and conducted interviewswith professionals, advocates, family members of patients, andpatients themselves. In doing so, we found evidence ofsignificant and wide-ranging deficiencies in Napa’s provision ofcare to its patients.

Tragically illustrative of the widespread and systemicdeficiencies that currently exist at Napa is the case of patientQ.R.,3 who committed suicide by hanging in December 2004.

with requested portions of charts from patients who authorized usto obtain such records.

We use pseudo-initials to refer to individual patients,in order to protect their privacy.

Several months before his suicide, Q.R. attempted suicide (alsoby hanging), which staff told his family was an attention-gettingbehavior, and not a realistic threat. This patient’s family wasin frequent contact with his counselor at Napa, and conveyed tothe counselor its concern that the patient’s escalating episodesof violence were uncharacteristic and needed to be treated. Onthe day of Q.R.’s death, a family member who had just spoken with

Q.R. phoned the nurses’ station on his ward to warn that Q.R. wasdespondent, crying, and in need of attention. Despite thisspecific warning and the patient’s history of suicide attempt,staff failed to act. Less than an hour later, Q.R. wasdiscovered by a peer, hanging by a sheet in his room. Becausethe State denied us access to the facility to investigate theseallegations, we have no reason not to conclude that thecontentions are accurate, and that Napa’s failure to interveneappropriately was a cause of this young man’s death.

The preceding incident is emblematic of the systemicdeficiencies at Napa. We have received overwhelming informationthat, following the dismissal of the consent decree in 1995,significant problems recurred at Napa, including: failure toprotect patients from harm from assaults and suicide; inappropriate use of seclusion, restraint and PRN (“pro re nata”or “as-needed”) psychotropic medications; and inadequate medical,nursing and psychiatric care. In addition, we have receivedinformation evidencing deficient treatment planning, programming,and nutritional management; unsanitary conditions; and failure toplace patients in the most integrated setting as required by theAmericans with Disabilities Act, 42 U.S.C. § 12132 et seq.(“ADA”), and the President’s New Freedom Initiative, whichprioritizes community-based alternatives for individuals withdisabilities. See Exec. Order No. 13217, §§ 1(a)-(c), 66 Fed.Reg. 33155 (June 18, 2001). Our findings, the facts that supportthem, and the minimum remedial steps that we believe arenecessary to correct deficiencies are set forth below.

I. BACKGROUND

Napa has been in operation since November 1875. It issituated on a 138-acre campus and houses almost 1,100 adultpatients. These individuals are classified as “low to moderaterisk” and are civilly committed or committed through criminalproceedings. In our previous investigation of Napa, weidentified deficiencies in the facility’s protections from harm,use of restraints, and provision of medical care, among otherareas. These concerns were addressed in a consent decree that was dismissed in 1995 based on the Department’s assessment thatNapa, at that time, was in substantial compliance with thedecree’s requirements.

II. FINDINGS

A. PROTECTION FROM HARM

Napa is constitutionally required to provide patientsreasonable protection from harm and freedom from bodilyrestraint. Youngberg v. Romeo, 457 U.S. 307, 315-16 (1982). Information from multiple, credible sources leads us to concludethat Napa fails to protect patients from harm and abuse. We havedetermined that the harm suffered by Napa’s patients is multifaceted, including physical injury by assault; death by suicidedue to inadequate suicide precautions; excessive andinappropriate use of physical and chemical restraints andseclusion; inadequate, ineffective, and counterproductivetreatment; and exposure to unnecessary environmental hazards.

A major factor in Napa’s failure to protect patients fromharm is inadequate supervision. As DHS has reported, “[e]venthough clients in the facility can be extremely unpredictable andviolent, they are left unsupervised for long periods of time.” Family members of patients and advocates who frequently visitNapa confirm that patients are left unattended, without staffobservation or interaction. A number of incidents occurred whenmedically required one-to-one staffing was cancelled, apparentlynot due to clinical decisions, but rather staff shortages. Moreover, as a nurse at Napa reported, “there are not enoughpeople on hand to subdue [out-of-control patients]…. So analarm is set off or the hospital police are called. But it takesat least five minutes, sometimes 10 or more to get there, and alot can happen during that time.”

