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John George PES has a long history of bad things happening. In 1998, state regulators investigated the facility and found that the hospital's administration had set up substandard injury-prevention programs, and that assaults committed by patients against other patients and against staff were common. The state issued citations, but not much changed. Again in 2003, state regulators made the same findings. Dean Fryer, a spokesperson for the California Occupational Health and Safety Administration (OSHA), told news reporters at the time that John George's administrators had made a "dismal showing," and that, in fact, the hospital's leaders had behaved in a "defiant" manner during the summer of 2003 by not increasing security and staffing as OSHA had advised.
Then in November 2003, tragedy struck. Rene Pavon, a 48-year-old patient who was being examined by veteran physician Erlinda Ursua, picked up a heavy blunt object and knocked the doctor over the head. Pavon then strangled Ursua to death using the doctor's scarf. The attack was not discovered for at least thirty minutes because Ursua had been examining Pavon alone, in an isolated examination room, a practice that OSHA and others had previously advised the hospital's administrators to end. Then in December 2003, Mark Oyarzo, a 38-year-old patient, hanged himself with a shoelace. Further investigation concluded that both of these deaths were preventable and partly due to under-staffing and poor safety practices.
Then in 2005, another patient committed suicide by hanging herself from a bathroom door hinge with a piece of clothing. This spate of tragedies — Ursua's death, multiple suicides, and even more numerous assaults, some of which the hospital's administrators did not immediately report to state health officials — caused the Alameda County Civil Grand Jury to investigate John George PES. The grand jury wrote in its final report, published in 2006, that the hospital appeared to be undertaking reforms suggested by state regulators but that "questions still remain regarding how well the training program is implemented and how policies and procedures are enforced" and that "safety concerns will remain until the facility's staffing needs are met."
The grand jury singled out the hospital's tendency to have too few nurses on shift and too many patients crowded into PES, calling it an "ongoing challenge." The number of patients often swelled to levels far exceeding the state mandated nurse-to-patient ratio, which, according to the grand jury report, should have been one-to-five.
Then, starting in 2007, the county's mental health care budget began taking hits — damaging cutbacks that undermined any progress that had been made. At an Alameda County Board of Supervisors meeting on January 11 of this year, Manuel Jimenez, director of the county's Behavioral Health Care Services, which helps pay for mental health care at John George Hospital, said that more than $70 million had been cut from the county's mental health care budget since 2007.
"I know there are problems at John George," said Jimenez during the meeting. When asked by county Supervisor Keith Carson to explain the problem of overcrowding, Jimenez listed factors mostly beyond the hospital's control. According to Jimenez, budget cuts have reduced the capacity of John George Hospital's inpatient facilities, which has forced the hospital to hold more patients in PES, rather than transferring some of them to the inpatient beds. Jimenez added that budget cuts have been compounded by the fact that John George PES is the sole psychiatric emergency services facility for the entire county, and Alameda County has a large and growing population of poor people living in "concentrated poverty" and other conditions of stress and trauma that produce an abnormally high incidence of mental health crises. Jimenez told the board of supervisors that social and economic conditions in Alameda County have caused it to have "one of the highest 5150 rates in the state." In fact, according to California's Office of Statewide Health Planning and Development, Alameda County has the highest per capita incidence in the state of involuntary holds placed on individuals experiencing a mental health emergency — 11 per every 100,000 people — with the next highest county only having placed 6.4 involuntary holds per 100,000.
Another factor causing overcrowding in PES is the hospital's high readmission rate. According to the county's Mental Health Board, too many patients make repeated visits, because there are too few mental health services available to them. For many mentally ill people, especially those who are homeless or very low-income and lack medical insurance, it's difficult to obtain treatment for substance abuse, to get into transitional housing, and to access medication, counseling, and other resources and therapies that would keep them from spiraling into another crisis. According to a recent Mental Health Board report, the high readmission rate at John George PES had the potential to feed a "vicious cycle of overcrowding," resulting in "patients being discharged and being readmitted when they fail to function outside the hospital setting."
Nurses at PES are already familiar with this cycle. Sloan said in an interview that lots of patients return to PES week after week, often as walk-ins, but others arrive repeatedly in ambulances after having fallen into a manic or severely depressed psychosis.