1. Patient-on-Patient Assaults

Napa patients suffer from repeated acts of aggression bypeers, resulting in serious injuries, and in one case, ahomicide. In egregious departures from accepted standards, staffoften fail to intervene and/or fail to report the incidents. Staff likewise do not attempt to prevent repeated assaults byaddressing the underlying behavior of the aggressors.

Many instances of inappropriate aggression in a psychiatrichospital such as Napa result from patients exhibiting symptoms of their mental health disorders. Without the benefit ofappropriate medication and therapeutic interventions, patientsoften lack the means to control such symptoms. Thus, inadequatemental health treatment exposes individuals to excessive levelsof violence. Examples of failures to prevent known aggressorsfrom repeated acts of serious aggression include:

- On May 3, 2002, a patient was strangled to death by hisroommate. The roommate had previously been convicted ofseveral violent crimes and had a history of attacking peers,including two attacks on sleeping patients. Reportedly,there are no bedrooms set aside to house separately patientswho demonstrate the potential to harm others.
- Between January and June 2003, one patient assaulted otherpatients at least 20 times, including at least 17 incidentsin which he punched or kicked other patients in the head orface. Staff were afraid of this patient and failed tointervene to protect other patients.
- In June 2002, a patient with a history of aggressivebehavior attacked another patient in the TV room, punchinghim and stabbing him in the neck with a portable radioantenna. Staff failed to report the assault to thelicensing authorities.
- On November 18, 2002, a patient who was ordered to be underconstant observation by staff assaulted another patient. Hepreviously had assaulted two patients on October 3, 2002,and one patient on September 18, 2002. In addition, anassessment dated September 3, 2002, indicated that he had”numerous recent assaults on peers.”
  1. • Two patients known to be “extremely assaultive” were placedin a bedroom together where they were not supervised forsignificant periods of time. On August 8, 2001, one patientattacked the other, punching him in the nose. The followingday, that patient retaliated by choking his roommate untilhe passed out.
  2. Patient advocates and patients themselves tell us that staffoften fail to intervene with violent patients because the staffare afraid. Last fall, Napa’s Clinical Administrator confirmedto CMS surveyors that “staff become fearful of patients who havebeen assaultive.” Examples of staff failing to interveneinclude:

Several Napa patients have committed suicide in recentyears, often using the same method to do so:

- - On March 20, 2005, Napa patient M.E. committed suicide byhanging himself in a locked bathroom.
  - Napa patient Q.R. committed suicide by hanging in December2004. Several months earlier, he had attempted suicide byhanging; notwithstanding his history, Napa staff failed tointervene or adequately supervise Q.R. when a family membercalled the nurses station on his unit the day of his deathand informed staff that Q.R. was despondent and crying andin need of attention.
  - On July 21, 2003, a man hanged himself from a door using aradio cord, on the same ward where another patient committedsuicide only a month earlier.

In February 2005, CMS cited Napa for failing to complete thesuicide assessment of a patient for more than six months afterhis admission. CMS found that Napa did not provide translationservices to complete the suicide assessment of this patient, whocould not communicate in English.

The State’s own surveyors previously cited Napa for failingto identify and address current symptoms of yet another patientwith a documented history of suicide attempts. In July 2004, DHSimposed a treble fine on Napa for failing to assess and treat apatient whose suicide attempt was reported to staff by a peer andwhose records contained numerous observations documenting hisdepression during that time, including: “verbalized feelings ofdepression;” the patient stating that his “spirit was broken;”and the patient requesting medication for depression andagitation. Notwithstanding this significant evidence of a mentalhealth treatment need, the facility’s nursing staff did notassess or evaluate the patient, and the treatment team did notamend his treatment interventions to address this need. I wouldnote that DHS imposes treble fines only when the violation is arepeat violation within a short time frame. Napa has been warnedrepeatedly of deficiencies in its suicide prevention practices,but has failed to remedy them.

3. Harmful Contraband

Napa also fails to protect patients from harmful contraband. The State’s own Department of Health Services has determined thatpolicies requiring investigation of all contraband are notfollowed. Numerous credible allegations corroborate our findingthat Napa fails to control traffic in harmful contraband,including illegal narcotics. We have determined that patientshave access to illegal drugs, including marijuana and cocaine,while residing at Napa. Patients allege, moreover, that staffprovide illegal drugs to patients in return for cash or sex. Evidence that patients are obtaining access to contrabandincludes:- 8

4. Seclusion, Restraints and PRN Medications

Generally accepted professional standards of care dictatethat seclusion and restraints: (a) will be used only whenpersons pose a safety threat to themselves or others and after ahierarchy of less restrictive measures has been considered and/orexhausted; (b) will not be used in the absence of, or as analternative to, active treatment, as punishment, or for theconvenience of staff; (c) will not be used as a behavioral

Misuse of seclusion and restraint was a significant area ofconcern during our first CRIPA investigation of Napa. Inaddition to overuse and misuse of physical restraints andseclusion, our earlier investigation found an exorbitant numberof PRN (pro re nata or “as needed”) medication orders, suggestingthat they were used for the convenience of staff to sedate andcontrol patients. Substantial evidence shows that misuse ofseclusion and restraint is a significant area of concern again. Statistics published on the DMH web site show the duration ofrestraint episodes at Napa to be substantially higher than thesystem’s average in 2004. The average duration of restraint episodes at Napa during each quarter of 2004 was more than doublethose at Metropolitan State Hospital (where we also foundunconstitutional use of seclusion and restraint) during this sametime.6 Data comparing administration of emergency psychiatricmedication7 in the State’s four public psychiatric hospitals also February 19, 2004 CRIPA Findings Letter Regarding Conditions at Metropolitan State Hospital. We currently arenegotiating to reach a resolution of the Metropolitaninvestigation. Of the State’s four psychiatric hospitals, theresidents at Metropolitan and Napa are the most similar, andinclude both civilly-committed and forensic patients. Patton andAtascadero State Hospitals admit only forensic patients.

shows that Napa’s rate was nearly twice that at Metropolitan.8This is a concern because we found the high levels of seclusion,restraint and PRN medications at Metropolitan to be evidence of afailure to follow generally accepted professional practices. Specifically, frequent resort to seclusion, restraint and PRNmedication is an indicator that a patient’s diagnosis iserroneous and/or that the treatment plan is inappropriate andshould be re-evaluated.

In September 2004, and again in February 2005, Napa wascited by CMS for continuing deficiencies in the use of seclusionand restraints. In both surveys, CMS found that Napa failed tojustify the use of restraints; failed to ensure physicians’orders and face-to-face assessments in application of restraints;and failed to limit use of restraints and seclusion to documentedemergencies. When interviewed by CMS surveyors regardingexamples of inappropriate restraint, Napa’s Clinical Directorstated, “[m]aybe our system is not working.” Examples ofinappropriate uses of seclusion or restraint include:

- - A patient identified in a February 2005 CMS survey wassecluded for 30 hours, during which time staff’s recordedobservations included: “appears sleeping,” “eating,””drinking,” “eyes open staring in space,” and “notresponding.” These behaviors do not reflect violencerequiring seclusion, and there was no evidence that thepatient was released during these times to see if she couldcontrol her behavior without being secluded. On a secondoccasion, the same patient was secluded for 36 hours, withthe following release criteria: “when client is able tomake eye contact to staff with relaxed muscle tone.” Duringthis second episode of seclusion, the patient was observed as “not responding to staff,” and “covering self withblanket, mute,” behaviors not indicative of violencerequiring seclusion.
  - The February 2005 CMS survey also identified a patient whowas admitted while under restraint and continued inrestraints for more than 48 hours. Documentation shows that

restraint was continued based on past behaviors; currentbehaviors noted in the documentation clearly did not justifyrestraint, including “demanding, whining,” “eating dinner,””staring at wall,” and “eyes closed.”

- - Another patient identified in the February 2005 CMS surveywas “walking wrist to waist restrained” for 50 hours basedon a physician order stating, “[w]alking wrist to waistrestraints when out of his own room. No release criteriaother than being release criteria [sic] in his own room.” The Medical Director, when questioned by CMS whether thisuse of restraints was justified based on an immediate threatof violence, stated, “I think it is less restrictive toallow the patient out in the milieu in these restraints,rather than having to stay in his room.”
  - Another patient was restrained on 20 occasions betweenAugust 2nd and September 21, 2004, for a total of 920.4hours, or 75% of her hospital time during this period. Oneepisode was for 369 consecutive hours.
  - Another patient, who had Down syndrome and whose primarylanguage was not English, was observed by CMS surveyors inthree-point restraints on September 20, 2004. Recordsshowed he had been restrained in three or five-pointrestraints since admission three days earlier. None of theinformation in his charts suggested any justification foruse of restraints.
    1. • PRNs are used inappropriately, and as a substitute forsufficient staff supervision and therapeutic interventions. For example, a patient who pushed away a peer in selfdefense when the peer assaulted her was given a PRN for herown “aggression.” Generally accepted practices and federalregulations, 42 C.F.R. § 482.13, prohibit use of restraints(including medications) unless the person poses an immediatesafety threat to themselves or others and after a hierarchyof less restrictive measures has been considered and/orexhausted.
    2. Previous CMS surveys confirm that Napa’s misuse ofrestraints and seclusion is a serious and long-standing problem:
    3. • On February 2, 2001, a patient died while in three-pointprone restraints in a seclusion room. The patient wasrestrained on his stomach and choked to death while eating.

– 12

- - The patient’s chart reflects that he was at increased riskof positional asphyxia because he suffered fromhypertension, obesity, and Huntington’s disease. Inexplicably, this patient was served a meal in thisposition and was monitored only by an audio/video monitorthat showed the back of his head.
    - In three of three records reviewed by CMS in August 2001,restraints were used without having been approved in thepatients’ plans of care. A supervisor interviewed by CMSwas unaware of accepted professional standards requiringthat patients subject to restraint have plans of careexpressly addressing the restraints used, includingassessments addressing the need for restraints, appropriate interventions based on those assessments, evaluation of theeffectiveness of the interventions, and re-intervention aswarranted.

Multiple independent sources have alleged that staff at Napagoad patients into behaviors that are then punished withrestraint or seclusion. More particularly, staff frequentlyprovoke patients into verbal confrontations to justify placingthe patients in seclusion. If a patient resists being placed inseclusion, the patient is then restrained. Because the State hasdenied us access to the facility to investigate theseallegations, we are compelled to conclude that they are accurate.

5. Failure to Control Environmental Hazards

In a facility serving people at risk of harming themselvesor others, the environment should be kept free of hazards. Napahas failed to meet this generally accepted professional standardof care.

Examples of Napa’s breakdown in environmental protectionsinclude the prevalence of appurtenances and other fixtures uponwhich patients tie off to commit suicide; jagged and broken walltiles; and highly unsanitary bathroom areas. CMS, in fact, hasdetermined that staff takes no action, or completely ineffectiveaction, to prevent patients from soiling common areas with humanwaste. Exposure to others’ wastes is a health hazard.

B. MEDICAL, NURSING, AND PSYCHIATRIC CARE- 13

The State is required to provide adequate medical care topatients, including adequate nursing care. Youngberg, 457 U.S.at 315, 322. We find that Napa does not provide adequate medicaland nursing care to patients. Regulatory agency surveys from2001 to as recently as February 2005 indicate persistentdeficiencies in medical and nursing care: nursing care is notprovided to all patients who need it; registered nurses do notconsistently supervise and evaluate the nursing care of eachpatient; the nursing staff does not consistently develop anursing care plan for each patient; staff fail to ensure theproper implementation of patients’ care plans; care plans areinadequate and outdated; dental care is inadequate; documentationand reporting of treatment and symptoms is inadequate; andmedications are not consistently administered properly. Inaddition, medical care –- including psychiatric assessments –- isnot consistently timely, responsive, or accurate.

Lapses in medical and nursing care can, and have had, fatalconsequences for Napa patients. In February 2005, patient B.X.complained of breathing problems. Although he used a nebulizerfor a history of breathing problems, his complaints were notaddressed by staff. He died sitting in his room and wasdiscovered by a peer. Because the State has denied us access tothe facility and its records in our investigation, we concludethat staff’s inattention to this patient’s serious medicalcomplaint was a cause of his death.

The following additional examples illustrate many systemicmedical, nursing, and psychiatric service deficiencies anddemonstrate Napa’s substantial departure from generally acceptedprofessional standard of care in these critical areas:

- - 1. In May 2005, a patient who suffered a seizure while in thecafeteria choked to death. In an inpatient hospitalsetting, it is difficult to imagine why there was no staffperson with sufficient training available to avert a deathby choking.
    2. In March 2005, a patient waited more than 48 hours for an x-ray and treatment for a broken arm.

2. Deficiencies in Provision of Occupational andPhysical Therapy and Dietary Supports and Services

The care provided at Napa to patients whose needs includeoccupational or physical therapy departs substantially from generally accepted professional standards. Napa alsoconsistently fails to provide adequate nutritional services, asubstantial departure from professionally accepted standards thatmay cause serious health problems. For example:

- - - In a February 2005 survey, CMS identified two patients whorequired equipment such as portable oxygen and/orwheelchairs to attend programming; staff neither encouragednor assisted the patients to use this equipment to attendprogramming but, instead, left the patients in bed in theirrooms.
    - In November 2002, at least six patients’ records weremissing observation data and information relevant tonecessary dietary supports and services.
    - In October 2002, CMS observed Napa staff incorrectlyadminister gastrosomy tube feedings for five of sixpatients, and observed a patient with a care plan thatincluded swallowing precautions being fed by staff that wasnot trained and not familiar with the patient’s plan.

The failure to provide physical, occupational, andnutritional supports and services to Napa patients may result ina loss of mobility and independence, and can also lead topreventable medical complications.

C. PSYCHOLOGY AND TREATMENT PLANNING

The State must also provide persons committed to psychiatrichospitals for an indefinite term with mental health treatmentthat gives them a realistic opportunity to be cured and released. Oregon Advocacy Ctr. v. Mink, 322 F.3d 1101, 1121 (9th Cir. 2003)(citing Ohlinger v. Watson, 652 F.2d 775, 779 (9th Cir. 1980);Sharp v. Weston, 233 F.3d 1166, 1172 (9th Cir. 2000) (same). Multiple independent sources, including regulatory agencies,independent professionals, patients, and patient advocates,inform us that Napa fails to provide adequate treatment planning,and in particular, fails to plan adequately to address patients’assaultive and self-abusive behaviors. In addition to the manyexamples of Napa’s failure to address assaultive and suicidalbehavior, discussed at §§ II.A.1 and 2, above, examples offailures to treat include:

interventions for those patients with a history ofassaultive behavior until after those patients haveassaulted someone at the facility.

D. DISCHARGE PLANNING AND PLACEMENT IN THE MOST INTEGRATEDSETTING

Napa fails to comply with the requirement of the ADA and itsimplementing regulations that patients be placed in the mostintegrated, appropriate setting consistent with the patient’sneeds and the terms of any court-ordered confinement. SeeAmericans with Disabilities Act, 42 U.S.C. § 12131, which states:

no qualified individual with a disability shall, byreason of such disability, be excluded fromparticipation in or be denied the benefits of theservices, programs, or activities of a public entity,or be subjected to discrimination by any such entity.

See also ADA implementing regulations, 28 C.F.R. § 35.130(d) (“Apublic entity shall administer services, programs, and activitiesin the most integrated setting appropriate to the needs ofqualified individuals with disabilities”); Olmstead v. L.C., 527 U.S. 581 (1999); President George W. Bush’s New FreedomInitiative, “Community-Based Alternatives for Individuals withDisabilities,” Exec. Order No. 13217, 66 Fed. Reg. 33155 (June 18, 2001)(the President emphasized that unjustifiedisolation or segregation of qualified individuals withdisabilities in institutions is a form of prohibiteddiscrimination, that the United States is committed to community-based alternatives for individuals with disabilities, and thatthe United States seeks to ensure that America’s community-basedprograms effectively foster independence and participation in thecommunity for Americans with disabilities).

We have received credible allegations that patients who seekto be discharged into community placements are retaliated againstby Napa staff. According to a patient’s family member, a patientwas placed on psychotropic medication in late 2002 in retaliationfor writing letters to the court requesting a discharge hearing. The prescribing doctor reportedly told him that he would not stopgiving him the medication until he stopped writing the letters. Another patient alleged that she was retaliated against forhiring an attorney to seek her release. She alleged that shereceived excessive dosages of medication and was awakened every 30 minutes at night to deprive her of sleep, until she stoppedseeking her release. Two other sources stated that patients weregiven large doses of psychotropic drugs before any courtappearance to inhibit their release from Napa. In addition, inNovember 2001, a staff member alleged that when patients wereready for discharge, supervisors instructed the medical staff toalter notations in patients’ records to indicate that patientswere not ready to be discharged.

Napa also fails to provide sufficient substance abuseprograms to meet patient needs, even though these are aprerequisite to participation in the “conditional release”program.9 A patient’s failure to complete the program leads Napato file a petition for an extension of time of commitment. Finally, multiple credible sources state that patients receivelittle or no treatment or interventions to prepare them fordischarge; discharge planning for patients is essentially “do ityourself.”

III. MINIMUM REMEDIAL MEASURES

Because the State has denied us timely access to Napa, weare not able to provide remedial measures with the samespecificity as we provided in our letters dated May 21, 2003 andFebruary 19, 2004, regarding Metropolitan State Hospital. However, because the deficiencies at Napa generally mirror thedeficiencies at Metropolitan, the specific remedies outlined inthe letters regarding Metropolitan are illustrative of those thatshould be implemented at Napa. To remedy the deficienciesdiscussed above and to protect the constitutional and federalstatutory rights of the patients at Napa, the State should, at aminimum, promptly implement the remedial measures set forthbelow.

A. Protection From Harm

1. To remedy deficiencies that result in excessive patient-on-patient assaults, patient suicides, and trafficking incontraband, including illegal street drugs, the State must:

a. Ensure that Napa provide its patients with adequate,integrated treatment planning consistent with generally

- - - (1) Develop and implement policies and proceduresregarding the development of treatment plansconsistent with generally accepted standards ofcare.
    - (2) Revise treatment plans as appropriate, based onsignificant developments in patients’ conditions,including patients’ progress, or lack thereof, asdetermined by the scheduled monitoring ofidentified criteria or target variables.
    1. b. Ensure Napa provides its patients with accurate,complete, and timely assessments, consistent withgenerally accepted professional standards of care;these assessments should drive treatment interventions.
    2. c. Ensure that Napa reviews, revises, as appropriate, andimplements comprehensive, consistent incidentmanagement policies and procedures consistent withgenerally accepted professional standards. At aminimum, revised policies and procedures shall provideclear guidance regarding reporting requirements and thecategorization of incidents, and address investigationof all serious incidents.
    3. d. Ensure that Napa develops and implements acomprehensive quality improvement system consistentwith generally accepted professional standards of care.

2. To remedy deficiencies that result in excessive andinappropriate use of seclusion, restraint and PRNmedications, the State must:

- - 1. a. Ensure that seclusion, restraints, and PRN psychotropicmedications are used at Napa in accordance withgenerally accepted professional standards of care.
    2. b. Ensure that restraints, seclusion, and PRN medicationsare used in a reliably-documented manner and only whenpersons pose an immediate safety threat to themselvesor others, after a hierarchy of less restrictivemeasures has been considered and/or exhausted, and are

terminated once the person is no longer an imminentdanger to himself or others.

- - 1. c. Ensure that seclusion, restraints and PRN medicationsare not used in the absence of, or as an alternativeto, active treatment, as punishment, or for theconvenience of staff.
    2. d. Ensure that the patient’s treatment team, in aclinically-justifiable manner, timely reviews the useof such interventions, and determines whether to modifythe patient’s treatment plan, and implements therevised plan, as appropriate.

3. To remedy deficiencies that result in an unsafe physicalenvironment, the State must:

a. Ensure that Napa provides its patients with a safe andhumane environment and protect them from harm. At aminimum, Napa shall conduct a thorough review of allunits to identify any potential environmental safetyhazards and develop and implement a plan to remedy anyidentified issues.

B. Medical, Nursing, Dental and Psychiatric Care

a. Napa develops diagnostic practices, guided by current,generally accepted professional criteria, for reliably-

reaching the most accurate psychiatric diagnoses foreach patient.

- - 1. b. Napa reviews and revises, as appropriate, psychiatricassessments of all patients, providing clinicallyjustifiable current diagnoses for each patient;modifies treatment and medication regimens, asappropriate, considering factors such as the patient’sresponse to treatment, significant developments in thepatient’s condition, and changing patient needs; andensures that each patient’s psychiatric assessments,diagnoses, and medications are collectively justifiedin a generally accepted professional manner.
    2. c. Napa’s patients receive pharmacy services consistentwith generally accepted professional standards of care.
  - 1. Napa should provide its patients with routine and emergencydental care and treatment on a timely basis, consistent withgenerally accepted professional standards of care.
    2. Napa should implement adequate infection control proceduresto prevent the spread of infections or communicablediseases.
    3. Napa should provide its patients with physical andoccupational therapy consistent with generally acceptedprofessional standards of care.
    4. Napa should ensure that its patients receive adequatedietary services, consistent with generally acceptedprofessional standards of care.

C. Psychology and Treatment Planning

1. Napa should provide psychological supports and servicesadequate to treat the functional and behavioral needs of itsadult patients according to generally accepted professionalstandards of care.

D. Discharge Planning and Placement in the Most IntegratedSetting

1. Within the limitations of court-imposed confinement, theState should pursue actively the appropriate discharge of patients and ensure that they are provided services in themost integrated, appropriate setting that is consistent withpatients’ needs.

I invite the State to discuss with us the remedialrecommendations, with the goal of remedying the identifieddeficiencies without resort to litigation. In the event that weare unable to reach a resolution regarding our concerns, theAttorney General is empowered to institute a lawsuit pursuant toCRIPA to correct deficiencies of the kind identified in thisletter, 49 days after appropriate officials have been notified ofthem. 42 U.S.C. § 1997b(a)(1).

We would prefer, however, to resolve this matter by workingcooperatively with you. We have every confidence that we will beable to do so in this case. The lawyers assigned to this matterwill contact your attorneys to discuss this matter in furtherdetail. If you have any questions regarding this letter, pleasecall Shanetta Y. Cutlar, Chief of the Civil Rights Division’sSpecial Litigation Section, at (202) 514-0195.

Sincerely,

Bradley J. SchlozmanActing Assistant Attorney General

cc: The Honorable Bill LockyerAttorney General State of California

Stephen W. Mayberg, Ph.D.DirectorCalifornia Department of Mental Health

Mr. Dave GrazianiExecutive DirectorNapa State Hospital

Kevin V. Ryan, Esq. United States AttorneyNorthern District of California